Stuttering
I.
Definition and Symptomatology
A.
B.
Definition of stuttering
1.
International Classification of Diseases (WHO, 1977:
Disorder in the rhythm of speech, in which the individual
knows precisely what he wishes to say, but is unable to say
it because of an involuntary repetition, prolongation, or
cessation of sound.
2.
Wingate (1984): Disruption in the fluency of verbal
expression that is characterized by involuntary audible or
silent repetitions or prolongations in the utterance of short
speech elements, namely: sounds, syllables, and words of
one syllable. These disruptions usually occur frequently or
are marked in character and are not readily controllable.
3.
Key words to distinguish normal disfluency from stuttering
are “not readily controllable.”
Types of Disfluencies
1.
Repetitions of sounds, syllables, monosyllabic words: may
be either audible or silent.
2.
Prolongations of sounds: may be either audible or silent.
3.
Whole word repetition: repetition of monosyllabic words is
classified as a part word repetition. Use for multisyllabic
words only.
4.
Phrase repetition or revision.
5.
Interjections or starters.
-- Only 1 and 2 are observed with greater frequency in the
speech of stutterers, as compared to non-stutterers. 3, 4, 5
are common in the speech or normally disfluent young
children.
C.
Primary characteristics of stuttering
1.
Part-word repetitions (audible and silent)
D.
II.
2.
Prolongations (audible and silent)
3.
Disfluencies occur more frequently and are longer in
duration than normal.
4.
Stuttering like disfluencies, as described by Yairi (1997),
comprise more than 50% of disfluency types exhibited by
preschool children in a speech sample of 100 words.
5.
Attitudes toward and reactions to stuttering
Accessory characteristics of stuttering (behaviors that stutterers
learn, that they use to cope with their stuttering)
1.
Speech-related movements: exaggerated or inappropriate
movements of the peripheral speech mechanism.
2.
Body-related movements.
3.
covert features: circumlocution, word substitution.
Differences between stutterers and non-stutterers
A.
Fluency: higher frequency of part word repetitions and sound
prolongations in the speech of stutterers.
B.
Speech and language development: stutterers may be slower
Nippold JSHD 2/90: but “The view that stuttering children, as a
group, are more likely than nonstutterers to have delayed or
disordered speech and language development has not been
proven despite 60 years of research.”
C.
Intelligence: stuttering more prevalent among the retarded.
D.
Motor performance:
1.
As a group people who stutter have slower and more
variable reaction times.
2.
acoustic characteristics of fluent speech:
a.
subgottic pressure differences upon initiation of voice.
b.
incoordination of articulatory subsystems for speech
during stuttering
E.
III.
Prevalence and Incidence
A.
Word wide phenomenon: Although the incidence and prevalence
figures higher in those societies that stress skilled verbal
performance in children, most cultures are aware of the stuttering
problem.
B.
Prevalence figures
C.
IV.
Cerebral hemispheric activation differences in adults who stutter
1.
Pre-adolescence approximately 1% in the United States
2.
Life-time incidence about 5%.
3.
Higher percentage among neurologically impaired (M.R.,
C.P., epileptics).
4.
75% of individuals recover from stuttering before
adolescence.
Incidence
1.
Sex ratio: males to females, 3 or 4 to 1.
2.
Familial Incidence: Kidd (‘84) 1/3 - 2/3 of stutterers have
immediate relatives who stutter or have ever stuttered.
Genetic predisposition is probable, but neither necessary or
sufficient to cause chronic stuttering. Environment may play
a part but factors such as imitation, and simple recessive,
dominant or sex-linked genetic transmission have been ruled
out.
Stuttering “triggers”
A.
Responses to stimuli (emotional, cognitive, voluntary).
1.
anticipation or expectancy, fear of specific words, sounds,
situations
2.
word substitutions and circumlocution
3.
perception of self as speaker
4.
time pressure
V.
Theories of Stuttering
A.
B.
C.
D.
VI.
Organic: Breakdown Hypothesis
1.
Etiology: combination of hereditary and environmental
factors.
2.
Physiological factors: insufficient or atypical cerebral
dominance; temporal programming, making sensory to
motor - motor to motor transformations, motor programming.
3.
Proponents: Orton-Travis, Kent, Neilson & Neilson, Smith &
Denny.
