Note: The reader is referred to A Systems Approach to Stuttering Therapy: SAST (Cross, 1996) for a more complete description of this model of fluency, stuttering, and treatment.

DESCRIPTION OF THE STUTTERING RESPONSE

Introduction

The Systems Approach to the problem of fluency and stuttering is based on the principle that talking is more than linking sounds into syllables, words, and sentences. Talking is a complex interaction of:

Cognition: what we think
Language: how we organize our thoughts into words and sentences
Sensation: how we perceive information from our bodies and the environment
Arousal: changes in emotion associated with past, present, and future events
Motor control: coordination of movement

While talking is a unique and complex activity, we can draw specific analogies between talking and performing other non-speech activities. Once a foundation and vocabulary are established for describing the components of talking. Rather than viewing "stuttering" as a mysterious combination of disfluency, emotions, and struggle, it can be described as a sequence of behaviors, reactions, and ineffective coping strategies. We can describe events that disrupt any step of the process and reaction patterns to these disruptions. These disruptions result from a breakdown in continuous speech (disfluency) and difficulty recovering effectively from these breakdowns (struggle). Stuttering is not an isolated behavior or event that occurs on certain sounds or words. "Stuttering", then, is a combination of dysrhythmic speech movements and the physical, emotional and psychological behaviors that develop from these disruptions. Research suggests that individuals who exhibit stutter-like symptoms at some time in their lives are more sensitive or "predisposed" to dysrhythmic speech disruptions. These interfere with the forward blending of movement, air, and sound. The source, nature, and degree of disruption can vary from one person to the next. Also, emergence and perpetuation of stutter-like symptoms can be influenced by both inherent and environmental conditions.

The stuttering response can be divided into two primary parts for evaluation and assessment. The first part describes the actual speech patterns exhibited during both fluent and non-fluent speech. These are described in terms of sequence, blending, pace, force, and rhythm of movement. The second part describes the response patterns that develop as involuntary and voluntary reactions to the breakdown in forward moving speech and communication. The response may include thoughts, memories, arousal, and actions associated with talking and experiencing speech disruptions. The specific form of disruption, and how the individual recovers, depend on the motor control, cognition, sensory integration, language processing, and emotional arousal occurring at that time. The response patterns exhibited by a client often become more consistent and severe as the duration of the disruption/recovery period increases. When this disruption in communication extends beyond the speaker's level of tolerance (herein referred to as the "window of acceptability"), perceptions of being helpless or out of control result.

Research indicates that some individuals have inherently less "stable" speech organization or control systems. Thus, intermittent disruptions in the coordination, rhythm, and/or timing of speech movements is more likely to occur. Many of these individuals also have difficulty making the automatic adjustments after a speech disruption needed to reorganize and coordinate movements back to fluid speech. Greater susceptibility to speech "stumbles", combined with difficulty recovering forward speech in a timely and effective manner, causes an increase in emotional arousal. This is accompanied by an increase in physical tension and struggle in the speech and non-speech structures. Continued experience with being "stuck" during speech leads to further arousal, anticipation of future trouble and escape-avoidance strategies. These difficulties are accentuated by increases in communication demands stemming both from within the individual and from the environment.

It should be cautioned that not all individuals who stutter have the same speech and non-speech characteristics. Likewise, not all people who exhibit one or more stutter-like behaviors develop more advanced forms of the problem. The clinician should carefully observe and study the client's speech and non-speech behaviors, attitudes, levels of arousal, and coping strategies. A profile of communication patterns can be developed to aid in making a professional judgment regarding intervention.

The stuttering disorder, as noted above, can be best understood as the interaction of two primary features, the characteristics of speech and the development of an anticipatory response pattern. The following sections will address these two areas.

Developing an Anticipatory Response Pattern: A Non-Speech Analogy

The Systems Approach to stuttering is based on the principle that there is a common base to the development of behavior and response patterns, whether speech or non-speech. We can understand development of a stuttering disorder by using a non-speech analogy that describes the development of an anticipatory reaction pattern. Development of the response pattern is presented in a three-step time frame, (before, during, and after a disruptive event) that triggers the system's reaction. This analogy is then used to describe how the stuttering response follows a similar pattern, reflecting natural arousal, thought, and behavior reactions to the perception of being out of control.

This analogy is based on a traumatic driving experience. The reader is encouraged to draw parallels between the act of driving and the act of talking as the episode unfolds. The car is likened to the speech mechanism and the car's movement down the road is analogous to the forward movement of speech and communication. While there are obvious differences between what we do when we drive and when we talk, the analogy can help "demystify" what seem to be unusual behaviors, emotions, and thoughts associated with stuttering. Figure 1 is a hypothetical time line that shows how the system responds to unpredictable events and the cognitive, arousal, and motor reactions of the system as it develops an anticipatory response.

