THE STUTTERING RESPONSE
AN OVERVIEW OF DEVELOPMENTAL STUTTERING
The Stuttering Response: Overview
The disorder of "stuttering" has been and controversial concept to describe
and define for both professionals and lay persons. Some
have referred to stuttering as a "mysterious" disorder due, in part,
to its apparent elusiveness to a single cause as well as its obvious multidimentional
symptoms. This section describes how a "systems" model can be used
to understand, describe, and treat stuttering. While there is no doubt that
talking is a highly unique and complex process, development of a stuttering
problem is consistent with how our "systems" respond to internal
and external stimuli in many other behaviors and experiences throughout our
lifetimes. That is, understanding the fundamental relationships among
our thoughts, language, sensation, emotional arousal, movement patterns, and
adjustment strategies can be applied to understand many of the key features
that underlay developmental stuttering. By using a systems approach to understanding
behavior and development of response patterns we can draw specific analogies
between what we do when we talk and what we do when performing other non-speech
activities.Stuttering is seen less as a mysterious combination of disfluency,
emotions, and struggle and more as a natural sequence of behaviors, emotional
reacting, and ineffective coping strategies.
Continuing along this line the stuttering response is the predictable
result of the interaction among some or all components of our behavioral system.
The form of disrupted movement would depend on the specific source and extend
of variation within the system. It is suggested that some individuals who
exhibit stuttering or stutter-like behaviors at some time in their lives are
more sensitive to speech disruptions. Factors that contribute to fluency problems
can occur in any of the system components: cognition/language processing,
memory/imagery, motor control, sensory feedback, and emotional arousal. Inherent
and environmental conditions interact over time in developing the stuttering
response. The nature and factors that contribute to fluency problems can,
and often do, vary from one individual to the next.
It is important to understand that the
problem labeled as stuttering is not a single behavior or clinical entity.
Stuttering is a process of communication, and as such, involves the interaction among
what we think, feel, and do. The disorder of stuttering is more than just
a pattern of speech; it is a response pattern that involves intermittent disruption
in the coordination of speech movements, difficulty recovering naturally from
these disruptions, and the emotions, thoughts, and adjustment strategies that
occur as a result.
To help understand the complexity of the stuttering response, we can
break it down into two main areas: (1) the speech patterns associated
with disrupted movement - sequence, blending, speed, force, and rhythm, and
(2) the cognitive, emotional, and behavioral responses to speech disruptions.
Stutter-like speech behavior is the intermittent disruption in the forward
or fluidity of speech movements that interfere with forward communication.
Stutter-like speech also involves difficulty readjusting movement from these
disruptions in an effective, timely manner. The disruption/recovery process
extends beyond a time period expected by the speaker and listener for normal
information flow, called the Window of Acceptability. Motor control,
cognition, sensory integration, language processing and emotional arousal
govern the specific form and frequency of occurrence of disruption/recovery.
The stuttering response
is how the system reacts to the disruption/recovery problem and the involuntary/voluntary
adjustment strategies used to cope with the perception of being "stuck"
or out of control. For the most part, these reaction patterns are natural
responses of a normal system to sudden disruptions and the arousal associated
with these disruptions. Stimulation of the limbic system and its interconnections
with the thought, emotion, memory, and motor areas of the brain trigger much
of this. Disruption or the anticipation of disruption triggers the primitive
"fight or flight" response, resulting in cognitive awareness of
danger and a sudden flow of adrenaline throughout the body. The result is
sudden increase in heart rate, blood flow, and respiration. This is accompanied
by a physical bracing behavior, such as holding the breath against tightened
vocal folds, tensing muscles, and rapid movement. Such behaviors, while normal
responses to perceived threat, disrupt normal speech movements and effective
recovery. Because of neural interconnections among the limbic system and areas
of the brain that regulate thought, association, language, motor control,
and memory a chain reaction develops creating a self-perpetuating response
pattern. The difficult part of the stuttering response is that the system
is responding normally to the perception of threat. Unfortunately,
most of what the person does naturally to cope with speech disruptions makes
the situation worse, reinforcing the chain reaction. In this sense, a person
does not "have" stuttering (a noun), as one would have a wart on
the end of the nose or a medical disease. Rather, stuttering is a process
(a verb) of disrupted speech movement, inappropriate recovery, and the response
patterns that accompany perceptions of being "out of control".
