Stuttering

Definition

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.

Description

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.

Demographics

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.

Diagnosis

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.

Treatments

General considerations

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.

Prognosis

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.

Resources

BOOKS

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.

ORGANIZATIONS

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.

Stuttering

Definition

Stuttering is a speech problem characterized by repetitions; pauses; or drawn-out syllables, words, and phrases. Stutterers are different than people experiencing normal fluency problems because a stutterer's disfluency is more severe and consistent than that of people who do not stutter.

Description

Normal language development in a child usually includes a period of disfluency. Children might repeat syllables or words once or twice. Sometimes, children experiencing normal disfluencies hesitate during speech or use fillers, including "um," with frequency. These developmental problems usually happen between one and five years of age. Often, parents are concerned about the disfluency they hear in their children.

A child with mild stuttering, however, will repeat sounds more than twice. Parents and teachers often notice the child's facial muscles become tense and he or she might struggle to speak. The child's voice pitch might rise with repetitions, and some children experience occasional periods when airflow or voice stops for seconds at a time. Children with more severe stuttering stutter through more than 10 percent of their speech. This child exhibits considerable tension and tries to avoid stuttering by using different words. In these children, complete blocks of speech are more common than repetitions or prolongations, during which children lengthen syllables or words.

Stuttering does not affect intelligence . Teens often experience more noticeable problems with stuttering as they enter the dating scene and increase their social interactions. Stuttering can severely affect one's life. Often, adults who are concerned about stuttering choose their careers based on the disability.

The degree of stuttering is often inconsistent. Stutterers can be fluent in some situations. Many find that they stop stuttering when singing or doing other activities involving speech. Some have good and bad days when it comes to stuttering. On good days, a stutterer might be able to talk fluently using words that usually cause him to repeat, pause or prolong sounds, syllables, parts of words, entire words, or phrases.

Demographics

More than 3 million Americans stutter and four times more males are affected than females. Stuttering usually begins in childhood when the child is developing language skills, and it rarely develops in adulthood with only 1 percent of the population affected by the disorder. Approximately 25 percent of all children experience speech disfluencies during development that concern their parents because of their severity.

Causes and symptoms

There is no known cause of stuttering. Some believe that it has a physical cause and that it might be related to a breakdown in the neurological system. Stuttering starts early in life and often is inherited. Brain scan research has revealed that there might be abnormalities in the brains of stutterers, while they are stuttering. Myths about why stuttering occurs abound. Some cultures believe that stuttering is caused by emotional problems, tickling an infant too much, or because a mother ate improperly during breastfeeding. None has been proven to be true. It is believed that some drugs might induce stuttering-like conditions. These include antidepressants , antihistamines , tranquilizers, and selective serotonin reuptake inhibitors.

When to call the doctor

The child's doctor should be contacted if parents have concerns about the speech patterns of their child. The doctor may refer parents to a speech-language specialist for evaluation if needed.

Diagnosis

Speech and language therapists diagnose stuttering by asking stutterers to read out loud, pronounce specific words, and talk. Some also order hearing tests. The tests will determine whether a person needs speech therapy.

Treatment

As of 2004, researchers did not understand what causes stuttering. However, progress has been made regarding what contributes to the development of the disability; therefore, in some cases it can be prevented in childhood with the help of therapy early on. Therapy can help people of all ages suffering from the speech disability. While not an overnight cure, therapy can offer positive results and more fluent speech patterns. The goals of therapy are for the stutterer to reduce stuttering frequency, decrease the tension and struggle of stuttering, become educated about stuttering, and learn effective communications skills, such as making eye contact, to further enhance speech. The therapy focuses on helping stutterers to discover easier and different ways of producing sounds and expressing thoughts. The success of therapy depends largely on the stutterer's willingness to work at getting better.

The duration of stuttering therapy needed varies among stutterers. Sometimes, stutterers find intermittent therapy useful throughout their lives.