Before the Disruption Occurs

Picture yourself driving a car down a highway. There is a slight covering of snow or rain on the road. Your focus of attention is on a variety of things (what you did that day, what you plan to do that night, etc.) Your brain automatically senses changes in the car's movements and makes the necessary adjustments as you cruise easily down the highway.

Your muscles are loose and comfortable and the slight adjustments you make with the wheel, accelerator, and brakes are smooth, effortless, and natural.

During the Disruption: Triggering the Reactive Response

Without warning, the tail end of your car begins to spin sideways. This sudden change in movement triggers the "fight or flight" response by sending a rush of adrenaline (arousal) to different parts of your body. This is an instinctive, primitive response of the brain designed to prepare your body for physical action or struggle against danger. A sudden bombardment of emotion overrides most of your voluntary thoughts and actions. The sudden jolts of adrenaline stimulate and tense your muscles (especially hands, arms, and legs) in a protective bracing stance. Your attempts to control the car seem involuntary. Rapid, jerky steering and sudden slamming down on the brakes are automatic "coping" movements designed to stop the slide as fast as possible. The intensity of emotional arousal and perception of threat determine the degree of force and speed of your movement. At this point your goal is no longer to drive the car forward, but to escape the fear.

Unfortunately, the emotional bombardment and physical reactions make it even more difficult to regain control of the car. Sudden bracing inhibits easy smooth movements as the car spins further out of control. The longer the spin lasts, the greater your panic and belief that your actions have no effect in stopping the slide. Thus more adrenaline enters the system.

Figure 1. Development of an Anticipatory Response Pattern ( Key: A - arousal; C - cognition; M - motor control).

People react differently to this surge in panic. Some struggle harder, fighting to gain control of the car by bracing, forcing and speeding movements of the wheel and brakes. Others relinquish control by pulling their hands and feet away from the steering wheel and brake pedal, waiting for the end. However, neither of these reactions is very effective in getting the car moving down the road smoothly and under control.

Despite these reactions, the laws of physics prevail and the car does stop spinning. Whether you regain control of the car's forward direction or end up in a ditch, you are left with the feeling that this event happened TO you, that you were out of control and helpless.

After The Disruption: The Anticipatory Response

Unfortunately, the problem does not end when the car stops or you recover from the spin. Residual panic triggers new images and feelings about the spin. You become more aware of your panic, feel your heart pound and your rapid, short breaths. Your whole body, especially your hands and legs, are tense. All these symptoms are the natural aftermath of feeling out of control.

What next? You need to drive the car to get home, but you are filled with a fear of driving. The emotions from what has just happened are stored in both short and long-term memory, dominating your thoughts and affecting future decisions. The mere anticipation of driving, or sliding into a spin, can be enough to trigger strong feelings of fear and loss of control. Your system is responding quite differently than before the mishap occurred. Your mind becomes clouded and distracted. No matter how much you tell yourself to "relax," it is impossible to get rid of the feelings. As you begin to drive again your muscles are tense, and movements are jerky and protective. Driving is no longer smooth and natural as your thoughts are dominated by keeping the car from going into another spin. Your heightened arousal makes you over-react to even the slightest movement of the car.

At this point a response pattern has begun to develop where anticipation of the feared event triggers feelings of panic and helplessness, which in turn triggers coping strategies to avoid or rapidly escape the event. All the way home you ride the brakes, jerk the wheel and generally drive poorly. What you do to protect yourself against spinning actually increases the likelihood that you will spin again.

The next day, thinking about driving your car to work triggers the thoughts and emotional reactions experienced the previous day. You begin anticipating losing control. To help you cope with these new thoughts and fears, one decision might be to avoid driving your car. This would reduce the immediate fear of driving and losing control, but would lead to additional problems. Besides not being able to get where you need to go, this coping strategy could lead to further frustration and feelings of inadequacy. But more importantly, by avoiding driving you strengthen the image of what might happen if you get behind the wheel again. Without new positive experiences with driving, you are left with your memory of your traumatic experience and your fear of "what would happen if...?"

A different decision might be to get back behind the wheel. Emotional flooding takes over as your mind focuses on the feeling of losing control. Rather than driving naturally and easily, your entire system becomes sensitive to the point where even the slightest bump triggers the "fight or flight" response. This reinforces the anticipatory avoidance pattern your system learned from the previous experience.

These anticipatory thoughts, sensations, emotions and movements develop into an involuntary pattern. This becomes the way you think and feel about driving , not only when you are actually driving the car, but even when anticipating driving.

Developing the Stuttering Response

What could cause a person to struggle over something as simple as his or her name? Why can a person say a particular word one moment and be hopelessly entangled the next? The Systems Approach attempts to demystify the stuttering problem by breaking the response pattern down into a series of reasonable, predictable, and understandable behaviors. These can then be used as a foundation for evaluating people with fluency problems and determining whether they are exhibiting behaviors, attitudes, or emotional responses that interfere with effective talking and communication.