Characteristics of Stutter-Like Speech
The position of this model is that
disruptions in speech, whether characterized as stuttering or normal disfluency,
arise from the same motor control system. Excessive or aberrant variation
in any component of the behavioral system
There is considerable overlap among the fluent and disfluent speech
characteristics of stutterers and non-stutterers. There are certain features
more characteristic of disordered speech. The following is a list of the most
prominent features associated with stutter-like speech patterns. These features
indicate the system is experiencing atypical breakdown in movement organization
and recovery processes. It should be cautioned that not all individuals who
stutter exhibit all of these behaviors. Nor are these patterns based on a
yes-no dichotomy. These behaviors fall on a continuum that can vary substantially within
and across talkers.
1.
Stutter-like speech is often
accompanied by disruption in the natural rhythm pattern across the utterance.
Non-stuttered speech and disruptions tend to maintain a constant or more appropriate
rhythm.
2.
Stutter-like disruptions
are often associated with a variation or cessation in movement of one or more
speech structures. This results in the prolongation of sound, the abrupt or
choppy repetition of sound, the complete cessation of sound, or a combination
of these.
3.
Stutter-like disruptions
are often associated with an involuntary blockage of the air stream through
the vocal tube.
4.
Stutter-like disruptions
are often accompanied by increase in the force and speed of speech movements,
exceeding what is necessary to generate natural movements. This is particularly
evident prior to as well as during a disrupted movement. This behavior is
characteristic of "jammed" movement resulting in increase in physical
struggle within or among the speech structures. This can also be observed
in non-speech structures as well.
5.
Variations in natural speech
movements before and during stuttered periods are often associated with attempts
to prevent or rapidly recover from disrupted speech.
6.
Releases from stutter-like
disruptions are often produced with excessive movement force and speed. The
recovery can be followed by an inappropriate pause not observed in non-stuttered
disfluencies. This feature is more common in advanced forms of stuttering.
7.
Speech onset, whether fluent
or disfluent, can be accompanied by extraneous speech and non-speech movements
not part of the natural sequence of the utterance. While some movements are
visible to the observer, others can occur in speech structures not readily
seen, such as vocal folds.
8.
The continuity or natural
speech rhythm can be disrupted by atypically long pauses, or pauses that occur
at unnatural linguistic boundaries in the utterance.
9.
Extraneous sounds, syllables,
words, and phrases can accompany stutter-like speech. These typically precede
words the speaker anticipates will be stuttered. These interjections occur
at both natural and unnatural linguistic boundaries in the utterance.
10.
Stutter-like speech disruptions
are often produced with inappropriate positioning of speech structures or
inappropriate sequence of speech movements.
The Stuttering Response
More than any other problem of speech and language stuttering carries
with it an aura of mystery and uncertainty for both the speaker and listener.
Up to this point we have explored the nature of speech production, disfluency,
recovery, and reactions that accompany deviant or delayed speech recovery.
The position is that motor and reactive behaviors share common characteristics
across speech and non-speech tasks. As such, the stuttering response is not
a unique process. Instead it is a familiar response pattern that arises from
the perception that the speaker is unable to prevent or effectively recover
from disruption in ongoing speech movement and forward communication.
But what would cause a person to struggle over something as simple
as their name? Why can a person say a particular word one moment and be hopelessly
entangled the next? Is the problem psychological or neurological? We do not
have
A Non-Speech Analogy of the Stuttering Response
It is the contention of the Systems model that the core of the stuttering
response is a natural
reaction pattern to disruption in the temporal organization of movement, the
inability to effectively recover in a timely manner, and the emotional-psychological
reactions of helplessness that stem from this predicament. To demystify the
stuttering response, it is helpful to begin with an analogy of how such an
anticipatory/adjustment pattern develops in non-speech behaviors. The intention
is to show that even the most mysterious of speech disorders has its origins
in understandable and natural human behavior. In order to clarify development
of the response pattern we will present the analogy in a three-step time frame.
What happens before, during, and after
a central event that triggers the system's reaction.
Our analogy is based on a driving experience and the events that lead
up to, occur during, and follow a traumatic experience. The reader is encouraged
to draw parallels between the act of driving and the act of talking as the
episode unfolds. While there are important differences between what we do
when we drive and when we talk the analogy should help demystify many of the
unusual behaviors associated with stuttering. Figure 1 depicts a hypothetical
time line that shows how the system responds to unpredictable events. The
cognitive, arousal, and motor reactions of the system at each stage of anticipatory
development are shown.