Parents, teachers and others can help ease stuttering. These include: talking slowly, but normally, clearly, and in a relaxed manner to a stutterer; answering questions after a pause to encourage a relaxed transaction; trying not to make stuttering worse by getting annoyed by a person's stuttering; giving stutterers reassurance about their stuttering; and encourage the stutterer to talk about his or her stuttering.

Electronic fluency aids help some stutterers when used as an adjunct to therapy. Medications, such as antipsychotics and neuroleptics, have been used to treat stuttering with limited success.

Some people use relaxation techniques to help their stuttering.

Prognosis

As of the early 2000s no answers had been found to explain the causes of stuttering; still, much has been learned about what contributes to stuttering's development and how to prevent it in children. People who stutter can get better through therapy. Winston Churchill, Marilyn Monroe, Carly Simon, James Earl Jones, and King George VI were childhood stutterers who went on to live successful professional lives.

Prevention

The location of some genes appears to predispose people to stuttering. While genetic factors do not explain all stuttering, genetics may help to uncover the disability's causes. Speech therapy, especially that performed at a young age, can stop the progression of stuttering.

Parental concerns

Many children experience brief episodes of stuttering. In many cases, these are transitory and disappear without treatment. Parents should be aware that some stuttering is quite normal when a child feels under pressure to talk. Thus, parents should wait to allow the child to communicate at his or her own speed, and not pressure the child to talk or make fun of the stutter.

KEY TERMS

Antipsychotic drug —A class of drugs used to control psychotic symptoms in patients with psychotic disorders such as schizophrenia and delusional disorder. Antipsychotics include risperidone (Risperdal), haloperidol (Haldol), and chlorpromazine (Thorazine).

Disfluency —An interruption in speech flow.

Neuroleptics —Antipsychotic drugs that affect psychomotor activity.

Resources

BOOKS

Boethe, Anne K. Evidence-Based Treatment of Stuttering: Empirical Bases, Clinical Applications, and Remaining Needs. Mahwah, NJ: Lawrence Erlbaum Associates, 2004.

Hulit, Lloyd M. Straight Talk on Stuttering: Information, Encouragement, and Counsel for Stutterers, Caregivers, and Speech-Language Clinicians. Springfield, IL: Charles C. Thomas, 2004.

Kent, Susan. Let's Talk about Stuttering. New York: Rosen Publishing Group, 2003.

Ramig, Peter R., and Darrell Dodge. The Child and Adolescent Stuttering Treatment and Activity Resource Guide. Albany, NY: Delmar, 2005.

PERIODICALS

Altholz, S., and M. Golensky. "Counseling, support, and advocacy for clients who stutter." Health and Social Work 29, no. 3 (2004): 197–205.

Maguire, G. A., et al. "Alleviating stuttering with pharmacological interventions." Expert Opinion on Pharmacotherapy 5, no. 7 (2004): 1565–71.

Messenger, M., et al. "Social anxiety in stuttering: measuring negative social expectancies." Journal of Fluency Disorders 29, no. 3 (2004): 201–12.

Michel, V., et al. "Stuttering or reflex seizure?" Epileptic Disorders 6, no. 3 (2004): 193–215.

Viswanath, N., et al. "Evidence for a major gene influence on persistent developmental stuttering." Human Biology 76, no. 3 (2004): 401–12.

ORGANIZATIONS

American Academy of Audiology. 8300 Greensboro Dr., Suite 750, McLean, VA 22102. Web site: <www.audiology.org/>.

American Speech-Language Hearing Association. 10801 Rockville Pike, Rockville, MD 20852. Web site: <www.asha.org/>.

WEB SITES

"Stuttering." National Institute on Deafness and Other Communication Disorders, May 2002. Available online at <www.nidcd.nih.gov/health/voice/stutter.asp> (accessed January 9, 2005).

"Stuttering." National Library if Medicine. Available online at <www.nlm.nih.gov/medlineplus/stuttering.html> (accessed January 9, 2005).