The stuttering response begins like the driving analogy in which the system responds cognitively, emotionally, and behaviorally to the involuntary feelings of being out of control. Applying the series of events from our driving problem to talking, we can see that a communication pattern emerges and develops over time. Figure 2 illustrates the relationships among speech breakdown, arousal, attitudes, and the development of inappropriate coping strategies of the stuttering response.

The Stuttering Response

The Stuttering response is the disruption in rhythmic flow and ineffective recovery combined with the cognitive, emotional, and behavioral reactions to the breakdown. Ironically, most reactions that make up the stuttering response are natural responses to sudden events perceived as threatening. Getting stuck on sounds or words, or even anticipating getting stuck, can trigger the limbic "fight or flight" response. The response sends a sudden flow of adrenaline that heightens sensory awareness and excites the muscles in a way that prepares for sudden battle or escape. The symptoms are a rapid increase in heart rate, blood flow, and changes in breathing patterns accompanied by tensing of the speech structure muscles in a "bracing" type behavior, (e.g., holding one's breath against tightened vocal folds.) Stimulation of the "fight or flight" response also affects the growth, association, language, motor control, and memory areas of the brain in a chain reaction that develops into a self-perpetuating anticipatory response pattern.

Figure 2. Schematic illustration of the stuttering response.

Although the system is responding normally to the perception of threat (or of being visible "stuck" in mid-thought or mid-utterance) and personal embarrassment, most of what the person does naturally to cope with the speech disruptions only makes the situation worse. Increased bracing and tensing behavior, combined with perceived time pressure to get a word out quickly, creates further struggle and discoordination in the speech structures making effective recovery more difficult. A chain reaction of fear, disruption, and struggle reinforces the anticipatory fear that stuttering will occur at any moment and continue out of control.

We can now see that a person does not actually have stuttering (a noun) as one would have a medical disease. Stuttering is a process that combines the susceptibility to disruptions in speech movement and inappropriate recovery with development of an anticipatory response pattern associated with the feeling of being out of control.

The stuttering response is very similar to the driving problem presented above. The Systems Approach provides a method to understand and describe the thoughts., emotions, and actions that develop as a part of the stuttering response. Obviously, speech communication is not the same as driving a car but the natural response of the system to the perception of threat and being out of control is similar in both experiences. By bringing the complex and confusing issues of stuttering into a common experience, the clinician and client can both explore and "demystify" what's happening.

Disfluency and Ineffective Recovery: Triggering the Response Pattern

An important feature of normal speech development is the occurrence of disruptions in fluidity and the ability to effectively recover from them once they occur. The ability of the system to automatically make the proper adjustments to the speech processes in a timely matter develops with age. Some do this faster and more completely, while others show signs that their motor systems lack the ability to reorganize speech effectively, resulting in longer, and more persistent forms of disfluency. It is the combination of both the occurrence of speech stumbles, and the ability to effectively recover fluid speech, that influences development of speech stability.

In our driving example above we see that the anticipatory response originates in unexpected movement of the car and the inability to effectively bring the car under control. Likewise, the trigger to the stuttering response is the unexpected disruption in the forward movement of speech and communication. This is compounded by the prolonged or ineffective ability to get speech and communication moving forward again. Together these elicit and reinforce a similar "fight or flight" response in the speaker and downward spiral into the perception that disruptions (and the emotional/psychological reactions that accompany them) are out of control...

During the early years of speech and language learning children are developing skills in organizing their thoughts into a complex language code and then translating the message into a series of continuous, rhythmic speech movements. The ability to organize and produce fluid speech is a complex process that develops over time, especially during the first to fifth year of life. Continued growth in the cognitive, motor, emotional, and sensory systems stabilizes the speech process during these years and into young adulthood. As in all aspects of maturation, the young child's communication system is quite "unstable" , susceptible to temporary disruptions in the language and speech production processes. Typical overt signs of temporary instability are hesitating before or during utterances, repeating and prolonging speech movements, restarting and revising the beginnings of utterances, and interjecting extraneous "filler' words or sounds (e.g., "uh", "um"). These temporary disruptions in the forward flow of speech are called disfluencies. (The reader is referred to Chapter 3 of SAST for a more detailed description of characteristics of fluent and disfluent speech patterns.) Disruptions can and often do occur for no obvious reason. However, problems with speech fluidity can stem from an increase in processing demand as the speaker attempts to communicate his or her message. In this context we refer to "demand" simply as anything that the child thinks, feels, or does that requires additional processing by the brain before or during talking. This increase in processing demand can come from a variety of sources and tends to interfere with the child's ability to organize and execute speech and language in a rhythmic sequence.