Figure
1.
Illustration depicting development of a hypothetical anticipatory
response pattern.
Before The Event
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. You focus minimal attention on specific driving movements.
Your body senses changes in the car and makes the necessary adjustments automatically
as you cruise easily down the highway. Your muscles are loose and comfortable
and the slight adjustments you make with the wheel, accelerator, and break
are natural and easy.
During The Event
Without warning the tail end of your
car begins to spin sideways. This sudden, unexpected behavior triggers a series
of instinctive reactions from your system. These behaviors occur so rapidly
that it seems your body is acting on its own. First, your focus of attention
(cognition) changes dramatically. Your thoughts are suddenly, almost forcefully,
jerked to awareness that the car is not moving in the expected way. The unexpected
swerving triggers a jolt of adrenaline through your body (arousal). This bombardment
of arousal and awareness of danger interferes with the other thoughts occurring
at the time. Your system interprets these combined reactions as being out
of control.
The motor system reacts spontaneously in response to the sudden changes
in attention, movement, and arousal. The muscles of your body, especially
your hands, arms, and legs tense in what appears to be a defensive, protective
type of bracing action. You put a death grip on the wheel and the muscles
of your arms and legs become rigid as your body executes a series of rapid
³coping² movements. Your arms jerk the wheel from side to side and as your
leg slams down hard on the breaks attempting to get out of the slide. Motorically,
these automatic actions reflect the system's natural recovery process. The
system tries to stop the car from spinning as fast as possible. The force
and speed of movement are tied to the intensity of the emotional arousal you
are experiencing. More panic increases the defensive motor reactions in an
attempt to decrease or escape the strong negative arousal experienced.
At this point your goal is no longer
to drive the car forward naturally but to prevent or escape fear and impending
danger. Your actions are motivated instinctively by the unexpected movement
of the car and the sudden emotional/physiological arousal interpreted as being
out of control.
Each of these reactions is involuntary. For the most part, the instinctive
coping strategies in response to panic make the situation worse. Attempts
to rapidly escape danger actually inhibit corrective readjustment in the car's
movement. This causes the car to spin more severely escalating the feelings
of panic. At this point people tend to react in individual ways. Some continue
to increase movement force and speed trying to get the car out of the spin.
Others respond to feelings of panic by giving up attempts to control the car.
They pull their hands and feet away from the steering wheel and brake pedal.
Neither of these instinctive reactions have a positive effect on getting the
car out of its spin and moving forward down the road.
Eventually, despite the feelings at the time, the laws of nature rule
that the car will stop spinning. It could eventually recover naturally, or
it could hit another car, tree, or ditch coming to a stop. Regardless of the
manner that the car stopped
After The Event
In most cases the problem does not
end when the car comes to a stop or recovers from the spin. The body continues
to experience a flow of emotional arousal. New forms of cognition emerge.
The mind is flooded with new thoughts; thinking about the event just experienced.
There is a conscious awareness of the panic as the adrenaline flows through
the body. The heart pounds faster and breathing is rapid and short. Your whole
body, especially your hands and legs, are tense and perhaps trembling. These
are all natural reactions of your system to the sudden danger you have just
experienced.
But now you must solve another problem. What happens next? How do you
get home? You are thinking about what has happened in the past in a way that
directly affects your present behavior and what you do in the future. The
strong emotional stimulation overshadows much of your thought processes. The
cognitive, sensory, and emotional cues associated with the incident become
stored in memory. In some cases, this memory is quite strong and visual. Just
thinking about the incident triggers similar feelings of panic and fear that
accompanied the original event. The thought of driving the car and anticipation
of loosing control again triggers thoughts and feelings of helplessness. Regardless,
you know you must start driving again. Now your system is responding quite
differently than before the accident occurred. Your mind becomes clouded and
distracted, attending to feelings of panic, thinking ahead, and anticipating
what will happen. No matter what you tell yourself it is impossible to control
your emotions. You cannot calm down or relax. As you drive the car again you
can't make natural and easy driving movements as before. Your muscles are
tense trying to keep the car from going into another spin. Thoughts and behavior
become anticipatory and
preventative rather than natural and forward. Your heightened arousal makes
you over sensitive to even the slightest movement of the car. Each movement
triggers the strong emotional and physical reactions. A response pattern has begun where
anticipation of a feared event triggers the feelings of panic and helplessness
associated with that event. This, in turn, triggers coping movements that
attempt to avoid, rapidly correct, or escape from the feared event. All the
way home you feel the car spin because your anxieties make it worse by tensing
and jerking the wheel.
