|Stuttering: Basic Information
Definition | Description | Diagnosis | Treatment | Recovery | Co-Occurring Conditions | Web links
n the most general sense, stuttering is defined as a disruption in the flow of speech. This disruption is often evident to the listener and the speaker, but it may not be. Many listeners are not able to detect the more subtle types of stuttering behavior. Many people who stutter may suffer greatly from their difficulty, but are totally unaware of the specific things they do when they stutter -- or may even not be aware of the occurrence or severity of many individual stuttering events. Developmental stuttering (the subject of this Web site) normally begins between the ages of 2 and 5 (although rarely as late as the mid-teens), and is highly changeable and dynamic in nature, varying in intensity with the speaker's perceptions of, and reactions to, his/her internal neurological state, emotional state, and external speaking environment. Acquired or neurogenic stuttering is the result of a neurological trauma or lesion and may happen at any age. Its symptoms are often more constant or stable than the developmental variety. Psychogenic stuttering is more difficult to define and diagnose, but is understood to include stuttering resulting from psychological trauma and stuttering that is associated with mental health issues.
The disruption of speech is experienced by the listener as a variety of observed speaker behaviors indicating struggle, ranging from simple repetitions and prolongations of word initial or medial sounds ("shuh-shuh-shuh sssugar"), to apparent speech attempts in which a sound is not uttered ("Please pass the ...."). The speaker may look away or close his/her eyes, grimace, move or jerk his head or limbs inappropriately. In adults or children who have been stuttering for a while, more subtle or internalized behaviors include word substitution ("Please pass the uh .. uh .. refined fructose") or circumlocution and interjection ("Please uh puh- could you ah puh- could I ha- uh could I ah hhhave th uh the ah shu- ah shuh- ah shuh- ah ruh-ruh-ruh-refined ah fruh-fruh-fruh fffruhooctose.") The struggle may look like the speaker is having difficulty "getting words out of his mouth," or (alternatively) that he/she is unaccountably or "illogically" disrupting or blocking the flow of his/her own speech.
To the stutterer, stuttering is a feeling that the intended speech sound cannot be produced or that the sound or the intended gesture is "stuck." This perception involves a feeling of loss of control over speech movements. The speaker tries to make his tongue move to the top of his mouth to form a "d" sound, but simply cannot at that moment. Or tries to stop going "zzzzzzz" and move on to the "oo" sound in "zoo," but cannot figure out how to do that. Often, these failures of movement and transition are accompanied by a mental fuzziness or even unconsciousness (petit mort.) Sometimes they are not remembered at all. At other times, the events may seem to be intense and interminable. Many of the extraneous features of stuttering, including hand, arm, head, mouth and eye movements, are used by the speaker to escape from the feeling of blocking or being stuck. Over time, these movements become classically conditioned by the intermittent reward of occasionally actually helping the person break out of the block.
|Diagnosing and Evaluating Stuttering
While it is important for both adults and children to have speech disruptions evaluated for evidence of stuttering, this is particularly crucial for children in the critical speech development years of 2.5 to 4. When possible stuttering is concerned, no pediatrician who counsels parents to wait for a child to "grow out of" stuttering should be heeded (although waiting for several days or weeks may not be too risky) before obtaining a diagnosis from a speech-language pathologist.
A child still stuttering through the fifth year of life is increasingly unlikely to recover complete fluency on his/her own. Achieving success through therapy may also be more difficult. This does not mean that such a child is "condemned" to a life of stuttering and there is certainly no reason for panic -- or justification for not intervening because it is "too late." It is never too late to begin stuttering therapy.
An evaluation for stuttering will usually involve 1) the collection of background speech, developmental and medical information from the parents or the adult client, 2) evaluation of speech samples collected in a variety of situations, including oral reading, conversation, and a spontaneous extended monologue, 3) administration of an age-appropriate instrument to capture the person's responses to questions which help to measure stuttering-specific health-related quality of life issues, and 4) preparation of a written report, often using a diagnostic tool like the Stuttering Severity Index - IV (SSI-4), in which the severity of stuttering and the severity of the observed secondary behaviors are documented. The evaluator will often use the results of previously given phonological tests and (if there are obvious structural issues or voice irregularities) oral peripheral examinations. However, these should be performed if they have not previously been. Supporting evaluations by a psychologist or psychiatrist or a voice specialist or ENT may be used or requested by the speech-language pathologist in some cases.
It is crucial that the therapist attempt to differentiate stuttering from speech behaviors associated with co-occurring conditions and/or to determine the impact of those conditions on fluency, as this will have an important influence on subsequent therapy.