"Stuttering Information." Stuttering Foundation of America. Available online at <www.stutteringhelp.org/> (accessed January 9, 2005).

"Stuttering Support." The National Center For Stuttering. Available online at <www.stuttering.com/>(accessed January 9, 2005)..

"Stuttering Support." The National Stuttering Association. Available online at <www.nsastutter.org/> (accessed January 9, 2005).

L. Fleming Fallon, Jr., MD, DrPH

Stuttering

Definition

Stuttering is a speech problem characterized by repetitions, pauses, or drawn out syllables, words, and phrases. Stutterers are different than people experiencing normal fluency problems because a stutterer's disfluency is more severe and consistent than that of people who do not stutter.

Description

Normal language development in a child can include a period of disfluency. Children might repeat syllables or words once or twice. Sometimes, children experiencing normal disfluencies hesitate during speech or use fillers, including "um," with frequency. These developmental problems usually happen between one and five years of age. Often, parents are concerned about the disfluency they hear in their children. In fact, about 25% of all children experience speech disfluencies during development concern their parents because of their severity.

A child with mild stuttering, however, will repeat sounds more than twice. Parents and teachers often notice the child's facial muscles become tense and he or she might struggle to speak. The child's voice pitch might rise with repetitions, and some children experience occasional periods when airflow or voice stops for seconds at a time. Children with more severe stuttering stutter through more than 10% of their speech. This child exhibits considerable tension and tries to avoid stuttering by using different words. In these children, complete blocks of speech are more common than repetitions or prolongations, during which children lengthen syllables or words.

Stuttering usually begins in childhood when the child is developing language skills, and it rarely develops in adulthood with only 1% of the population affected by the disorder. Stuttering does not affect intelligence. Teens often experience more noticeable problems with stuttering as they enter the dating scene and increase their social interactions. Stuttering can severely affect one's life. Often, adults who are concerned about stuttering choose their careers based on the disability.

The degree of stuttering is often inconsistent. Stutterers can be fluent in some situations. Many find that they stop stuttering when singing or doing other activities involving speech. Some have good and bad days when it comes to stuttering. On good days, a stutterer might be able to talk fluently using words that usually cause him to repeat, pause or prolongate sounds, syllables, parts of words, entire words, or phrases.

Causes and symptoms

There is no known cause of stuttering. Some believe that it has a physical cause and that it might be related to a breakdown in the neurological system. Stuttering starts early in life and often is inherited. Brain scan research has revealed that there might be abnormalities in the brains of stutterers, while they are stuttering. Myths about why stuttering occurs abound. Some cultures believe that stuttering is caused by emotional problems, tickling an infant too much or because a mother ate improperly during breastfeeding. None have been proven to be true. It is believed that some drugs might induce stuttering-like conditions. These include antidepressants, antihistamines, tranquilizers and selective serotonin reuptake inhibitors.

Diagnosis

Speech and language therapists diagnose stuttering by asking stutterers to read out loud, pronounce specific words, and talk. Some also order hearing tests. The tests will determine whether or not a person needs speech therapy.

Treatment

Researchers don't understand what causes stuttering. However, progress has been made into what contributes to the development of the disability and, therefore, in some cases it can be prevented in childhood with the help of therapy early on. Therapy can help people of all ages suffering from the speech disability. While not an overnight cure, therapy can offer positive results and more fluent speech patterns. The goals of therapy are to reduce stuttering frequency, decrease the tension and struggle of stuttering, become educated about stuttering, and learn to use effective communications skills, such as making eye contact, to further enhance speech. The therapy focuses on helping stutterers to discover easier and different ways of producing sounds and expressing thoughts. The success of therapy depends largely on the stutterer's willingness to work at getting better.

The duration of stuttering therapy needed varies among stutterers. Sometimes, it helps stutterers if they have therapy intermittently throughout their lives.

