Stuttering: Perspectives, Theories, and Treatment

**Theoretical Perspectives About 1-Constitutional Factors in Stuttering** **Stuttering as a Disorder of Brain Organization** caused by abnormal hemispheric dominance REMEMBER: L hemisphere is dominant (specialized for processing language) for language in most people. R hemisphere is subservient (p...

**Theoretical Perspectives About 1-Constitutional Factors in Stuttering** **Stuttering as a Disorder of Brain Organization** caused by abnormal hemispheric dominance REMEMBER: L hemisphere is dominant (specialized for processing language) for language in most people. R hemisphere is subservient (playing a less but still important role in the production and comprehension of language) =inappropriate location of speech networks in the R hemisphere combined with inefficient speech networks in the L hemisphere: poorly timed speech with disruptions/stuttering & PWS often may have overactive R hemispheres and that overflow, especially from R hemisphere regulated emotions (e.g., fear, excitement), would disrupt supplementary motor area functions in planning, initiating, and sequencing speech motor output=stuttering **Stuttering as a Disorder of Timing** caused by abnormal hemispheric dominance \*pulls on similar ideas to above **Stuttering as Reduced Capacity for Internal Modeling** Not enough evidence to support this **Stuttering as a Language Production Deficit** stuttering often begins when a child enters a period of intense language development stuttering is most frequent when the load on language functions is heaviest (e.g., in longer utterances, at the beginnings of sentences, and on longer, less familiar words) Kolk and Postma's covert repair hypothesis provides evidence that the benefits of a slower speech rate on stuttering might be derived from the greater amount of time that PWS have for phonological encoding. Relating to the first couple of theories- Perkins, Kent, and Curlee's (1991)'s dyssynchrony between two components of language production. 1- "paralinguistic" component is a R hemisphere controlled social-emotional process that is responsible for vocal tone and prosodic functions. 2- linguistic component is a L hemisphere segmental system that is responsible for the content and structure of language (semantics, syntax, and phonology). The two components must be integrated before spoken language is produced. If one lags behind the other for whatever reason, the resulting dyssynchrony produces disfluency Perkins et al. added 2 elements if disfluency is stuttering: 1-the speaker must experience time pressure from either an outside source or an inner feeling, so that he continues trying to speak even though the dyssynchrony in paralinguistic or linguistic processes has resulted in an incomplete or anomalous speech motor program. 2-the speaker must experience a feeling of "loss of control," which arises from being unaware of why he cannot say the word. **Stuttering as a Multifactorial Dynamic Disorder** Smith's theory that stuttering is a motor speech disorder, the appearance and severity of which are influenced by a multitude of cognitive, linguistic, and psychosocial factors Smith thinks it is inappropriate to search for a single underlying "cause" of stuttering but instead it's important to look for which factors interact in stuttering and determine how they interact. **Theoretical Perspectives on** 2-**Developmental and** 3-**Environmental Factors** **DISPROVEN: Diagnosogenic Theory** stuttering was caused by its diagnosis or in this case, misdiagnosis **(mainly 3-Environmental Factors)** specific factors create stuttering proposes that stuttering begins when parents mistakenly diagnose normal disfluency as stuttering It pinpointed [environmental factors] (negative reactions of parents and other listeners) as the sole cause of stuttering, "the problem was not in the child's mouth but in the parent's ear." Created from research in the 1930s by **Wendell Johnson** & was the most widely accepted explanation of stuttering throughout the 1940s and 1950s. DISPROVEN BC: We now have a better understanding of SLDs vs disfluencies. SDLs=Sound/Syllable/Part-word repetitions, audible sound prolongations, and complete inaudible blocks. CWS= more frequent syllable repetitions, sound prolongations, and complete blocks typical disfluencies/nonstuttering=Multisyllabic whole word repetitions, phrase repetitions, pauses, and interjections. CWNS= more frequent phrase repetitions, pauses, and interjections new findings about genetic and constitutional factors in stuttering also disprove this theory One take-away from Johnson's idea "that if a child is made self-conscious about his normal disfluencies, he may begin to stutter." is NOT that we should ignore it (which happened in the 1960s-2000s) but that we should support our kids where they are at (acceptance). **Communicative Failure and Anticipatory Struggle Demands (2-Dev. and 3-Env. Factors)** specific factors & many different variables may interact to produce stuttering some form of communication difficulty precipitates stuttering Created from research in the 1950s-1970s by Oliver Bloodstein proposes that stuttering emerges from a child's negative experiences when trying to talk: - frustration: criticism by significant listeners, difficult/traumatic experiences reading aloud, constantly asked "slow down" "what?," emotionally traumatic events during attempts to speak and - failure: typical disfluencies, delays in the development of articulation and language, cluttering If a child cannot make himself understood or is penalized for the way he talks, he may begin to tense his speech muscles and fragment his speech, reactions