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|Treatment of Stuttering
Professional treatment for stuttering is provided by speech-language pathologists (SLPs) in the United States and by other types of specialists elsewhere. Public schools may not provide treatment for stuttering unless the SLP is able to show that the child's speech disability is negatively affecting her or her academic performance. Private practitioners provide diagnostic services for $100 to $300 and offer therapy services at prices ranging from $50 to $150 per session, depending on local factors. Children's hospitals may charge $150 or more. Most insurance companies will not routinely provide coverage for stuttering therapy, but clinicians will often assist clients in trying to obtain it, (usually unsuccessfully.)
The frequency of treatment desired at the outset is two or three times per week, tapering down to once per week for the bulk of therapy and once per month or so during the stabilization phase at the end of treatment. The duration of successful stuttering treatment depends upon the client, but normally ranges from several weeks or months (for some pre-schoolers) to one year or more. Some children may require continued therapy for years. Some adults may require 12 to 36 months of treatment before they are ready to manage their own fluency. A figure of 100 hours of therapy is sometimes used as a rough rule of thumb for older children and adults. "Intensive programs" that promise complete success in three weeks may require retaking the 3-week course or attending refresher sessions over a period of years. Such programs may therefore actually involve 250 or even more hours of therapy, although this is usually not "hands-on" therapy.
There are several treatment approaches for stuttering that may provide relief to varying degrees. The primary techniques are fluency shaping and stuttering modification. In fluency shaping, several "fluency enhancing" techniques are employed, including slow rate speech, gentle onsets of the voice, elongated initial sounds ("slides" or "stretches"), and maintaining nearly continuous vibration of the vocal folds during speech. Fluency shaping commonly targets laryngeal "blockage," which refers to the feeling that speech is blocked due to the vocal folds being held closed or open in a tensed manner that cannot be automatically resolved. The objective of fluency shaping is fluent speech or speech without blocking.
In stuttering modification therapy, the client is encouraged to change the pattern of stuttering as it is occurring using such techniques as voluntary stuttering, freezing of the stuttering moment and relaxation of the speech muscles during stuttering (pull-outs), slow and easy bounces of initial sounds, exaggerated smooth mouth movements during speech, "preparatory sets" which allow the person to relax and deal with anxiety before speaking, and cancellations or repairs of stuttered words after they are spoken. Stuttering modification targets the articulators (tongue, jaw, lips, etc.) as well as laryngeal tension. The speech target for stuttering modification is an easier and more fluid form of speaking, which may mean an easier form of stuttering.
The integrated or individualized approach combines fluency shaping and stuttering modification, based on the client's age, the severity and dynamics of the person's stuttering, and other key characteristics.
The ultimate clinical objective of all stuttering therapy is improved speech communication, and an increased ability to manage stuttering and the person's reactions to it, not necessarily fluent speech.
|Success, Failure, and Recovery
Successful stuttering therapy cannot be equated with complete fluency or a "cure" for stuttering. Because developmental stuttering is not a disease caused by a virus, bacteria, or physical injury, there is no cure. This type of stuttering is a unique and specific developmental and psycho-neurological behavior involving a physical predisposition that is triggered and neurologically conditioned by internal reactions to an extended cycle of repeated performance failures, environmental stressors, and psychological injury. The extended duration of the neurological conditioning involved in the development of stuttering (from several months to many decades) places it in the category of disorders (including post traumatic stress disorder) that can be extinguished to varying degrees, but (according to recent research) not totally erased. Although neurological traces of such classical conditioning cannot be totally eliminated, therapy can largely extinguish -- or help the person who stutters to manage -- the negative effect of this conditioning on fluency and communication in many cases. Some people (particularly pre-school children) may be able to totally recover their original fluency. Other people may experience relatively little change in fluency, but achieve an increased ease of communication. Others may attain a remarkable degree of fluency and communicative ease in many or most situations. There are many gradations.
While what actually occurs during stuttering therapy is not often explained or acknowledged, it is the premise here that increased fluency results from de-conditioning stuttering responses and reactions to various speech gestures, sensory stimuli (most importantly auditory and kinesthetic feedback), and environmental factors that serve as triggers for an automatic inhibition or disruption of speech initiated by the person's internal threat detection, evaluation, and response system. This occurs in various ways, depending upon the therapy approach. Those interested in this process are invited to continue the exploration in the Veils of Stuttering and the paper Stuttering as a Reactive Inhibition of Speech.
Stuttering may co-occur with virtually any condition, however, some are more problematic for therapy and communication. More common ones include cluttering, articulation or phonological disorders, ADHD and ADD, apraxia of speech, Asperger's syndrome, cerebral palsy, Down syndrome and Tourette syndrome.
Stuttering may also co-occur with a fluency disorder called cluttering, which has been known about for years but not seriously addressed by speech-language pathologists until quite recently.
© 1994 - 2014 Darrell M. Dodge, M.A., CCC-SLP
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Last Updated: Saturday, January 10, 2015