Parents, teachers and others can do things to help ease stuttering. These include: talking slowly, but normally, clearly, and in a relaxed manner to a stutterer: answering questions after a pause to encourage a relaxed transaction; trying not to make stuttering worse by getting annoyed by a person's stuttering; giving stutterers reassurance about their stuttering; and encourage the stutterer to talk about his or her stuttering.

Electronic fluency aids help some stutterers when used as an adjunct to therapy. Medications, such as antipsychotics and neuroleptics, have been used to treat stuttering with limited success.

Alternative treatment

Some use relaxation techniques to help their stuttering.

KEY TERMS

Antipsychotics— A class of drugs used to treat psychotic or neurotic behavior.

Disfluency— An interruption in speech flow.

Neuroleptics— Antipsychotic drugs that affect psychomotor activity.

Prognosis

More than three million Americans stutter and four times more males are affected than females. Winston Churchill, Marilyn Monroe, Carly Simon, James Earl Jones and King George VI are among the many people who stuttered but went on to live successful professional lives. Decades of research have yielded no answers to the causes of stuttering; still much has been learned about what contributes to stuttering's development and how to prevent it in children. People who stutter can get better through therapy.

Prevention

New and exciting developments are occurring in researchers' understanding of the genetics of stuttering. Researchers are finding the locations of genes that predispose people to stuttering. While genetic factors will not explain all stuttering, genetics will help to uncover the disability's causes. Speech therapy, especially that performed at a young age, can stop the progression of stuttering.

Resources

ORGANIZATIONS

National Stuttering Foundation of America. 1-(800) 992-9392. 〈http://www.stutteringhelp.org〉.

OTHER

The Stuttering Home Page. Minnesota State University, Mankato. 〈http://www.mandato.msus.edu/deprt/comdis/kuster/stutter.html〉.

"Stuttering." The Nemours Foundation, KidsHealth.org. 〈http://kidshealth.org〉.

"What is Stuttering?" Robert W. Quesal, PhD, Professor and Program Director. Communications Sciences and Disorders. Western Illinois University. 〈http://www.wiu.edu〉.

stuttering Stuttering (or stammering, as it is often called in Britain) is probably the best known and most researched speech disorder, but perhaps the most difficult to define, to explain, and to treat, especially in adults. Both names are onomatopoeic: the essential features of stuttering are frequent repetitions and prolongations of sound or syllables. Other problems of fluency may also characterize stuttering, including blocking of sounds or interjection of words or sounds. However, the sudden sensation of a loss of control over the ability to produce an utterance distinguishes stuttering from other forms of unfluent speech. Another characteristic of stutterers, especially adults, is their avoidance of anticipated problem words and situations, in order to cope with the problem.

Chronic stuttering usually begins in early childhood (development stuttering), although occasionally the disorder starts in adulthood (acquired stuttering), usually as a result of brain damage. Stuttering seems to occur in all nationalities with a prevalence of approximately 1% and an incidence of 4% to 5%. Approximately 40% to 80% of children with the disorder recover, for various reasons, by the time they reach adolescence or adulthood. More males than females stutter: the ratio of males to female stutterers ranges from 2–3:1 in childhood, up to 4–5:1 by adulthood. The incidence of the disorder is much higher among other members of the family of a stutterer than in the general population: in other words, there is probably a genetic factor in this condition.

Stuttering may vary greatly in its frequency and severity in different situations. It is, for instance, dramatically reduced when speaking alone or reading aloud in chorus with an accompanist. Wearing headphones that alter the feedback of one's own voice can also reduce stuttering, and so too can the use of certain regular speech patterns (e.g. singing, unusual accents, speaking in rhythm). The reliability with which such techniques for inducing fluency can reduce or even abolish stuttering is considered a key to understanding the disorder — they also form the basis of some treatments.

The social and vocational effects of chronic stuttering may be quite devastating, perhaps because of the suspicion that it is the outward sign of a personality disorder. However, there is remarkably little evidence that stuttering is related to any unusual personality characteristics or neuroses; and there is little support for the claim that stuttering is associated with anxiety. Many prominent individuals, including well-known actors and politicians, have managed to control their stuttering and achieve successful careers. Nevertheless, the handicapping effects of the disorder in children and adults are undeniable.

