There is no standard definition of stuttering, but most attempt to define stuttering as the blockages, discoordination, or fragmentations of the forward flow of speech (fluency). These stoppages, referred to as disfluencies, are often excessive and characterized by specific types of disfluency. These types of disfluencies include repetitions of sounds and syllables, prolongation of sounds, and blockages of airflow. Individuals who stutter are often aware of their stuttering and feel a loss of control when they are disfluent. Both children and adults stutterers expend an excessive amount of physical and mental energy when speaking. Older children and adults who stutter show myriad negative reactive behaviors, feelings, and attitudes. These behaviors, referred to as "secondary behaviors," make the disorder more severe and difficult.
Stuttering is a confusing and often misunderstood developmental speech and language disorder. Before discussing stuttering, it is important to understand the concepts of speech fluency and disfluency. Fluency is generally described as the forward flow of speech. For most speakers, fluent speech is easy and effortless. Fluent speech is free of any interruptions, blockages, or fragmentations. Disfluency is defined as a breakdown or blockage in the forward flow of speech, or fluency. For all speakers, some occurrence of disfluency is normal. For example, people may insert short sounds or words, referred to as "interjections," when speaking; examples of such are "um," "like," or "uh." Also, speakers might repeat phrases, revise words or phrases, or sometimes repeat whole words for the purpose of clarification. For young children, disfluency is a part of the normal development of speech and language, especially during the preschool years (between the ages of two and five years).
The occurrence of disfluency is not the same as stuttering, though stuttered speech is characterized by an excessive amount of disfluency. The disfluencies produced by people who stutter will often be similar to those in the speech of individuals who do not stutter; however, certain types of disfluent behavior are likely to appear only in the speech of people who stutter. These disfluencies are sound and syllable repetitions (i.e., ca-ca-ca-cat), sound prolongations ("sssss-salad," "ffffff-fish"), and complete blockages of airflow. These behaviors, often referred to as stuttering type disfluencies, distinguish stuttered speech from nonstuttered speech.
Unlike speakers who do not stutter, most people who stutter react negatively to their disfluencies. A person may develop a number of physical reactions, including tension of the muscles involved in speech (tongue, jaw, lips, or chest, for example) and tension in muscles not related to speech (such as shoulders, limbs, and forehead). In addition to these physiological reactions, people who stutter will often have negative emotional reactions to the disorder. Among the emotions that people who stutter report are embarrassment, guilt, and frustration.
Finally, many people who stutter will develop a number of negative attitudes and beliefs regarding themselves and speaking—because of their stuttering. These may be negative attitudes and beliefs in certain speaking situations, with people with whom they interact, and in their own abilities. These physiological, emotional, and attitudinal (cognitive) reactions to stuttering, described as secondary stuttering behaviors, are often very disruptive to the communication process and the person's life.
Stuttering behaviors can develop and vary throughout the life span. Sometimes, children will experience periods when the stuttering appears to "go away," only to return in a more severe pattern. Many children, (estimates range between 50 and 80%) will develop normal fluency after periods of stuttering. For those who continue to stutter during late childhood, adolescence, and into adulthood, stuttering can become a chronic problem. Lifelong efforts will be needed to cope successfully with the behavior.
Due to the effect that stuttering has on communication, the person who stutters may experience certain difficulties in various parts of his/her life. These problems might be secondary to factors inside the person (symptoms of stuttering) and outside the person (society's attitudes toward stuttering and other barriers). For example, many people who stutter report difficulties in social settings. Children who stutter often experience teasing and other social penalties. Adolescents and adults also report a variety of social problems. Academic settings may be difficult for children who stutter because of the emphasis schools place on verbal performance.
Finally, there appears to be some evidence that people who stutter might confront barriers in employment. These barriers might take the form of inability to do certain tasks easily (talking on the phone, for example), limitations in job choices, and discrimination in the hiring and promotion processes.