Children naturally progress through periods of physical neurological, and emotional/social growth and are more susceptible to dysrhythmic speech early in development. The ages between one and five years are particularly vulnerable periods, as speech and language are developing rapidly. It is also clear that not all children develop at the same rate or eventually develop the same degree of speech stability. Some children have systems that are inherently less "stable" than others and are thus more susceptible to disfluency. While all children and adults exhibit periodic episodes of disfluency, a majority of children stabilize their general fluency skills by twelve years of age. Yet others continue to experience atypically frequent episodes of disfluency throughout adulthood. It is important to caution however, that merely having difficulty organizing and producing fluid speech does NOT necessarily mean someone has a stuttering disorder. It merely indicates that one has a system at that point in time, more prone to disruptions in translating ideas into fluid, rhythmic speech sequences.

Whatever the cause(s) of disruptions in speech fluency and fluidity, one can reasonably assume that individuals who develop stutter-like problems have speech systems that are susceptible to disruptions in the natural rhythm, timing and coordination of speech movements and exhibit difficulty recovering from disruptions once they occur.

Changes in Emotional Arousal

As with our driving example, arousal plays a significant role in the nature and extent of the stuttering response. Experiencing an episode of disfluency, combined with difficult recovery, triggers onset of arousal similar to that experienced at the initiation of the "spin" in the driving analogy. A rush in adrenaline triggers a series of thoughts, sensations, and motor reactions that add to the perception that talking is becoming out of control. In such instances, the emotion is tied directly to the experience itself. The reactions are rapid, often strong, and difficult to control or extinguish. As with our driving reactions, the sudden flooding of emotion often results in physical bracing behaviors such as rapid inhalations, breath holding (by closing the vocal folds) and tensing speech and non-speech muscles. There is also an increase in movement speed, yet a reduction in accuracy and control. Movements often become quick and jerky.

With continued experiences, there may be development of anticipatory reactions. Merely thinking about stuttering, or associating certain speaking situations with stuttering, can trigger emotions similar to the fear of driving after a loss of control. The emotional reactions are triggered by self-generated thoughts and images of what might happen. In most cases, the emotional arousal associated with talking and stuttering serves to accentuate the disruptive thoughts and physical reactions. As with most activities, excessive anxiety inhibits the ability to focus attention, organize language, and coordinate movement. Attempts to rapidly reduce the feelings of panic and embarrassment further disrupt the system. This creates a change in reaction and invokes a vicious cycle.

Emotions and arousal are involuntary behaviors, therefore extremely difficult to control. For the most part, arousal stems from experience and the way an individual interprets that experience. Change in emotion, therefore, is the byproduct of experience and attitude. To a large degree, the speaker associates the prediction, occurrence, and problem of stuttering with the emotional cues triggered by events, people, situations, images, and memory.

Disruptive Thoughts and a Shift in Focus of Attention (Cognition)

Our thoughts, perceptions, and attitudes are integral to the development and maintenance of stuttering. Like the driver, how we think about our past, present, and future behavior affects changes in arousal and how we respond. With continued experience with speech disruption and ineffective recovery, the person begins to focus attention on what might occur in the future when talking. This type of anticipatory thinking elicits protective emotional and physiological responses from the system. These responses, in turn, can trigger further problems with fluency. Anticipatory behavior is a primary component of the developing and chronic stuttering response. The natural thought processes of communication are combined with and sometimes overshadowed by distracting anticipatory thoughts and arousal about stuttering. Thoughts can become clouded with images of stuttering, how people will react, the feelings of embarrassment and dread that precede and accompany stuttering, and ways of preventing or coping with the problem. Many thoughts about talking are directed toward ways to prevent, hide, or rapidly escape the bonds of a stuttering episode.

The fear of stuttering, the personal and social consequences of stuttering, and what can be done to prevent or minimize the feeling of being out of control become natural parts of the person's communication style. These patterns serve to further interfere with the ability to focus on and produce more natural, easy speech movements.

A common characteristic of a developing anticipatory response is scanning ahead; looking for land mines. But, changing words, phrases, sentences, or even complete ideas can serve to reinforce the belief that if something is not done to prevent the stutter, it will be a traumatic experience. Such thoughts become "distracters" from natural communication. Common distracting thoughts that signal a developing problem include 1) "will I stutter on a sound or word," 2) "will I lose control of speech and not be able to get a word out," 3) "will listeners identify me as a stutterer," and 4) "will listeners react to the way I'm talking."

Heightened Sensitivity to Movement, Emotions, and External Reactions

An important feature of enlightened limbic arousal is an increased sensitivity to emotions, behaviors, and cues of impending threat. After experiencing a traumatic stuttering event, there is an increased sensitivity to visual, auditory, linguistic, and speech cues which signal that stuttering might occur again. Even slight hesitations in speech that go unnoticed by listeners can trigger strong emotional and physical reactions within the speaker. A person can become overly sensitive to perceived reactions from listeners and the embarrassment associated with them. Attending and reacting to these cues elicits interfering thoughts, emotions, and behavior.