It is now the next day. Thinking about driving your car to work triggers
the thoughts and emotional reactions experienced the previous day. You begin
thinking about what will happen all over again, anticipating and perhaps imagining
loosing control. You can make many different decisions that would help you
cope with
these new thoughts and fears. One decision
would be to avoid driving your car. This would reduce the immediate fear of
driving and loosing control. But this would lead to additional problems. You
would not be able to get where you need to go. This coping strategy could
lead to frustration with yourself. It could lead to feelings of guilt or inadequacy
for being unable or afraid to drive. But more importantly, avoiding new driving
experiences would reinforce what you imagined would happen if you got back
behind the wheel. There is no new positive experience to increase your confidence
in driving. Without new positive experiences in driving you are left only
with the memory of your traumatic experience and your fear of "what would
happen if . . .?"
A different decision would be to gut it out and get back behind the
wheel. Like the day before your mind focuses on what might happen at any moment.
You begin to relive the emotional and motor consequences of loosing control
of the car. Rather than allowing your system to drive naturally and easily
your entire system becomes protective. Now the slightest bump triggers emotional
responses equivalent to the actual spin. This only serves to reinforce the
anticipatory avoidance response pattern your system has developed from the
experience.
The anticipatory thoughts, sensations, emotions, and movements develop
into an involuntary pattern. This becomes a natural way for you to think and
feel about driving, not only when you are actually driving the car, but also
when thinking about driving in the future.
The Stuttering Response Pattern: Characteristics
We can use this driving analogy to understand the stuttering response.
Replace the act of driving with the act of talking. The car becomes your speech
and language mechanisms. Instead of using your arms, hands, and legs you are
using your respiratory, laryngeal and articulatory structures. The reader
can create a reasonable description of what a person might think, feel, and
do when experiencing the beginnings stuttering problem. Obviously, we are
not suggesting that speech communication is the same as driving a car. We
are suggesting that the natural response of the system is the same in the
two experiences. These commonalties can be used by the client and clinician
to further explore and perhaps demystify the problem of stuttering. It is
important to remember that this interaction is not unique to stuttering, but
reflects natural behavior.
First and foremost, the stuttering response begins like our driving
analogy. When the system responds with thoughts, emotions, behaviors, and
adjustments to the involuntary feelings of being out of control of speech.
Applying the series of events from our driving problem to talking we can see
that at pattern of ineffective communication emerges and develops with time
and negative experiences. Figure 2 presents a block diagram depicting the
relationship among speech breakdown, arousal, attitudes, and the development
of inappropriate coping strategies of the stuttering response. We can begin
to understand the nature of the stuttering response by describing how each
part of our communication system behaviors and responds.
Figure 2. Schematic representation of the stuttering response.
Speech Breakdown
We begin with speech breakdown and
ineffective recovery. At the present time, there is just not enough research
evidence to suggest that all stuttering problems derive from a single cause.
Causes of stuttering are most likely multidimensional, varying substantially
across individuals. Evidence strongly suggests the existence of subgroups
of persons who stutter each with a unique set of interacting variables. Genetic
predisposition, linguistic-phonological difficulties, neuromotor instability
and a host of other potential predisposing factors interact with environmental
and individualized personality traits for each person. Regardless of the original
cause or causes, the fact is that some individuals have less stable communication
systems that are more susceptible to disruptions in the natural organization,
timing, rhythm, and sequence of speech that leads to what we see as disfluency.
This is accompanied by difficulty making the rapid, involuntary adjustments
that result in the timely recovery back to fluid speech. The flow of speech,
and thus communication is hesitant at best and comes to a complete, although
temporary halt in its extreme.
In most cases, the automatic motor response to breakdown for the developing
or chronic stutterer inhibits natural movement. Movements within the speech
and non-speech structures become protective and preventative rather than natural
and fluid. Both fluent and disfluent periods are often characterized bracing
the speech musculature, rapid movements, and/or slow over controlled speech.