There is currently no accepted theory that offers a satisfactory explanation for all the features of stuttering. At different times, psychoanalytic or organic theories have held sway over research and/or therapy. Traditional, formal learning has been blamed; so too have errors in control systems in the brain. Most current researchers consider developmental stuttering to be a disorder of motor control, with strong genetic underpinnings, influenced by environmental factors. This position has gained support with evidence that signs of severe stuttering may appear almost as soon as a child starts to produce connected speech.

Recent studies of right-handed adult stutterers, using techniques for imaging activity in the brain, have revealed unusual patterns of activation and inhibition during stuttered speech, particularly in parts of the right hemisphere involved in hearing and the control of movement, and especially exaggerated in the cerebellum. The unusual activity in these regions, which appears to occur only during speech, is very different when stuttering is reduced or absent as a result of strategies for improving fluency. These findings have intensified the search for a neurological system or systems that might be specifically related to stuttering.

The treatment of stuttering is an area of controversy. There is no evidence that any drug treatment is effective in removing stuttering in children or adults. The most convincing effects have been reported for behavioural treatments, although there is much debate about the evaluation of such therapy. Other forms of treatment emphasize learning to adjust to the disorder rather than removing the problematic behaviour.

Probably the most dramatic change to therapy for stuttering in the last decade is the use of mild verbal corrections for each occasion of stuttering, and verbal praise for periods of fluency, which has beneficial effects in treating young children. Recovery commonly occurs without treatment in the first year after onset, but this becomes less likely without intervention if the disorder persists. Indeed, there is an urgent need to correct the widely-held belief that children will recover from stuttering if their problem is merely ignored. Currently, the preferred therapies for older stutterers involve a combination of behavioural techniques and methods for training speech–motor strategies. However, there is no convincing evidence that these therapies result in complete recovery.

The most successful therapeutic approaches for adults and children involve three general features: first, a method that establishes reduced stuttering or stutter-free speech under relatively controlled conditions; then a procedure for transferring that improvement beyond the treatment setting; and finally, strategies for maintaining that improvement. The most favoured techniques for establishing control over stuttering fall into three categories: behavioural methods based on rewarding performance; teaching stutterers to prolong their speech; and mechanical aids. These techniques are also often used in conjunction with control of the rate of speaking. Once improvement has been produced in the controlled conditions, ‘transfer’ procedures are used, which systematically introduce increasingly demanding speaking situations. The most successful maintenance procedures require intermittent management over periods lasting up to two or three years. Given the variability of stuttering across situations, over time, and with relatively slight alterations to the manner of speech production, stuttering therapy evaluation presents considerable challenges, which are now occupying the attention of clinical researchers.

Roger J. Ingham

Bibliography

Bloodstein, O. (1995). A handbook on stuttering. Singular, San Diego, CA.
Fox, P. T.,, Ingham, R. J.,, and Ingham, J. C., et al. (1996). A PET study of the neural systems of stuttering. Nature, 382, 158–62.

STAMMERING

Stammering is a disorder in the rate of speech delivery. It appears in the communication patterns of children aged between two and five and is characterized by repetitions or blockages that lead to ruptures in the rhythm and melody of speech. Three out of four children are destined to overcome it before adolescence. Stammering is a universal complaint and has been documented in the most ancient cultures.

Sigmund Freud associated this type of disorder with hysteria, but classified it separately as a fixation neurosis (on an organ [of speech]). Otto Fenichel located this functional speech disorder in the group of pregenital conversion neuroses. The patient's mental structure was the same as that of an obsessive, whereas the symptomatology was of the conversion type. Speech had acquired an unconscious significance related either to its verbal content or to the general meaning of the function of "speaking" itself, as in severe cases of stammering in which the speech act represents a reprehensible drive.

