Stuttering: Theories and Recovery

• Fluency is the effortless flow of speech
• Normal fluency includes temporal aspects (speech rate) and prosodic aspects (very little intonation) plus stuttering events

Universality of Stuttering

• Stuttering exists across nearly all cultures and languages, indicated by the presence of a word for stuttering
• Aron (1958) described stuttering in Bantu and Zulu children
• Universality may provide insights into the nature of stuttering

Factors Affecting Disfluency Perception

• Disfluency types include sound repetitions, syllable repetitions, word repetitions, phrase repetitions, sound prolongations, interjections, revisions, and blockages

Incidence & Prevalence

• Incidence is the probability of new cases of a disorder developing over time
• Prevalence estimates all cases of a disorder at a given time
• Prevalence is typically less than incidence
• Incidence and prevalence guide clinical decision-making: who to serve, when to serve, and how long to serve
• Spontaneous recovery differentiates incidence from prevalence
• Spontaneous recovery is not sudden
• Incidence includes those who once stuttered

Prevalence Statistics

• Most studies on prevalence are cross-sectional surveys
• Prevalence ranges from 0.7% to 2.1%
• Stuttering Foundation of America estimates a 1% prevalence across all age groups

Prevalence & Incidence Variability with Age

• Stuttering prevalence decreases with age
• Prevalence remains relatively stable between 1st and 8th grade
• Children who stutter at age 12 are likely to continue stuttering as adults

Factors Affecting Spontaneous Recovery

• No family history is a positive sign for recovery
• A family history of persistent stuttering is a negative sign

Gender & Severity

• Male gender is associated with poorer outcomes
• Female gender is associated with better outcomes
• More severe stuttering reduces the likelihood of recovery

Other Factors

• Presence of secondary behaviors reduces the likelihood of recovery
• Greater stimulability suggests a better prognosis
• Early treatment may benefit boys with a family history and severe stuttering, while girls with no family history and less severe stuttering start treatment later.

Age of Onset

• Stuttering typically begins in early childhood, while anatomical structures, language, and phonology systems are growing
• Onset range is from 18 months to the teenage years
• Onset after age 9 is rare
• The average onset range is 30 to 60 months
• 59% begin stuttering between 24 and 36 months
• 85% begin by 42 months
• 95% begin by 48 months

Loci Factors

• Stuttering loci are specific sounds or words where stuttering behaviors are more likely to occur
• Research focuses on special features and placement of stuttered words, syllables, and sounds
• Factors influencing stuttering loci are individualized
• Potential loci include distinctive sound features and the position of the sound/word
• Loci depend less on word features and more on learned fear
• Focusing on specific sounds can disrupt fluency due to anticipation
• First word utterances tend to be stuttered more often with a likely cause of situational fears at the beginning

Loci Characteristics

• Stuttering often begins at the start of words (92-97%)
• Stutterers have more trouble on specific sounds that are not universal, and tend to stutter more on voiced sounds
• Longer and novel words, and propositional speech increases stuttering

Loci Studies

• People may have different fluency when reading and speaking
• Word avoidances may increase stuttering when reading
• Skilled readers may stutter more when speaking due to fewer cognitive processes
• Differences in prosody, reading/speaking rate, reading proficiency, and anxiety level affect repeated readings and comparison across individuals

Physical Review

• Individuals who stutter (PWS) appear similar to controls during silence/rest regarding muscle activity, audition, vision, and touch
• Differences exist in neuroactivity and auditory feedback
• There are many conflicting reports in the area

Personalities

• PWS may be maladjusted due to their stutter
• Overall adjustment ratings tend to be lower than the control group
• The condition would rarely be comorbid with other diagnostic criteria
• Ratings tend to fall within the average range

Caution and Defeatism

• PWS may exhibit over-cautious or defeatist behaviors, with lower goal-setting
• PWS have been associated with higher achievement drives and greater fear of failure, but in adults moreso than children
• Handwriting may be untidy, clumsy, and disrupted in fluency/continuity, marked by interruptions, repetitions, and errors
• Language can highlight maladjustment measures

Anxiety in PWS

• Anxiety levels in PWS can differ based on measurement type
• adults often show higher anxiety on questionnaires
• there is higher anxiety on Projective measures
• Physiological measures show no difference
• Behavioral measures reveal higher anxiety levels