Many of these patterns are reactions to the anticipated and real episodes
of being out of control. In addition, the system's automatic reactions to
escape the moments 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 speeding of speech movements.
Emotional Arousal
Obviously, as with our driving example,
arousal plays a significant role in the nature and extent of the stuttering
response. When the recovery of forward speech is delayed, there is a natural
activation of our arousal systems leading to the involuntary activation of
our primitive "fight or flight" response. Experiencing a moment
of stuttering (temporary halt in forward speech movement and communication)
or merely anticipating its occurrence triggers negative thoughts, feelings,
and motor reactions. The emotions when anticipating or experiencing a stuttering
episode are not unlike the driver hit with the panic of being out of control.
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 or resume fluid, easy movement. Typical
physiological reactions to emotional stress are increase in muscle tension,
rapid jerky movement, and poor coordination. Attempts to rapidly reduce the
feelings of panic and embarrassment further disrupt the already disrupted
system. The faster one tries to escape or fix the disruption the worse the
disruption becomes. This leads to the chain reaction and vicious cycle that
marks the beginning of the stuttering response.
For clarity sake, we might want to divide the emotional arousal often
associated with moments of stuttering into two distinct yet overlapping categories.
These are not limited only to stuttering, but reflect changes in arousal associated
with most all human behaviors. We will simply break them down into two simple
categories, spontaneous and long-term arousal.
Spontaneous arousal this involves
the sudden increase in autonomic arousal that can immediately precedes or
accompany a stuttering episode. The onset of this arousal is virtually instantaneous
and often triggers automatic fight or flight responses. This arousal state
is a major component of the feeling of being momentarily helpless or out of
control.
Long-term arousal develops with
continued experience with stutter-like speech disruptions and the spontaneous
emotions that accompany them. They evolve into attitudes and feelings associated
with the act of talking, speech disruption, and the personal/social stigma
the person attaches to stuttering. These feelings, thoughts, and images often
become habitual and naturally tied to specific speaking situations. These
emotions and attitudes persist long after the actual stuttering moment has
ended and can begin to occur long before an actual stuttering event occurs.
These responses become a part of the person's natural thought/emotional/
action link. While spontaneous arousal is often triggered by the occurrence
of actual events perceived to be threatening, the long-term arousal can become
self-generating. That is, a person's thoughts and the mental images generated
by these thoughts stimulate the emotional centers of the brain, triggering
the defensive arousal and physiological reactions.
While our emotions and variations states of arousal can be triggered
rapidly and intensely by even the slightest thought or experience, they are
extremely difficult to voluntarily control or reduce quickly. With proper
training, however, an individual can learn to monitor and more effectively
alter the physiological reactions that accompany perceptions of threat and
fear. Individuals can also learn to monitor and more effectively shape changes
in emotion and arousal. Together, the individual can learn to prevent and/or
respond more effectively to the situations and stimuli that previously resulted
in the feelings of anticipation, fear, and anxiety and more effectively shape
the speech (or driving) behaviors for a better outcome. Being able to voluntarily
produce more natural, easy talking while experiencing strong emotional
reactions to stuttering
is what leads to the development of confidence and an eventual reduction in
the long-term fear of talking.
As with our driver friend continued fear of loosing control heightens
the speaker's sensitivity to variations in visual, auditory, linguistic, and
movement activity that indicates stuttering might occur. This is characteristic
of the limbic system and its interconnections with sensory/memory areas of
the brain. Even slight hesitations in speech trigger strong emotional and
physical reactions. In addition to internal cues, the speaker becomes over
sensitive to perceived reactions from listeners. Attending and reacting to
these cues elicits interfering thoughts, emotions, and behavior - increased
disruption.
Thoughts, Attitudes, and Beliefs
As suggested above, our thoughts, perceptions, and attitudes are integral
players in development and maintenance of a stuttering problem. Like our driver,
how we think about, react to, and evaluate our past experiences strongly influences
what we believe will happen in the future. Focusing on the past and anticipating
the future has a significant influence on what we do in the present.