Bernard Barrau draws attention to the frequent presence of situations of oral violence in these cases, and fantasies of "forcible introduction," whether in relation to forced food or its metaphorical equivalents (the voice and speech of the mother). Ivan Fonagy stresses the fact that speech is capable of absorbing narcissistic, oral, anal, or genital libido, and reports observations of parallel strategies in the anal and glottal sphincter (stammering when establishing sphincter control), and upward transfers of anal libdinal cathexis (one of Charlotte Balkany's patients identified resonant air with air emitted by the anal sphincter). René Diatkine points to the absence of a psychic structure specific to stammering subjects, whose symptom, as a disorder in verbal communication, modifies their relational system, particularly the balance between narcissistic- and object-cathexes.

Annie Anzieu traces the elements in the neurotic dynamics of stammering subjects. An anal-sadistic relation is often established between the (grasping and abusive) mother and the child, with the child fixating on a dual, merging relation with the mother, excluding all connections to a third object, unless it takes part in the mother-child whole. Stammerers thus have difficulty in engaging oedipal problems. Supervisions must be redoubled in order to integrate oedipal prohibtions into the ego, because what enters the body or comes out of it assumes a new erotic meaning. The speech act permanently alludes to castration anxiety. This relational mode leads to the persistence of what Melanie Klein calls the paranoid-schizoid position. Indeed the stammerer is persecuted by a particularly demanding father and mother. All verbal emissions are problematic. Like feces, words are experienced as aggressive objects whose true intentions may be to wound or kill. They become the concrete symbols of interiorized aggressive objects. These paranoid characteristics entail a considerable obsessional element as well. Stammerers exhaust their discourse to the point of fragmentation; they remain haunted by the specific words they should be saying. Obsessional cathexis of discourse can be understood in the process of neurotic construction as a superegoic symptom in relation to the hysterical symptom stammering constitutes. The phonetic dysfunction and suffering caused by verbal emission are a form of hysterical conversion, a conversion that lends genital significance to an originally anal-sadistic symptom. The stammerer expresses the conflict he has always experienced through his symptom; the subject hides behind it. The act of speaking conceals what is said. The psychotherapy or psychoanalysis of stammerers always evinces these hysterical, obsessional, and paranoid contents in a more or less typical fashion depending on the moment in treatment and patient in question. For Nicole Fabre, stammering is an archaic difficulty shot through with oral aggressivity and anal sadism, from which the subject has not yet been able to break free in order to fully accede to oedipal triangulation.

Although psychoanalytic treament is rarely indicated initially, especially with children, this approach does provide an understanding of the disorder that does not exclude its meaning from the outset.

The etiology of stammering is unknown. Constitutional factors interact with environmental ones in addition to factors linked to the personal dynamics of the child in varying proportions depending on the subject in question, thus illustrating the uniqueness of the trouble each stammerer faces.

Christian Payan

See also: Tics.

Bibliography

Anzieu, Annie. (1989). De la chair au verbe. In Psychanalyse et langage: Du corpsà la parole (pp. 103-127). Paris: Dunod. (Original work published 1977)

Barrau, Bernard. (1989). Begaiement et violence orale. In Psychanalyse et langage: Du corps à la parole. Paris: Dunod. (Original work published 1977)

Fabre, Nicole. (1986). Des cailloux plein la bouche. Paris: Fleurus.

Fenichel, Otto. (1953). Respiratory introjection. In The collected papers, first series. New York, W.W. Norton.

Fonagy, Ivan. (1983). La Vive Voix: essais de psycho-phonétique. Paris: Payot.

Freud, Sigmund, and Breuer, Josef. (1895d). Studies on hysteria. SE, 2: 48-106.

stuttering or stammering, speech disorder marked by hesitation and inability to enunciate consonants without spasmodic repetition. Known technically as dysphemia, it has sometimes been attributed to an underlying personality disorder. About half of all those who have speech and voice defects suffer from stuttering or stammering (the terms are used interchangeably). In 65% of people who stutter, there is a family history of the disorder, thus suggesting a genetic link. Studies with twins have also indicated that inheritance has an important role in stuttering; comparing pairs in which at least one twin stuttered, it has been found that identical twins were much more likely to be stutterers than fraternal twins (see multiple birth ). Brain scans of stutterers have found higher than normal activity in brain areas that coordinate conscious movement, suggesting that in people who stutter speech occurs less automatically than it does in most people.