that become the core behaviors of the child's stuttering. Other developmental (internal) aspects: personality may be perfectionistic, emotional need to live up to parental expectations Other environmental (external) aspects: family w/high standards for speech, find any speech abnormality unacceptable, or otherwise pressure conformity to age inappropriate standards Take-aways: related to the following C&D model its important to consider intrinsic and extrinsic factors. An individualist approach will also allow a clinician to focus more on reactions to stuttering if necessary. **Capacities and Demands \***Capacities then demands bc capacities exist in children before demands are placed on them. **(2-Developmental and 3-Environmental Factors)** many different variables may interact to produce stuttering almost any developmental or environmental pressure may precipitate stuttering Created from research in the 1970s-1980s by most notably Starkweather disfluencies as well as real stuttering emerge when a child's capacities for fluency are not equal to speech performance demands. others who contributed: Joseph Sheehan (1970, 1975) "a child who has begun to stutter is probably a child who has had too many demands placed on him while receiving too little support" (Sheehan, 1975, p. 175). Andrews and colleagues (1983) reduced capacity for internal modeling theory of stuttering "whether one will become a stutterer depends on one's neurological capacity... and the demand posed by the speech act" (p. 239). **Capacities** **Demands** ----------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- capacities for fluency rapid development of language between ages 3 and 7 years neurological capacity fast-talking parents Support=the environment's capacity to provide love, care, and encouragement Demands for speech performance sometimes come from within the child potential for rapid movement of speech structures in well-planned sequences that are coordinated with the rhythms of his language internal environment: increasingly complex thoughts to be expressed, which require more sophisticated phonology, syntax, semantics, and pragmatic skills external environment/parents' interactions: ask questions rapidly, interrupt frequently, use complex sentences choked with big words, show impatience about normal disfluencies, expectations only met at high levels of performance Take-aways: careful dx of the child's capacities and the demands in her environment, tx designed to enhance capacities, decrease demands, and provide support for child and family while these changes are taking place **Integration of Perspectives on Stuttering** **A Two-Stage Model of Stuttering:** stuttering begins in most children as repetitions, of which they are hardly aware and to which they don't react. He thought that over time, many of these children become aware of their disfluencies and react to them by increasing the tension and tempo of their repetitions. These repetitions then become fast, irregular, and halting as children are bothered by them and do what they can to stop them. As they tense further, the repetitions become blocks and sometimes prolongations. ***A Perspective on* Primary Stuttering:** Early stuttering, near the onset of the disorder, that is characterized by [loose, easy repetitions]. For those children who begin stuttering in this fashion, it is assumed that at first they are not aware of their stuttering and do not react to it. 1º cause: genetics, brain A&P ***A Perspective on* Secondary Stuttering:** Stuttering characterized by [tension and struggle and sometimes by avoidances]. In some views, this type of stuttering is thought to be a reaction to primary stuttering, as the child becomes [self-conscious and frustrated by difficulty] w/speaking. 1º cause: temperament & in-the-moment emotional responses interacting with learning **Temperament.** "sensitive" and "reactive" personality or temperament (inhibited): a behavioral & emotional style characterized by being easily aroused by novel stimuli, as well as a tendency to withdraw when confronted by unfamiliar people or situations A CWS interacts with a complex environment, and this influences temperament and emotion, which in turn influence stuttering. CWS may be more likely to increase their laryngeal tension (as well as elsewhere) in response to primary stuttering, which they experience as threatening because it seems out of their control and thus emotionally upsetting. This may be the mechanism that causes many children's disfluencies to change from easy, relaxed repetitions to tense repetitions and progressively more tense prolongations and blocks. Research has demonstrated that PWS: tend to have more sensitive or reactive temperaments increases in physical tension as part of defensive response that is triggered more easily in individuals with reactive temperaments the more reactive individuals are, the more they will engage in innate responses to feat/threat is freezing (i.e., widespread muscular contractions that produce tense and silent immobility), flight (i.e., speeded up activity to escape), or fight-escape behaviors and avoidance behaviors (that characterize secondary stuttering). PWS who are more reactive are more prone to behaviors regulated by right-hemisphere emotions (specialized for emotions that accompany avoidance, withdrawal, and arrest of ongoing behavior) CWS have greater emotional reactivity, less emotional regulation, and poorer attention regulation **Learning. From the text "**children with reactive temperaments are more likely to respond to the multiple repetitions of primary stuttering with tension, escape, and avoidance and are also much more