With continued experience with speech disruptions and ineffective recovery
a child can begin to focus their attention away from the natural free flow
of thoughts and communication an onto the anticipatory fear of what will occur
if they try to talk. Most often, this involves the belief that they will get
stuck on words, repeat sounds or words endlessly, etc. In some cases these
thoughts are accompanied by visual images of stuttering, that is, images of
the very thing they do not want to happen. This type of anticipatory thoughts
and images combine to produce the primitive protective emotional and physiological
reactions discussed above. These thoughts, in turn, often further disrupt
the smooth, natural speech and language behaviors. This can result in a negative
downward spiral of anticipation, arousal, fear, and more disruption associated
with development of a more chronic stuttering response problem. The natural
free flowing process of talking becomes overshadowed by anticipatory fears
and thoughts about how they talk and what will happen if they stutter. The
motivation of talking shifts from expressing ones ideas to one of avoiding
and hiding potential or actual talking mistakes. Rather than the easy, natural
flow of thoughts, the child's attention is directed toward a protective "not
to stutter" mode of communicating.
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 a natural part 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. They also play a significant role in the development
of a person's self-image, attitudes and beliefs about relationships, and their
role in society.
Adjustment and Coping 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 adjustment or coping strategies.
Adjustment 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 that the speaker has begun to react to talking and the occurrence
of speech disruptions in a negative way. Adjustment strategies are often perceived
by the speaker as the only effective means to handle their speech problem.
In fact, 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.
An important element in any treatment program will be to first identify
if and what the clients are doing to help themselves talk more effectively.
In doing so, the clinician determines if these are involuntary (learned or
reflexive) and/or voluntary (intentional) changes and whether or not the motivation
of these strategies is to prevent, rapidly escape from, or hide the occurrence
of disfluencies out of fear or embarrassment. An important goal of treatment
will be to help the client understand and shape their speech, not out of fear,
but in a manner that promotes the most natural, easy, and forward communication
possible.
This might not always mean totally disfluency-free or stutter-free speech.
Distracters and the Problem of Stuttering
As we have seen stuttering involves not only disruption in coordinated
speech but also the thoughts, perceptions, emotions, and behaviors that develop
from experiencing these disruptions. These response patterns can be presented
in a clinically useful way by introducing the concept
of distracters. In essence, a distracter is any thought, feeling, or
behavior that draws the speaker's attention away from the natural processes
of communication and the specific behavioral goals to be accomplished at any
point in time and/or
motivates an unnatural variation in communication. Distracters can emanate
from many sources but are most frequently associated with the anticipatory thoughts and feelings by the speaker.
These include: 1) a stuttering episode will occur, 2) there will be a loss
of control of speech, 3) listeners will identify and negatively react to the
person as someone who stutters, and 4) listeners will negatively react to
the specific stuttering episodes. These distracters often become a natural
part of how the individual communicates and further interfere with the ability
to speak effectively. It is important during the evaluation and treatment
process to help the client identify and more effectively respond to the occurrence
of these distracters.
DEVELOPMENT OF THE STUTTERING RESPONSE
AND POTENTIAL WARNING SIGNS
A person is not born with the stuttering response. Some individuals
might be born with an unstable communication system that, at least in some
part of their lives, predisposes them to disruption in the natural sequence,
timing, rhythm, and movement patterns of speech. What we refer to here as
the stuttering response
is a pattern of thought, emotion, speech, and adjustments that develops over
time and experience with continued speech interruption and the natural thought,
arousal, and behavioral coping reactions to those disruptions. The specific
nature and speed of development of each pattern differs from one person to
the next. Some might begin to show warning signs of potential stuttering problems,
only to recover natural speech spontaneously and without any type of intervention.
The research data strongly suggests that a majority of individuals presumed
to have exhibited some form of stuttering at some time in their lives will
recover without intervention. Unfortunately, it is very difficult at the present
time to predict if and when spontaneous recovery will occur. This places the
client, parents and guardians, and the fluency clinician at a distinct disadvantage.
There are, however, general patterns of development of the stuttering response
that can be used as a guide. Caution should be given here to emphasize that
each person is unique and that symptoms can vary substantially both within
and across clients.
These two sections are presented as outlines
to guide the clinician in making thoughtful and informed observations and
decisions about potential problems. The first section called Four Phases
of the Stuttering Response is an outline describing the most
salient characteristics of a developing stuttering response across time. 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 problem, often with overlap from one phase
to another. The second section called, Warning Signs of Stuttering Development is an outline listing those features
of communication that are most indicative of a potential stuttering problem.