Problems Coordinating Easy Movements

Arousal associated with limbic stimulation is meant to brace the body for action in the presence of danger. This primitive reflex sends adrenaline rushing to parts of the body preparing to either brace for a fight or escape quickly. The goal is gross force and speed, not fine precision and coordination. While this works for running from harm, it has an adverse effect on speech production. The arousal response interferes with the precise motor control and coordination needed for easy, fluid speech. Heightened attention to automatic movements and attempts to prevent or hide stuttering episodes often result in fragmented, forceful, and inhibited speech movements. Both fluent and disfluent periods are often characterized by bracing the speech musculature, rapid movements, and/or slow over-controlled speech. Many of these patterns are reactions to anticipated and real episodes of being out of control. In addition, the system's automatic reactions to escape the moment of stuttering lead to additional force, further inhibiting effective recovery. Trying to keep speech moving against the resistance of being "stuck" is evident. Difficulty in motor readjustment results in over-tensing, pushing, and the speeding of speech movements.

Development of Disruptive Coping and Adjustment Strategies and Stuttering

We have shown how stutter-like disruptions are accompanied by feelings of "helplessness" to move speech forward. The result is involuntary and voluntary actions designed to prevent, hide, and rapidly escape from uncontrolled speech disruption. We call these voluntary and involuntary behaviors "coping strategies".

Coping behaviors in the developing or chronic stuttering problem can take many forms and change with experience. They can be physiological behaviors in the speech mechanism, such as forcing, speeding, or otherwise disrupting the natural sequence of speech movements. They can be non-speech physiological behaviors, such as extraneous movement of body parts before or during stuttering episodes or fluent speech. They can be voluntary avoidance of specific sounds, words, people, or situations. They can even take the form of intellectual rationalization or denial of the speaking problem.

The key here is that development of ineffective coping strategies is a primary symptom. The speaker has begun to react to talking and the occurrence of speech disruptions in a negative way. Coping strategies are often perceived by the speaker as the only effective means to handle his or her speech problem. However, coping strategies typically draw the speech/communication process further away from the most natural forms of thought, feelings, and behavior of talking. An important goal in therapy will be to identify all forms of ineffective coping strategies and provide the client with more natural ways to respond to the disruptions in speech movement, heightened arousal, and invasive thoughts.

Characteristics of Stutter-Like Speech: Disfluency and Ineffective Recovery

A continuing argument among professionals in fluency disorders is whether "stuttering" disfluencies are categorically and etiologically different from "normal" disfluencies. There is not a clear answer to this question, nor perhaps is one necessary. Most likely, there are multiple sources of speech disruptions that listeners categorically identify as disfluency. The sources of disruption influence not only the frequency of occurrence, but also the form of disruption and recovery characteristics. The nature and degree of the problem probably varies form one individual to the next and thus is not readily amenable to simple categorization. From the point of view of the Systems Approach, this categorical differentiation is unnecessary, and most likely, invalid. The issue is not whether a person has "stuttering" per se, but whether they are exhibiting disruptions that by their frequency of occurrence or form are interfering with their ability to convey their message in a perceptually comfortable and intelligible manner. In addition, are there indications that the individual is exhibiting behaviors that reflect development of a "fight or flight" response pattern, and if so, how and to what degree?

The clinician can use the following descriptors as a basic guideline for characteristics associated with stutter-like speech patterns:

1. Stutter-like speech is often characterized by atypical or unnatural sounding rhythm patterns within and across utterances. These patterns are independent of the disfluencies themselves and are typically characterized by atypical pause durations, pause location, atypical intonation and stress patterns, and fragmentation of utterances.
   
2. There is often a noticeable variation or cessation of movement of one or more speech structures in stutter-like speech. In many cases this results in the prolongation of sound/movement, or a combination of these features.
   
3. There is often an involuntary blockage of air flow through the vocal tube during stutter-like disruptions. Blockages typically occur at one or more of the "valving" points along the vocal tract.
   
4. Stutter-like disruptions are often accompanied by excessive force and speed of speech movements, particularly prior to and during stuttering episodes. This gives the impressions that a sound or word is "stuck" or "jammed," needing additional effort to push the word out. The atypical increase in speed during the disfluency, as well as during fluent episodes, influences the perception that speech rhythm is disrupted.
   
5. The struggle behaviors noted in the speech structures prior to or during stuttering episodes can carry over to non-speech structures, giving the impression of various degrees of contortion in the face, neck, trunk, and limbs.
   