Causes and symptoms
Though research has not identified a single cause, there appears to be several factors that are viewed as being important to the onset and development of stuttering. Therefore, stuttering is often described as being related to multiple factors and having possibly multiple causes. First, there is a genetic predisposition to stutter, as evidenced by studies of families and twins. A second important factor in the onset of stuttering is the physiological makeup of people who stutter. Research suggests that the brains of people who stutter may function abnormally during speech production. These differences in functioning may lead to breakdowns in speech production and to the development of disfluent speech.
Third, there is some evidence that speech and language development is an important issue in understanding the development of stuttering. Studies have found some evidence that children who are showing stuttering type behaviors may also have other difficulties with speech-language. Additionally, children with speech-language delays will often show stuttering type behaviors. Finally, environmental issues have a significant impact on the development of stuttering behaviors. An environment that is overly stressful or demanding, may cause children to have difficulties developing fluent speech. Though the environment, in particular parental behaviors, does not cause stuttering, it is an important factor that might adversely affect a child who is operating at a reduced capacity for developing fluent speech.
There is no evidence that stuttering is secondary to a psychological disturbance. It is reasonable to assume that stuttering might have some effect on psychological adjustment and a person's ability to cope with speaking situations. People who stutter might experience a lower self-esteem and some might report feeling depressed. These feelings and difficulties with coping are most likely the result and not the cause of stuttering. In addition, several research studies have reported that many people who stutter report high levels of anxiety and stress when they are talking and stuttering. These feelings, psychological states, and difficulties with coping are most likely the result and not the cause of stuttering.
Generally, children begin to stutter between the ages of two and five years. Nevertheless, there are instances when individuals begin to show stuttering type behaviors in late childhood or as adults. These instances are often related to specific causes such as a stroke or a degenerative neurological disease. This type of stuttering, stuttering secondary to a specific neurological process, is referred to as neurogenic stuttering. In other cases, stuttering may be secondary to a psychological conversion disorder due to a psychologically traumatic event. When stuttering has abrupt onset secondary to a psychological trauma, it is described as psychogenic stuttering.
As stated earlier, the primary symptoms of stuttering include excessive disfluency, both stuttering and normal types (core behaviors), as well as physical, emotional, and cognitive reactions to the problem. These behaviors will vary in severity across people who stutter from very mild to very severe. Additionally, the behaviors will vary considerably across different speaking situations. There are specific situations when people tend to experience more stuttering (such as talking on the phone or with an authority figure) or less stuttering (speaking with a pet or to themselves, for example). It is likely that this variability might even extend to people having periods (days and even weeks) when they can maintain normally fluent or nonstuttered speech.
Stuttering is a relatively low-prevalence disorder. Across all cultures, roughly 1% of people currently has a stuttering disorder. This differs from incidence, or number of individuals who have been diagnosed with stuttering at some point in their lives. Research suggests that roughly 5% of the population has ever been diagnosed with a stuttering disorder. This difference suggests that a significant number of individuals who stutter will someday develop through or ""grow out of" the problem. Research suggests that roughly 50-80% of all children who begin to stutter will stop stuttering. In addition, approximately three times as many men stutter as women. This ratio seems to be lower early in childhood, with a similar number of girls and boys stuttering. The ratio of boys to girls appears to get larger as children become older. This phenomenon suggests that males are more likely to continue to stutter than females.
Speech-language pathologists are responsible for making the diagnosis and managing the treatment of adults and children who stutter. Preferably, a board-certified speech-language pathologist board should be sought for direct intervention or consulting. Diagnosis of stuttering, or identifying children at risk for stuttering, is difficult because most children will show excessive disfluencies in their speech. With children, diagnostic procedures include the collection and analysis of speech and disfluent behaviors in a variety of situations. In addition, the child's general speech-language abilities will be evaluated.