In many instances the speech disturbance appears to be precipitated by such situations as a change of surroundings, the advent of a younger child in the family, or by a family environment in which parents are overly concerned with childhood speech interruptions, which occur normally. Negative reactions to the stuttering frequently create feelings of inadequacy and anxiety, which, in turn, intensify the condition. Parents with young children who stutter have been urged by specialists to help their children develop positive attitudes about themselves and their speech. Older stutterers are taught to understand what processes interfere with fluent speech and to speak without the disruptions caused by tension. Psychiatric treatment and group psychotherapy have been helpful for many.

Bibliography: See M. Jezer, Stuttering: A Life Bound Up in Words (1997).

Stuttering

What Is Stuttering?

What Causes Stuttering?

How Is Stuttering Linked to Fear?

How Is Stuttering Diagnosed?

How Is Stuttering Treated?

Resources

Stuttering is a speech disorder in which the normal flow of speech is broken by sounds that are repeated or held longer than normal, or by problems with starting a word.

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Communication disorders

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People who stutter may repeat a speech sound over and over (st-st-stuttering), or they may hold a sound longer than normal (sssssstuttering). In some cases, they may have trouble starting a word, leading to abnormal stops in their speech (no sound). Yet many people who stutter learn to control the problem. The list of famous people in history who overcame stuttering includes Isaac Newton, Charles Darwin, Clara Barton, King George VI of England, Winston Churchill, and Marilyn Monroe.

What Is Stuttering?

Stuttering is a speech disorder in which the normal flow of speech is broken. Along with the effort to speak, some people who stutter also make unusual face or body movements, such as rapid eye blinking or trembling of the lips. Certain situations, such as speaking on the phone, tend to make stuttering worse. On the other hand, people usually do not stutter when they sing, whisper, or speak as part of a group, or when they do not hear their own voices. No one is sure why this is so.

Most children go through a stage of choppy speech when they are first learning to talk. In addition, teenagers and adults often add extra sounds (for example,“uh”and“um”) to their speech, and they occasionally repeat sounds. This is perfectly normal. Such problems are considered a disorder only when they last past the age when most children outgrow them and get in the way of communicating clearly. Treating stuttering even in young children may help prevent a lifelong problem. Treatment may be considered for children who stutter longer than 6 months or for those who seem to struggle when they speak. Sometimes, however, no treatment is the best treatment, especially in the case of children whose stuttering worsens when attention is focused on the problem.

What Causes Stuttering?

Stuttering usually begins between the ages of 2 and 6 years. About 1 percent of children stutter, and boys are three times more likely to do so than girls. The most common form of stuttering is thought to arise when children’s developing speech and language abilities are not yet able to keep up with their needs. Stuttering occurs when they search for the right word. This kind of stuttering usually is outgrown.

Being a Good Listener

When talking to someone who stutters, you should:

• Be patient. Do not finish sentences or fill in words for the person. This might be taken as an insult, or you might guess the wrong words.
• Make normal eye contact. Try not to look embarrassed or concerned.
• Be understanding. Do not make remarks such as“slow down”or“relax.”The person probably has tried this already, so your comments will not help.
• Set a relaxed pace. Try to keep your own speech at a medium speed.
• Be sensible. If you do not understand what someone says, politely ask the person to repeat it. This is better than risking a misunderstanding.

Another form of stuttering is caused by signal problems between the brain and the nerves or muscles involved in speech. The brain is unable to control all the different parts of the speech system. This kind of stuttering sometimes is seen in people who have had a stroke or brain injury. Yet another, less common form of the disorder is caused by severe stress or some types of mental illness. Some kinds of stuttering seem to run in families, and it is likely that stuttering is genetic* (je-NE-tik) in some cases, although no gene for stuttering has been found yet.