6. Movements in the speech and non-speech structures that are not directly related to what is being said can occur before stuttering episodes. Such behaviors are seen as attempts to prevent the stuttering from occurring, or hiding it from the listener. While some movements are visible to the observer, others are more covert and require careful observation.
   
7. The end of a stuttering episode is often produced with excessive movement, force, and speed. This recovery might be followed by a pause not observed in non-stuttered disfluencies. This feature is more common in advanced forms of stuttering.
   
8. Silent pauses that occur at atypical points in the utterances, or are accompanied by signs of tension, are often indications of complete stoppage of speech movement or attempts to avoid a stutter. These pauses can occur in fluent sounding speech where no overt sign of disfluency or struggle is evident. In some instances, pauses occur at unnatural linguistic boundaries making speech sound "choppy" or dysrhythmic.
   
9. Interjecting extraneous sounds, syllables, words, and phrases into an utterance can be stutter-like attempts to postpone or prevent the stutter from occurring. In stutter-like speech these interjections are used to get speech started without stuttering. It is important to differentiate normal interjections from those used as "techniques" to hide, postpone, or prevent stuttering.
   
10. During stutter-like disfluencies one or more of the speech structures might be out of position or out of sequence relative to the sound/movement being produced or the sound/movement that will occur next. It appears as though there is difficulty making the appropriate transition movements from one sound or syllable to the next. One common example of this behavior is neutralizing the vowel sound in a stuttered syllable or word (e.g. "ba-ba-ba beet" instead of "be-be-be-beet").
    

What develops into what the Systems Approach refers to as the Stuttering Response Disorder begins when an individual, often a child, exhibits continued disruptions in speech rhythm and has difficulty recovering effectively. This triggers a natural cognitive, emotional, and physical response pattern in the person. The response pattern exhibited in developmental stuttering problems is similar to the pattern that developed in our troubled driver described previously.

DEVELOPMENT OF THE STUTTERING RESPONSE: FOUR PHASES

As we have discussed, a person is not born with stuttering. The stuttering disorder is a response pattern that develops over time. Presented below is an outline that describes some of the more salient characteristics of a developing stuttering response. While presented in four phases, the clinician should consider these as general boundaries of development. Children are very individualistic in the characteristics and development of their stuttering problems, often with overlap from one phase to another.

Each phase is divided into four primary components of the communication system, speech production, cognition (thoughts), emotional arousal, and coping strategies. During an evaluation of a non-fluent child or adult, the clinician should identify those characteristics that indicate the client is speaking, thinking, feeling, or coping with speech and communication in an ineffective manner.

PHASE I:

A distinguishing characteristic of this phase is a total lack of awareness or concern about talking or talking mistakes made by the child. There is little or no overt or covert reaction to disfluency.

Speech Production

1. Intermittent periods of disfluency. These periods can vary substantially in duration. Tendency to come and go.
2. Disfluency typically emerges after onset of connected speech. Most will experience a period of fluent connected speech before disfluency emerges.
3. Most common segmental characteristics of disfluency:
   • revisions
   • false starts
   • phrase and word repetitions
   • interjections
4. Most common non-segmental characteristics of speech and disfluency:
   • Continuity and underlying speech rhythm is maintained during fluent and disfluent episodes.
   • No indication of change in movement, speed, or force during speech and non-speech movement.
   • No evidence of variation or cessation of air flow during speech.
   • No evidence of variation or cessation of continuous movement during speech.
   • Blending, sequencing, force, and speed are generally appropriate during fluent episodes.

Cognition

1. No evidence that the child is aware of disfluencies.
2. No evidence that the child anticipates future speech difficulties.

Emotional Arousal

1. No evidence of changes in arousal before, during, or after disfluencies occur.
2. No evidence of fear or apprehension of speaking.

Coping Strategies

1. No evidence of avoidance behaviors by the child.
2. No evidence of attempts to vary the speech act or the message.
3. No evidence of changes in interaction, frequency, or style.
   

PHASE II

The child begins to exhibit awareness of some difficulty talking, primarily getting "stuck on words". All thoughts and reaction patterns are related solely to occurrence of the disruption itself.

Speech Production

1. Disfluency becomes more chronic and occurs more frequently in response in cognitive, linguistic, social, and emotional distracters/demands.
2. Intermittent periods of fluency and disfluency are common.
3. Segmental features of disfluency:
   • Same features as PHASE I.
   • Evidence of fragmentation of speech.
   • Often includes part-word repetitions, hesitations, prolongations, and dysrhythmic phonation.
4. Non-segmental features of speech and disfluency:
   • Continuity is disrupted by hesitation, prolongation, and/or complete cessation of movement.
   • Increased evidence of disrupted air flow and sound during disfluent episodes.
   • Evidence of involuntary "pushing" of speech structures during disfluency.
   • Some involuntary variation in tension of speech musculature.
   • Little evidence of pre-disruption variation in speech behavior.