likely to store their stuttering memories indelibly. Such reactions and memories can snowball. The child's natural defensive response to a repetition that feels out of control (or to parent reactions that are perceived as negative) is to tense their muscles. This increased tension soon makes the stutter last longer, which increases feelings of helplessness which triggers a bigger threat response that includes more tension. The child's reactive amygdala mediates the storage of unpleasant memories of stuttering, largely on a nonconscious level. At the same time, another part of the limbic system, the hippocampus, stores information about the situations in which stuttering occurs (e.g., whom the child was talking to, what word was being said, where it happened). These contextual cues cause stuttering to spread rapidly from isolated experiences to more and more repeated experiences in similar contexts and eventually to many other situations. Children with reactive temperaments are not only more likely to learn to increase tension when they anticipate or experience stuttering but are also more likely to engage in other components of the behavioral inhibition system. These include increases in tempo, other aspects of escape behaviors, and a wide array of avoidances. Thus, they quickly develop secondary symptoms, such as eye blinks and changing words, to escape from the moment of stuttering or to avoid anticipated stuttering. **Two Predispositions for Stuttering** *"no matter how many predispositions a child may have, the chance of his actually developing primary or secondary stuttering may be enhanced or diminished by both developmental and environmental factors"* the most common occurrence is for a child to have a predisposition for primary stuttering that is resolved through neural maturation or reorganization---this accounts for the 70 percent or so of children who recover naturally. Children w/very nonreactive temperaments may have their primary stuttering continue into adulthood and secondary behaviors never emerge. These adults may simply be considered highly disfluent, rather than people who stutter. Then there are CWS w/reactive temperaments\>increased tensions\>escape & avoidance which leads to persistent secondary stuttering Van Riper's beliefs that "...most children who begin to stutter become fluent perhaps because of maturation or because they do not react to their... repetitions, or prolongations by struggle and avoidance... \[while\] those who struggle or avoid because of frustration or penalties will probably continue to stutter all the rest of their lives no matter what kind of therapy they receive" ***Interactions with Developmental Factors*** Ex 1: predisposition for primary stuttering + dysfunctional/inefficient speech+language networks - functional plasticity of the child's brain may allow these pathways to reorganize or repair themselves so that the child processes spoken language more efficiently as he strives to communicate. - the exponential growth of the child's speech and language at this very time may compete for cerebral and other brain resources, straining or exceeding the child's capacity to handle the demands of both reorganization and advancing language, at the same time Ex 2: predisposition for primary stuttering + earlier maturation of the brain/natural flexibility to respond to anomalies in the wiring for speech+language networks - girls more likely to recover from early stuttering---either naturally or with treatment, probably because of their inherently greater organizational plasticity and their more widely distributed language centers - some boys may recover more readily than is average for boys IF they are genetically endowed with more flexibility for reorganizing their cerebral circuitry Ex 3: normal neural circuitry for spoken language + sensitive/reactive temperament (inhibited) - Typical social-emotional development challenges for most children include some stress/frustration at not being able to speak as fast or with the same complexity as adults and older children in the family. - example 3 child may not *only* be frustrated but embarrassed at his inability to produce more advanced speech and language. - right-hemisphere proclivity toward avoidance, withdrawal, and arrest of ongoing behavior may manifests itself while they are speaking - causes hesitancies that may consist of long pauses, phrase repetitions, or both and may produce increased tension, escape, and avoidance behaviors associated with speech - stuttering eval would NOT manifest the typical signs of stuttering - may diminish in time as myelination of neural circuits and systems serving speech production continues ***Interactions with Environmental Factors*** a child's family will have the most opportunities to either: A. provide acceptance and support= accommodations they provide may foster adaptations of the child's inefficient, dyssynchronous neural networks & enable the child to develop her own adapted rate of speech and language output: - accepting reactions toward the child's stuttering, - using slower speech rates, - fewer interruptions, - dedicated one-on-one listening time OR B. stress the child's speech and language production system= inhibit the successful adaptation of the child's system to its original anomalous wiring & "overdrive" the child's immature speech and language production system, causing an excess of disfluencies: - evident disapproval of the child's stuttering, - many interruptions, - rapid conversational give and take, - demands for recitations, - little time for the child to talk **Implications for Treatment** ***Preschool Children*** 1^st^ help the child take the time needed to coordinate the elements of speech with the components of language to produce a fluent utterance. - maximize these children's fluent speech, by creating an environment filled with: - models of slower speaking rate, including pauses - reduce pressure on the child's speech by asking fewer questions, not interrupting, and giving the child adequate attention when he's speaking. 