Again, the reader should be warned that seldom does one or two items alone
signify the clear presence of a stuttering problem or indicate that a stuttering
problem will probably occur. They should be used in aggregate to help develop
a profile that describes the client's communication patterns and whether these
patterns warrant professional attention.
Four Phases of
Stuttering Development
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
The child shows no awareness or reaction to disfluency in speech.
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 children 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.
·
little or no evidence of
increase in movement speed or force used in the speech and non-speech structures.
·
little or no evidence of
observable variation or cessation of airflow or articulatory movement during
speech.
·
blending, sequencing, force,
and speed generally appropriate during fluent episodes.
Cognition
1. No evidence that the
child is aware of disfluencies.
2. No evidence that the
child anticipates disruption.
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.
Occurrence of disfluency
becomes more chronic. Disfluency 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
4.
same features as PHASE I
5.
evidence of fragmentation
of speech. This often includes part-word repetition, hesitation/pauses, prolongation,
and dysrhythmic phonation
6.
Non-segmental features of
speech and disfluency
7.
speech continuity is disrupted
by hesitation, prolongation, and/or complete cessation of movement of the
speech structures.
8.
Increased evidence of disrupted
airflow and sound during disfluent episodes.
9.
Evidence of involuntary "pushing"
of speech structures during disfluency. Some involuntary variation in tension
in speech musculature.
10.
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.
Evidence of emerging avoidance behaviors observed in some children. The child may talk less often.
Phase III
Characterized by awareness
and emotional/cognitive reaction to speaking difficulty. This is combined
with perceptual-physical reactions to being out of control.
Speech Production
1. Chronic episodes of disruption.
Less frequent extended periods of fluency. Disfluency generalized to specific
speaking situations.
2. Segmental features of disfluency
·
primary fragmentation of
speech units. Part-word/sound repetitions, extended prolongations, dysrhythmic
phonation are common
·
interjections used as postponement
behaviors
·
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 and
speeding in speech musculature during disfluent episodes.
·
evidence of involuntary and
voluntary changes in movement sequence, force, and/or speeding prior
to disfluent episodes.
·
release from disfluent episodes
is often abrupt and forceful.
·
evidence of generalization
of struggle-type behaviors in the non-speech musculature.
Cognition
1. Verbal and non-verbal evidence that child is aware of inability
to "get words out". Might call him/herself a "stutterer."
2. Focus of attention prior to and during talking shifts to anticipation
of impending disruptions.
3. Focus of attention shifts to negative internal and environmental
"cues" associated with disruption.
Emotional Arousal
1. Increase
in overt evidence of fear/panic reactions during disruption. This is associated
with perception of being out of control (Window of Acceptability).
2. Overt
and covert evidence of anticipatory emotional reaction of fear and panic to
disruptions. Increase in arousal is generalized to certain speaking situations.
Verbal/non-verbal 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. Development of specific coping strategies is evident. These
are associated with attempts
to avoid, postpone, escape, or hide disruptions
·
recoil/postponement behaviors
·
excessive "pushing/forcing"
behaviors
·
increase in more covert forms
of disruption (holding back)
·
sound/word avoidance
·
circumlocutions (change or
avoid certain words)
·
decreased in specific situations
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.
Speech Production
1. Chronic disruptions. Generalization of
disruption to talking in general.
2. Segmental features: same as Phase III
but increased in frequency and severity.
3. Non-segmental features: same as Phase III but increased in frequency and severity.
4. Decrease in the rhythm, sequence, and
timing of fluent utterances. This is associated with anticipation and prevention
of impending stuttering.
Cognition
1. The individual now "thinks like a stutterer". Focus
of attention prior to and during talking is on anticipation of disruptions.
The client believes s/he is out of control when talking.
2. Primary focus of attention when talking
is on hiding, preventing, or rapidly escaping from disruption.
3. There is a marked increase in anticipatory "scanning"
of the utterance for potential disruptions.
4. The individual focuses attention on emotional
cues prior to and during disruptions on being "a stutterer."
5. Development of specific attitudes and perceptions about h/herself
associated with stuttering and being "a stutterer."
Emotional Arousal
1. A strong bond is created between the anticipation
and occurrence of speech disruptions and the emotional reactions of fear and
panic.
2. Strong emotional arousal prior to and
during moments of disruption that correspond to panic of being out of control.
3. Strong long-term emotional arousal to
anticipation of stuttering and the stigma that accompanies being out of control
of talking.