Cognition

1. Verbal or non-verbal signs that child is aware of speaking difficulty.

Emotional Arousal

1. Some evidence of increased arousal reactions to extended disfluency may be observed. This occurs during disfluency only.
2. No evidence of strong panic or fear-related reaction to anticipation of disfluent episodes or speaking in general.

Coping Strategies

1. Child may verbalize concern about speaking difficulty.
2. Some evidence of emerging avoidance behaviors observed in some children. The child may talk less often.
   

PHASE III

The individual is now aware of and reacts emotionally and cognitively to speaking difficulty. This is combined with perceptual-physical reactions to being out of control. Concerns focus not only on actual stuttering episodes, but anticipation of stuttering during fluent periods as well.

Speech Production

1. Chronic episodes of disruption. Less frequent extended periods of fluency. disfluency generalized to specific speaking situations.
2. Segmental features of disfluency:
   • Fragmentation of speech units (e.g. part-word/sound repetitions).
   • Extended prolongation, dysrhythmic phonation are common.
   • Interjections used to postpone/avoid disfluency.
   • Hesitation/pauses observed prior to actual disruption.
   • Some evidence of speech "starters".
3. Non-segmental features:
   • Disruption in air flow and structural movement observed at one or more valving points.
   • Evidence of involuntary and voluntary struggle behavior in the speech structures.
   • Increase in force in speech musculature and speeding of movement during disfluent episodes.
   • Involuntary and voluntary changes in movement sequence, force, and/or speeding prior to disfluent episodes.
   • Release from disfluent episodes are often abrupt and forceful.
   • Evidence of struggle-type behavior in the non-speech muscles.

Cognition

1. Verbal and non-verbal evidence that the child is aware of inability to "get words out". Might call themselves a "stutterer".
2. Focus of attention prior to and during talking shifts to anticipation of impending disruptions.
3. Focus of attention shifts to negative feelings, thoughts, and images about stuttering.

Emotional Arousal

1. Increase in overt signs of fear and panic during disfluencies. This is associated with perception of being out of control (see "Window of Acceptability").
2. Overt and covert signs of anticipation of disfluencies and the emotional reactions that accompany them. Verbal/non-verbal signs of fear of talking in certain situations.
3. Verbal and non-verbal signs of frustration, embarrassment, and confusion about getting stuck on sounds and words.

Coping Strategies

1. Evidence of intentional or unintentional attempts to "fix" speech or avoid fear associated with talking and being disfluent. These are associated with attempts to avoid, postpone, escape, or hide disruptions.
2. Speech avoidance:
   • Recoil from onset of disfluencies.
   • Use of interjections to postpone disfluency.
   • Excessive use of "pushing/forcing" in speech structures.
   • Covert attempts to hide disfluency while talking ("holding back").
   • Avoids using certain sounds or words.
   • Changes words while talking (circumlocution).
3. Situation avoidance:
   • Decrease in attempts to talk in specific speaking situations.
   • Decrease in desire or attempts to talk to specific individuals

    

PHASE IV

This phase is characterized by a fully developed stuttering response pattern. A bond is created between emotional cues and arousal, feelings of being out of control of speech, and physical struggle/avoidance behaviors. In actuality, the stuttering response is the "normal" or most "natural" communication pattern for the speaker.

Speech Production

1. Chronic disruption. Generalization of disruption to talking in general.
2. Segmental features: same as Phase III but increased in frequency and severity.
3. Decrease in the rhythm, sequence and timing of fluent utterances. This is associated with anticipation and prevention of impending stuttering.

Cognition

1. Focus of attention prior to and during talking is on anticipation of disruption. The client feels that stuttering can occur at any time and they are unable to prevent getting stuck.
2. Primary motivation is typically on hiding, preventing, or rapidly escaping from stuttering moments.
3. There is a marked increase in anticipatory "scanning" of the utterance for potential danger words, often resulting in attempts to change or avoid them.
4. The individual also attends to emotional cues prior to and during stuttering moments and on the embarrassment of being "a stutterer".
5. Specific attitudes and perceptions begin to develop about what it means to be a stutterer and the consequences this brings.

Emotional Arousal

1. A strong bond is created between the anticipation and occurrence of stuttering and the emotional reactions of fear and panic they bring.
2. There is an increase in emotional arousal prior to and during moments of stuttering, much of which is associated with anticipatory fear and feelings of being out of control.

Coping Strategies

1. The client continues to develop individualistic strategies to prevent, hide, minimize, or rapidly escape from moments of stuttering.
2. The client is often motivated to keep others from knowing they stutter.
3. Coping strategies can be overt (visible on the surface) and/or covert (not visible on the surface).
   