Psychoneurotic Theories:
1.
Stuttering serves to satisfy an unconscious need.
2.
Stuttering as approach - avoidance conflict (Sheehan)
Leaning Theories:
1.
stuttering as anxiety: motivated instrumental avoidance act
(Wischner)
2.
stuttering as conditioned disintegration of speech (Brutten &
Shoemaker)
Anticipatory struggle theories (cognitive)
1.
Stuttering due to belief in the difficulty of speech.
2.
Diagnosogenic theory- Johnson: stuttering results from
effort to avoid normal disfluencies that have been
misdiagnosed by parents.
3.
Theory of communicative pressures and failures
(Bloodstein): stuttering is precipitated by difficulties or
pressures involving any aspect of speech and language
development.
Evaluation
A.
Normal disfluency and early stuttering (Yairi, 1997)
VII.
1.
Quantitative dimension: frequency of instances, number of
iterations or duration.
2.
Quantitative dimension: spacial distribution (clustering) in
speech.
3.
Physical dimension: temporal characteristics and other
acoustic features.
4.
Physiologic dimension: associated tension.
B.
Stuttering like disfluencies (SLD): part-word and monosyllabic
word repetitions, disrhythmic phonation, and tense pause.
C.
Neurogenic (acquired) stuttering: a symptom of brain injury
characterized by sound and syllable repetitions. Adult onset is
sudden following a stroke or head trauma.
D.
Cluttering (St. Louis, 1992): a speech-language disorder
characterized mainly by “(1) abnormal fluency which is not
stuttering and (2) a rapid and/or irregular speech rate”.
Treatment
A.
B.
Iowa School (Van Riper, Johnson, Sheehan, Williams):
1.
Individualized treatment: symptom reduction and
psychotherapy.
2.
Emphasis on fear reduction and non-avoidance and
improving attitudes regarding self as a speaker.
3.
Advantage: use of natural sounding spontaneous speech
and/or open stuttering.
4.
Disadvantage: lack set criteria for management makes
clinician training difficult.
5.
Outcome: improved speech fluency, reduced situational and
word fears.
Behavior therapies
1.
Emphasis on immediate reduction of disfluency.
2.
Programmed (operationally defined) treatment plans.
C.
VIII.
3.
Treatment phases include: baserate, establishment of
fluency, transfer, maintenance and follow-up.
4.
Fluency shaping (Webster, Shames, Schwartz)
a.
fluency established by reducing speech rate through
syllable prolongation (DAF).
b.
focus on specific aspects of speech productions
gentle onset of phonation, air flow.
c.
speech rate systematically “shaped-up” to a normal
rate.
5.
Outcome: controlled fluency or spontaneous fluency.
6.
Advantages: immediate fluency, systematic desensitization
to feared situations.
7.
Disadvantages: no attention to feelings and attitudes, little
individualization relapse.
Integrated approaches
1.
combination of fluency control and individualized attention to
feeling and attitudes.
2.
Outcome: spontaneous fluency, controlled fluency,
acceptable stuttering.
Treatment for children
A.
Indirect: Capacities and Demands (Starkweather): assess impact
of oromotor, linguistic, cognitive and emotional status on speech
output: adjust environmental variables such as reducing speech
rate and linguistic complexity in the speech of others, increase
pause time, decrease demand for speech.
B.
Direct: Treat concomitant speech or language disorders; model
slow easy speech (Gregory and Hill); gradually increase length and
complexity of utterances (Ryan, Stocker).
Suggested Readings
Bennett, E.M. (2006). Working With People Who Stutter: A Lifespan
Approach. Columbus, Ohio, Pearson, Merrill, Prentice Hall.
Curlee, R.F. & Siegel, G.M. (1997). Nature and Treatment of Stuttering:
New Directions, 2nd ed.). Needham, MA: Allyn & Bacon.
Peters, T.J. & Guitar, B. (1991). Stuttering: An Integrated Approach to Its
Nature and Treatment. Baltimore, MD: Williams & Wilkins.
Starkweather, C.W. & Givens-Ackerman, J. (1997). Stuttering. Austin,
TX: Pro-ed.
Yairi, E. & Ambrose, N.G. (2005). For Clinicians By Clinicians: Early
Childhood Stuttering. Austin, TX, Pro-Ed.