Finally, the speech-language pathologist will interview parents and teachers regarding the child's general developmental, speech-language development, and their perceptions of the child's stuttering behaviors. For adults and older children, the diagnostic procedures will also include gathering and analyzing speech samples from a variety of settings. In addition, the speech-language pathologist will conduct a lengthy interview with the person about their stuttering and history of their stuttering problem. Finally, the person who stutters might be asked to report his/her attitudes and feelings related to stuttering, either while being interviewed or by completing a series of questionnaires.
It is generally accepted that conducting interventions with children and families early in childhood (preschool) is the most effective means of total recovery from stuttering. The chances for a person to fully recover from stuttering by obtaining near-normal fluency are reduced as the person ages. This is why early intervention is critical. For older children and adults for which stuttering has become a chronic disorder, the focus of therapy is on developing positive coping mechanisms for dealing with the problem. This therapy varies in success based on the individual.
Treatment options for young children
Treatment of young children generally follows one of two basic approaches. These approaches may also be combined into a single treatment program. The first type of approach, often referred to as indirect therapy, focuses on altering the environment to allow the child opportunities to develop fluent speech. With this approach, counseling parents regarding the alteration of behaviors that affect fluency is the focus. For example, parents may be taught to reduce the amount of household stress or in the level of speech-language demands being placed on the child. In addition, parents may be advised to change characteristics of their speech, such as their speech rate and turn-taking style; this is done to help their children develop more fluent speech.
The other basic approach in treatment with young children targets the development of fluent speech. This type of approach, often referred to as direct therapy, teaches children to use skills that will help them improve fluency and they are sometimes given verbal rewards for producing fluent speech.
Treatment options for older children and adults
Treatment approaches for older children and adults usually take one of two forms. These approaches target either helping the person to modify his/her stuttering or modify his/her fluency. Approaches that focus on modifying stuttering will usually teach individuals to reduce the severity of their stuttering behaviors by identifying and eliminating all of the secondary or reactive behaviors. Individuals will also work to reduce the amount of emotional reaction toward stuttering.
Finally, the speech-language pathologist will help the individual to learn techniques that allow them to stutter in an easier manner. Therapy does not focus on helping the individual to speak fluently, though most individuals will attain higher levels of fluency if this approach is successful. The other groups of approaches will focus on assisting adults and children who stutter to speak more fluently. This type of therapy, which focuses less on changing secondary and emotional reactions, helps the person to modify their speech movements in a specific manner that allows for fluent sounding speech. These procedures require the individual to focus on developing new speech patterns. This often requires a significant amount of practice and skill. The successful outcome of these approaches is nonstuttered, fluent sounding speech. Many therapists will integrate stuttering modification and fluency shaping approaches into more complete treatment programs. In addition, psychological counseling may be used to supplement traditional speech therapy.
Complete alleviation of recovery from stuttering is most likely possible when children and their families receive treatment close to the time of onset. Thus, early identification and treatment of stuttering is critical. For older children and adults, stuttering becomes a chronic problem that requires a lifetime of formal and self-directed therapy. For individuals who show this more chronic form of the disorder, internal motivation for change and support from significant others is an important part of recovery.
Bloodstein, O. A Handbook on Stuttering. 5th ed., revised. San Diego, CA. Singular Publishing, 1995.
Guitar, B. Stuttering: An Integrated Approach to Its Nature and treatment. 2nd edition, text revision. Baltimore, MD: Lippincott Williams and Willkins, 1998.
Manning, W. H. Clinical Decision Making in Fluency Disorders. 2nd. ed., revised. San Diego, CA. Singular Publishing, 2001.
National Stuttering Association. 5100 East La Palma, Suite #208, Anaheim Hills, CA 92807. <http://www.nsastutter.org> .
Stuttering Foundation of America. 3100 Walnut Grove Road, Suite 603, P.O. Box 11749, Memphis, TN 38111-0749. <http://www.stuttersfa.org> .
See also Speech-language pathology
Rodney Gabel, Ph.D.