Theory and therapy in stuttering: A complex relationship

There are many treatments currently available for stuttering, for both children and adults. These range from direct interventions intended to reduce the severity and/or frequency of the speech behaviors of stuttering, to those intended to alleviate the anxiety and other mental health issues that can accompany the disorder. However, as there are little supporting data for many of these treatments, there is little consensus about which to use. Another way to evaluate stuttering treatments is to explore the extent to which they address the cause of the disorder. However, the cause of stuttering is not yet known. In this theoretical paper, a 3-factor causal model is presented, to which the mechanisms thought to be driving different treatments are then aligned. The model is innovative, in that it attempts to explain moments of stuttering. It is argued that all causal factors must be operating at each moment of stuttering. The model is intended as a new way of looking at cause, and how treatments may address cause. It is hoped this will stimulate discussion and lead to further lines of inquiry.Educational objectives: The reader will be able to: (a) describe the P&A 3-factor causal model of moments of stuttering; (b) state how indirect direct stuttering treatments relate to cause, according to the P&A model; (c) describe how direct stuttering treatments relate to cause, according to the P&A model; (d) state the purpose of cognitive behavior therapy; and (e) describe at least one suggestion for further research arising from the P&A model.     

The recovery rate of early stuttering

PurposeAcross studies there is great variability in reported rates of stuttering recovery. This study examined the impact that different definitions of recovery had on calculation of recovery rates and factors associated with recovery within the same sample of children.MethodSpeech samples and parents and child reports of their experiences of stuttering were collected from 38 children who stuttered aged 2–5 years of age (Occassion-1) and again at 9–13 years of age (Occassion-2). Four different criteria for recovery that were developed representing variations in criteria reported in previous research were applied to data from these children.Results. The majority of the participants (82%) showed very little disfluent speech (<1% syllables stuttered) at Occasion 2. Recovery rate varied greatly depending on the criteria used, ranging from 13.2%–94.7%. Definitions ordered from least to greatest recovery that were (a) parent and clinician report no stuttering and no stuttering observed (13.2 %); (b) ≤1% syllables stuttered; severity rated at ≤1; parent, clinician, and child report recovery (55.3 %); (c) ≤1% syllables stuttered; severity rated at ≤1; parent and clinician report recovery (71.1 %); (d) <3.0 % syllables stuttered (94.7 %). Five participants were considered recovered and two were considered persistent stutters across all criteria. Different factors were associated with recovery from stuttering depending on the criterion used.ConclusionThe concept of recovery from stuttering is complex and estimations of recovery rate are likely to be greatly affected by differences in definitions and measurement across studies. This has a flow-on effect in determining the factors associated with recovery from stuttering.     

Are there constraints on childhood disfluency?

Analysis of the spontaneous speech of eight stuttering and eight normally fluent children reveals that (a) the location of both stuttering and normal disfluent moments is constrained by sentential constituent structure, and (b) stuttering children experience fluency breakdown with a particular type of constituent (verb phrase) not usually disfluently produced by normals. A view of early stuttering as a sentence planning and integration disorder is present.     

Word-by-word analysis of observer agreement utilizing audio and audiovisual techniques

The purpose of this study was to compare audio and audiovisual techniques of analyzing stuttering behavior using a recently developed index of agreement (Young, 1975). Twenty speech pathologists identified moments of stuttering for ten adult stutterers using both audio and audiovisual methods. Although no statistically significant differences existed between the two conditions, the listeners had more difficulty identifying moments of stuttering during the audio condition when mild stutterers were used.     

Comparing judgments of stuttering made by students, clinicians, and highly experienced judges

Purpose: The purpose of this study was to compare judgments of stuttering made by students and clinicians with previously available judgments made by highly experienced judges in stuttering. Method: On two occasions, 41 university students and 31 speech-language pathologists judged the presence or absence of stuttering in each of 216 audiovisually recorded 5-s intervals of the speech of adults who stutter. Intrajudge and interjudge agreement were calculated, and comparisons were made to judgments previously made about the same recordings by 10 highly experienced judges of stuttering. Results: Students and clinicians showed similar and relatively high levels of intrajudge and interjudge agreement, but both students and clinicians identified less than half as much stuttering as the highly experienced judges had identified. Conclusions: These results replicate previous findings of high agreement coexisting with low accuracy in students’ judgments of stuttering, extending those findings to show that similar problems are evident in judgments made by practicing clinicians. Implications include the need for explicit stuttering judgment training programs for both students and practicing clinicians.

Educational objectives: After reading this article, the reader will be able to: (1) describe different methods for identifying stuttering and possible problems associated with each method; (2) describe two different methods for reporting interjudge reliability; (3) describe how the identification of stuttering differs for student, clinician, and highly experienced judges.     

Learning from negative outcomes in stuttering therapy: II. An epiphany of failures

Proceeding on the premise that learning advances on the feet of failure, a litany of therapeutic failures with stutterers across 3 decades is recounted. The basis for these failures included the assumptions that stuttering is a neurotic symptom; that “lucky fluency” can be maintained permanently; that a fluent drone is preferable to stuttering; that controlled fluency, once established, can be maintained permanently; that a proper task for clinicians is to motivate clients to achieve and preserve fluency; that the clinician has the responsibility for marching clients through their therapeutic paces; and that stuttering is punishing to the stutterer, so it is not preserved by reinforcement. Unfortunately, more has probably been learned about what does not work than what does.     