Coping Strategies
1. The client continues to develop a variety
of strategies intended to hide, prevent, minimize, or rapidly escape from
moments of stuttering.
2. Coping strategies can be overt and/or
covert in nature.
Warning Signs Associated
with Developmental Stuttering
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 responses pattern that
is the important issue, rather than a specific classification of stutterer
or non-stutterer based on isolated behaviors. The stuttering response is typically
not limited to just one or two characteristics, but is made up of a combination of thoughts, emotional reactions, speech
behaviors, and attempts to fix or hide their speech difficulties from others.
The
following are some of the more common characteristics the clinician should
assess when considering whether or not a child is developing, or has developed
a stuttering problem. Remember that not all children will exhibit the same
characteristics. They will vary on the origin of the problem, the childıs
personality, the childıs environment, and how each child tends to react to
perceptions of difficulty and/or failure.
I. Speech Patterns
Segmental Characteristics
of Speech
·
Fragmentation of utterances
into atypically smaller units. This can include
fragmentation
of connected utterances, phrases, or words. Pauses often occur at atypical
linguistic boundaries are not uncommon features. For example "I want-want-want-want
to go to the store with you" becomes "I wa-wa-wa-wa-want to go to
the store with you".
·
Vowel neutralization during
disfluencies. This is where the appropriate vowel sound is replaced
with the "schwa" ("uh") sound. For example "be-be-beet"
becomes "ba-ba-beet"
Movement Characteristics of Speech
·
Excessive number of pauses
and/or atypically long pause lengths at atypical linguistic boundaries during
either fluent or non-fluent speech
·
Any form of voluntary or
involuntary variation of natural sequence of speech structural movements before,
during, or after either fluent or disfluent moments.
·
Any form of voluntary or
involuntary increase in physical effort in respiratory, laryngeal, neck, and
or facial areas before, during,
or after fluent or disfluent moment. This is often perceived as the speaker
fighting their speech or trying to "push words out".
·
Any form of voluntary or
involuntary increase in physical effort in other areas of the body (such as
the hands, arms, legs, torso, etc.) before or during speech. In some instances,
this can be observed when the person is not speaking as well.
·
Evidence of atypically fast
or slow speech pace and/or structural movements during fluent or disfluent
talking.
·
Evidence of atypical cessation
or disruption in the flow of air and/or sound during fluent or disfluent talking.
·
Evidence of atypical breathing/laryngeal
patterns during speech. This can take many forms such as bracing the chest
and/or abdomen during pauses, at the beginning of utterances, or during disfluencies.
Other variations include, but are not limited to, taking a rapid (deep or
shallow) breath before initiating an utterance, holding ones breath immediately
before initiating an utterance, initiating speech with tightly closed vocal
folds.
II. Atypical Adjustment
or Helping Strategies
·
Decrease in talking or indications
of reluctance to initiate speech.
·
Reluctance to continue talking
following moments or periods of non-fluency.
·
Evidence of attempts to alter
message by avoiding, substituting,
or changing sounds or words.
·
Attempts to hide disfluencies
from the listener
·
Evidence of reluctance to
talk in certain speaking situations.
·
Reluctance to enter into
certain speaking situations
·
Uses extraneous words (starters)
to initiate speech
·
Uses extraneous body movements
or gestures to help initiate speech
·
Times extraneous body movements,
such as the head, hands, or feet with occurrence of disfluencies
III. Thoughts,
Beliefs, Attitudes, and/or Perceptions
·
Shows or indicates frustration,
anger, or embarrassment about talking in general.
·
Shows, frustration, anger,
or embarrassment during disfluencies.
·
Indicates verbally or nonverbally
that talking is hard.
·
The child believes they talk differently from
other children.
·
The child shows confusion about the way they
talk.
·
The child believes they do
not talk well.
·
The child believes others
do not like the way they talk.
·
Attempts to hide talking
mistakes or their stuttering
THE STUTTERING PROBLEM: A SUMMARY
Putting what we have together we can summarize some basic characteristics
of the stuttering response.
1.
Stuttered speech behavior is characterized by intermittent disruption
in the rhythm and timing of speech movements. Inappropriate pause breaks and
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.
Stuttered speech is characterized by difficulty 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 from 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 adjustment 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 speakerıs ability to focus on and produce more natural speech/communication
behaviors.