* genetic

means having to do with genes, which are chemical substances that help determine a person’s characteristics such as hair or eye color, and also determine some health conditions. Genes are contained in the chromosomes, threadlike structures found in the cells of the body. A person’s genes are inherited from his or her parents.

How Is Stuttering Linked to Fear?

Contrary to popular belief, there is no evidence that stuttering is caused by anxiety (ang-ZY-e-tee), an intense, long-lasting feeling of fear, worry, or nervousness. Yet people who stutter may become fearful of meeting new people, speaking in public, or talking on the phone. In such cases, it is the stuttering that causes the fear, not the reverse.

How Is Stuttering Diagnosed?

Stuttering usually is diagnosed by a speech-language pathologist (paTHAH-lo-jist), a professional who is specially trained to test and treat people with speech, language, and voice disorders. The speech pathologist will ask questions about the problem, such as when it first started and when it is most and least noticeable. The speech pathologist also will test speech and language abilities. In addition, some people may be sent to other professionals for hearing tests and medical tests of the nervous system.

How Is Stuttering Treated?

There are several treatments that may improve stuttering, although none is an instant cure. With young children, the focus often is on teaching parents how to help the child at home. Parents typically are told to have a relaxed attitude and give their children plenty of chances to speak. They may be warned not to criticize their children’s speech problems or even not to pay attention to them at all. Instead, they can be good role models, speaking in a slow, relaxed manner themselves and listening patiently when their children talk.

With older children, teenagers, and adults, speech therapy can help them relearn how to speak or unlearn faulty ways of speaking. Some people who stutter have fears related to the disorder, such as a fear of speaking in public. Such problems caused by the stuttering can be helped with psychotherapy (sy-ko-THER-a-pea), in which people talk about their feelings, beliefs, and experiences with a mental health professional who can help them work out issues that play a part in their speech problems.

See also

Anxiety and Anxiety Disorders

Selective Mutism

Social Anxiety Disorder

Resources

Books

De Geus, Eelco. Sometimes I Just Stutter. Mempis, TN: Stuttering Foundation of America, 1999. This book tells young people about the causes of stuttering and discusses the fears and embarrassment of people who stutter. It is available to buy or to read at the foundation’s website: http://www.stuttersfa.org.

Sugarman, Michael, and Kim C. Swain. The Adventures of Phil Carrot: The Forest of Discord. Anaheim, CA: National Stuttering Association, 1995. This is the story of an unusual day in the life of a boy who stutters and his classmates.

Organizations

American Speech-Language-Hearing Association, 10801 Rockville Pike, Rockville, MD 20852. This professional association for speech-language pathologists offers reliable information on stuttering. Telephone 800-638-TALK http://www.asha.org

National Stuttering Association, 5100 East La Palma, Suite 208, Anaheim, CA 92807. This organization is the largest self-help and support group in the United States for people who stutter. Telephone 800-364-1677 http://www.nsastutter.org

Stuttering Foundation of America, 3100 Walnut Grove Road, Suite 603, P.O. Box 11749, Memphis, TN 38111-0749. This nonprofit group works toward the prevention and improved treatment of stuttering. Telephone 800-992-9392 http://www.stuttersfa.org

U.S. National Institute on Deafness and Other Communication Disorders, 31 Center Drive, MSC 2320, Bethesda, MD 20892-2320. This government institute is a source of facts and figures on stuttering.
Phone 301-496-7243 http://www.nih.gov/nidcd

stammering (stuttering) (stam-er-ing) n. halting articulation with interruptions to the normal flow of speech and repetition of the initial consonants of words or syllables. The symptoms are most severe when the stammerer is under any psychological stress. Medical name: dysphemia.
—stammerer n.

stuttering (stut-er-ing) n. see stammering.

stammering see stuttering .