Personality Profiles

• PWS generally do not appear maladjusted or neurotic as a group
• PWS may show some evidence of being less well-adjusted than control groups
• Tests tend to fall within the normal range, but lower than normal control groups

Importance of Defining Stuttering

• Defining stuttering sets boundaries, identifies those who need treatment, and quantifies/justifies treatment
• It also informs treatment approach and makes progress measurable

Ways of Defining Stuttering

• Defining stuttering as a verb focuses on the stuttering event
• Features include: part-word repetitions, whole-word repetitions, prolongations, silent postural fixations, circumlocutions, interjections, and struggle behaviors
• Overt stuttering events are open to view

Covert Stuttering

• Covert stuttering events are concealed, secret, or disguised, including circumlocutions, avoidances, and subperceptual forms
• Event-only definitions may not fully describe the experience of a person who stutters

Defining Stuttering

• Defining stuttering as a noun (disorder) expands on overt symptomatology
• Considers overt speech characteristics, physical concomitants, physiological activity, affective features, cognitive processes, and social dynamics
• Disorder-only definitions may not fully account for cause

Fluency Shaping

• Fluency shaping assumes that all human behavior is under voluntary control
• The goal is to unlearn bad speech habits and learn good speech habits
• It is a current prevailing explanatory theory, is highly embraced by SLPs, and involves step-by-step programs
• Speech can be taught like any other motor skill
• Goal: no stuttering

Stuttering Modification

• Stuttering modification is a neuromotor disorder that can be brought under voluntary control
• Charles Van Riper was an advocate for stuttering modification
• Goal: stutter fluently

Historical Perspectives

• Shulthess (1830) described lalophobia: fear of producing certain sounds
• Merkel (1842) noted a failure in confidence to speak
• Beesel (1845) viewed struggles as an effort to overcome an imagined difficulty
• Significant because all these people stuttered, and started to focus on the emotional aspect, not just the physical
• Wyneken (1869) found sphrachzweifler

Orton & Travis Theory

• Stutterers believed to be more left-handed or ambidextrous
• Stuttering is caused by a lack of sufficient dominance of one half of the brain over the other
• Treatment involved using a belt to restrict the use of the left hand to promote right hemisphere control

Johnson Theory

• There is no organic etiology
• Stuttering is defined by those who listen to it
• Stuttering results from parents placing unrealistic demands on their child's speech
• Parent Blame

Issues with Behavioral Approaches

• Behavioral approaches may not work long-term even with a 70% remission
• Assumes all human behavior is under voluntary control
• Questions the number of motoric skills requiring relearning and retraining
• Requires active learning of how to talk, considers whether stuttering is voluntary
• Speech is voluntary, stuttering is not

Model (Levels 1-3)

• The central involuntary block model suggests that all overt manifestations of stuttering are compensatory strategies
• The central involuntary block is responsible for all overt manifestations of stuttering(stuttering events) are compensatory strategies for the block
• The purpose of the stuttering event serves to relieve the block

Level One

• Central is compensatory strategies
• All stuttering behaviors are not observable by the eye or ear, or if people cant tell if they are avoiding certain words
• The block itself and disrupted speech patterns, anticipations, reactions, sounds words, people, places, situations, and circumlocutions affect this level

Level Two

• Subperceptual forms of stuttering, struggle behaviors at the neuromuscular level and represents a transition between the covert level 1 and overt level 3
• Acoustic and kinematic phenomena that are invisible with sensitive equipment

Level Three

• Focus of most therapies
• Encompasses overt stuttering behaviors: repetitions, prolongations, silent postural fixations, and ancillary behaviors
• All three levels occur to avoid or release the central involuntary block and a voluntary action of word avoidance

Overt and Covert

• Overt stuttering is open to view and not concealed
• Repetitions, prolongations, interjections, silent postural fixations, and struggle behaviors
• Covert stuttering is concealed, secret, and disguised
• Includes circumlocutions, avoidances, and sub-perceptual forms

Explore the complexities of stuttering, including incidence vs prevalence and factors influencing spontaneous recovery. Examine the connection between word placement in sentences and stuttering likelihood. Consider the impact of defining stuttering as noun vs. verb for research and treatment.