WARNING SIGNS ASSOCIATED WITH FLUENCY DISORDERS IN CHILDREN: EVIDENCE OF "REACTIVE" OR "COPING" BEHAVIORS

There are a variety of behaviors that indicate a child is developing "stutter-like" communication problems. As with the development of the stuttering response, these characteristics should be viewed as guidelines, rather than specific diagnostic indicators. It is the development of the response pattern that is the important issue, rather than a specific classification of "stutterer" or "non-stutterer" based on isolated behaviors.

Segmental Characteristics of Speech

1. Fragmentation of utterances into atypically smaller units. this can include fragmentation of connected utterances, phrases, or words. Frequency observed disfluency "types" associated with stutter-like speech are part-word repetition, sound prolongation, tense pause, silent blockage, and dysrhythmic phonation.
2. Frequent pauses accompanied by indications of posturing of the speech structures, cessation of air flow, or "bracing" behavior in the respiratory system. Pauses can occur at atypical linguistic boundaries.
3. Evidence of neutralization of vowel position during nonfluencies. The appropriate vowel sound is replaced with the "schwa" (e.g. "ba-ba-beet" for "be-be-beet").
   

Movement Characteristics

1. Excessive pauses and/or pause lengths at unnatural linguistic boundaries during either fluent or non-fluent talking.
2. Evidence of any form of voluntary or involuntary increase in the degree of physical effort or "pushing" before, during, or after fluent or non-fluent moments.
3. Evidence of any form of voluntary or involuntary increase in the degree of physical effort or "pushing" before, during, or after fluent or non-fluent moments.
4. Evidence of voluntary or involuntary variation in the speed of speech pace and/or structural movements during fluent or non-fluent talking.
5. Evidence of cessation or disruption in the flow of air/sound during fluent or non-fluent talking.
6. Evidence of "bracing" in the speech muscles before or during talking. Look especially at breath holding and/or tightly closing the vocal folds before beginning to talk.
   

Behavior Indications of Concern About Talking and/or Stuttering

1. A decrease or reluctance to initiate speech.
2. A decrease or reluctance to continue talking, following moments or periods of non-fluency.
3. Evidence of attempts to alter message by changing words, sounds, etc.
4. Evidence of unwillingness to enter specific speaking situations.
5. Evidence of frustration, anger, or embarrassment during fluent or non-fluent periods.
6. Verbal indications of concern about talking and/or stuttering.
7. Verbal indications that the child feels s/he is having trouble talking.
8. Verbal indications that child feels s/he is different from other children.
9. Verbal indications that child is confused about talking.
10. Verbal indications that child does not like to talk or feels s/he is a poor talker.
    

SUMMARY OF THE STUTTERING PROBLEM

Putting what we have together, we can summarize some basic characteristics of the stuttering response.

1. Stutter-like speech behavior is characterized by intermittent disruption in the rhythm and timing of speech movements. Inappropriate pause breaks, stoppage or prolongation of speech movement, and sound, interferes with the forward sequencing of speech. This creates the perception that speech is "stuck" or not moving forward.
2. Stutter-like speech is characterized by difficulty in rapidly and appropriately recovering from disrupted movement.
3. Individuals are not born with stuttering. Some individuals may be predisposed to intermittent disruption in continuous speech and/or natural recovery from these disruptions. Disruption in continuous speech can occur form a variety of sources and vary within and among talkers. Because of temporary or long-term sensitivity to speech disruption, speech behaviors exhibited by normal speakers can interfere with the speech of people who stutter.
4. the "stuttering response" includes the thoughts, emotions, and behaviors associated with anticipation and experience of uncontrolled disruption in forward speech. This response pattern develops over time.
5. A major component of the stuttering response is development of a "FEELING OF HELPLESSNESS" to produce forward speech or recover from speech disruption. This is caused, in part, by delayed or inappropriate recovery from disrupted speech. This elicits automatic cognitive, emotional, and behavioral reactions of panic.
6. Certain speech behaviors are more likely to trigger stuttering episodes. These behaviors include, but are not limited to:

   - Rapid onset and offset of speech movements

   - Forceful onset and offset of speech movements

   - Fast speaking rates

   - Forceful contacts of articulators

7. Increase in cognitive, linguistic, emotional, and motor demand on the system interferes with forward speech and effective recovery from disruption.
8. Stuttering episodes are often preceded and accompanied by behaviors that further interfere with natural speech movement or the recovery process. In many cases, these behaviors are natural reactions associated to the anticipation and experience of feeling helpless.
9. Development of the stuttering response is accompanied by the use of behavioral "coping strategies" designed to prevent, hide, reduce, escape from, or rationalize the speech problem. Many coping strategies interfere with more natural speech processes. This behavior often develops from natural motor reflex patterns combined with typical reactions to feelings of panic.
10. Development of cognitive, emotional, and behavioral "distracters" interferes with the speaker's ability to focus on and produce more natural speech/communication behaviors.