2^nd^ prevent the child from having a defensive reaction to his disfluencies (which would trigger the tension response) - helping caregivers and the child to be comfortable with and accepting of the repetitive stuttering. - Parents can reassure the child, if he seems frustrated or upset by his stuttering - "It's ok. Lots of kids get stuck sometimes on words" may be enough. - Parents' demeanor at this moment can be relaxed and convey, "It's no big deal." ***School-Age Children*** Dx to find out how much negative reaction (tension+ escape and avoidance behaviors) the child has added to stuttering? - Are moments of stuttering often characterized by tense postures and physical struggle that are the result of reacting to the threat of runaway repetitions/fear of being "trapped" in a stutter? - Do they use extra movements or sounds to break free of stutters? - Do you hear and see "starters" or other behaviors before stutters or do they talk "all around" to dodge possible stutters? IF -- reaction: 1^st^ focus on reducing the fear of stuttering to reduce reactions to it 2^nd^ practice ~~talking fluently so that the child develops confidence that she will be fluent~~ fluency shaping/modification techniques to offer children the feeling of "more control" when they choose IF mostly tension free and there are few, if any, escape or avoidance behaviors: Focus on becoming a confident communicator who says what they want to when they want to (fluency shaping/modification techniques may be apart of this but fluency should NOT be \#1 goal) ***Adolescents and Adults*** diminish their defensive reactions and fear that trigger the excess tension and the escape and avoidance behaviors 1^st^ confront and explore his stuttering behaviors, attitudes and feelings. CTFAR model thoughts create feelings and thoughts can be controlled!!!! 2^nd^ stutter easily, without avoidances prior to the speech attempt, without the excess physical tension, and without trying to "blast out" of the moment of stuttering but instead remain relaxed as he eases the word out **Accounting for the Evidence** Not necessary to know all the ins/outs of these 11 facts/sections but these are some generalities related to stuttering that are helpful to remember (except the 2^nd^ one) ***Stuttering Occurs in All Cultures*** ***~~Stuttering is a Low-Incidence Disorder (~~https://stutteringtherapyresources.com/blogs/blog/stuttering-is-not-a-low-incidence-disorder)*** I often hear people talk about how stuttering is a "low-incidence" disorder, and it makes me nuts! Why? Because according to the research, we should be seeing a lot more people who stutter than we actually are! Put simply, people who stutter are a dramatically underserved population. Here's why: According to best estimates, the prevlance of stuttering is about 1%. That would mean that there are approximately 3,000,000 people who stutter in the United States alone---and maybe 70,000,000 worldwide! If we take just that 3,000,000 figure and divide that up by the number of practicing speech-language pathologists in the US (figure roughly around 170,000), then each of us would have 17 people who stutter on our caseloads! ***Where are they?*** Of course, most people who stutter aren\'t currently receiving treatment. (Research shows that the vast majority, about 93%, have had treatment in the past, but only a small fraction are seeking treatment presently.) And, not all of those 170,000 clinicians work in settings where they would see people who stutter. Still, in the schools, we would expect there to be quite a few children in need of treatment. Moreover: Even though the prevalence of stuttering is 1%, the incidence of stuttering is much higher. The commonly accepted figure is about 5%, though some studies show it as high as 11%. Using the 5% figure would mean that at least 1 out of 20 young children is going to go through a period of stuttering. *Note how much higher that is even than the incidence of autism!* Yet, people still persist with the myth that stuttering is a \"low incidence\" disorder (they really mean \"low prevalence,\" but that\'s just nitpicking ). It is not; instead, it is an underserved disorder. (Just for a fun exercise, compare the accepted prevalence of stuttering - about 1% - with the accepted prevalence of aphasia - just 0.33%! Clearly, there is a need to ensure that we are training student clinicians adequately for treating stuttering, just as we need to train them adequately for treating aphasia.) Bottom line? Next time tells you that stuttering is low incidence, tell them they're wrong and that we, as a profession, are missing out-literally-on *millions* of people who stutter who might benefit from our help\--or, at least, our recognition. ***Stuttering Does Not Begin with the Onset of Speech*** ***Stuttering Sometimes Begins with Tense Blocks, but Often with Repetitions*** ***Stuttering Appears as Repetitions, Prolongations, and Blocks*** ***Stuttering Severity Changes over Time*** ***Not All Stutterers Have Relatives Who Stuttered*** ***Stuttering Is More Common in Boys Than in Girls*** ***Many Conditions Reduce or Eliminate Stuttering*** ***Individuals Who Stutter Often Have Poorer Performance on Sensory and Motor Tasks*** ***Other Research Findings and Clinical Observations That Should Be Accounted for***