Psychological counseling as an adjunct to stuttering treatment: Clients’ experiences and perceptions

PurposeStuttering can trigger anxiety and other psychological and emotional reactions, and limit participation in society. It is possible that psychological counseling could enhance stuttering treatment outcomes; however, little is known about how clients view such counseling. The purpose of this study was to gain an understanding of clients’ experiences with, and perceptions of, a psychological counseling service that was offered as an optional adjunct to speech therapy for stuttering.MethodNine individuals who stutter (13-38 years old) participated in semi-structured interviews. Six participants had taken part in psychological counseling; three participants did not do so. Interview data were analyzed using grounded theory as a guiding framework.ResultsFour thematic clusters emerged from participants’ accounts: insights into personal decision-making, why others may not participate in counseling, psychological counseling as a worthwhile part of therapy, and counseling as a necessary component in a stuttering treatment program.ConclusionIn addition to experiencing barriers and facilitators to help-seeking that are reported in related fields, participants accounts also revealed novel facilitators (i.e., a ‘why not’ mentality and the importance of having a pre-existing relationship with the clinician who offered the service) and barriers (i.e., viewing the service as a ‘limited resource,’ and, the overwhelming nature of intensive stuttering treatment programs). Findings suggest that clients value the option to access psychological counseling with trained mental health professionals to support the stuttering treatment provided by speech-language pathologists. Participants made recommendations for the integration of psychological counseling into stuttering treatment programs.     

The use of self-efficacy scaling in training student clinicians: Implications for working with stutterers

A scaling technique developed by Bandura for determining an individual's personal performance expectations (self efficacy) was applied to student clinicians working with stutterers. The self-efficacy scores of clinicians conducting treatment increased significantly while the scores of clinicians without treatment experience showed no significant change. As the student clinicians gained clinical experience there appeared to be a corresponding reduction in fear and avoidance of the treatment situation. Clinician fear concerning stuttering treatment appeared to have little relation to performance in treatment as rated by supervisors. The results indicate that self-efficacy scaling may be used to indicate clinician avoidance of working with stuttering clients.     

Effects of stuttering on fundamental frequency

The purpose of this study was to systematically investigate quantitative fundamental frequency measures prior to moments of stuttering, and relate these measures to the severity and type of stuttering. A repeated readings adaptation procedure was employed to acquire samples of the stuttered and identical fluent speech of stutterers. Thirty-six utterance pairs were classified by type of stuttering (absence of phonation, prolongation, or repetition). A fundamental frequency meter was sampled by a microprocessor computer system at a rate of 256 samples/1.024 sec. Four temporal periods (each 256 msec) preceding the stuttering block were compared with the same periods in a fluently produced sample of similar speech. The analyses revealed differences relative to mean fundamental frequency, variation around the mean fundamental frequency, and the number of voiced data points contained within each temporal segment. The results of this study confirm the existence of acoustic changes in the vocal production of stutterers prior to overt blocks. These changes relate to the type of block that follows. Individual variations that emphasize the need for analyses of within subject differences were found.     

Australian speech-language pathologists’ experiences and perceptions of working with children who stutter: A qualitative study

PurposeEffective early intervention is recommended to ameliorate the potential long term negative effects of stuttering. Efficacious treatments are available, but speech-language pathologists (SLPs) report finding implementation to be challenging due to a range of clinician, client and clinical context factors. Previous survey-based research has found that SLPs lack self-efficacy working with CWS, however the reasons contributing to this are not well understood. This study presents the first in-depth analysis of the current practices and perceptions of SLPs working with children who stutter (CWS).MethodsIn this qualitative study 18 Australian SLPs who provide services to CWS were interviewed using a semi-structured interview approach. Data were analysed using reflexive thematic analysis.ResultsThe thematic analysis identified four themes: (1) A stronger sense of self-efficacy is needed in stuttering management compared to other areas of clinical practice; 2) SLPs’ sense of self-efficacy in stuttering management is influenced by early career experiences, client factors and the practice context; 3) Professional development and collaboration strengthen self-efficacy; and 4) Parental involvement and engagement are crucial to treatment success.ConclusionSLP self-efficacy for working with CWS appears a critical factor in the provision of effective management for this population. This study provides an in-depth analysis of the role of SLP self-efficacy and the factors that influence it.     

Electromyographic indications of laryngeal-area activity during stuttering expectancy

Using surface electrodes, mean microvolt values of laryngeal-area muscle activity were determined for 13 male and 6 female stutterers during 10-sec periods in which single words were silently read and stuttering expectancy was indicated. No significant differences in levels of laryngeal-area muscle activity were found between periods of fluency expectancy and stuttering expectancy preceding both fluent and stuttered speech. The results were interpreted as being nonsupportive of the hypothesis that a breakdown in stutterers' laryngeal-area muscle activity occurs during moments of stuttering expectancy. In addition, the results suggest that the most common rationale for the utilization of laryngeal biofeedback procedures to enhance fluency should be questioned.     

A survey of communicative disorders students' attitudes toward stuttering

Cooper's (1975) Clinician Attitudes Toward Stuttering (CATS) inventories were conpleted by 1,902 speech-language pathology and audiology students from 33 universities, each in a different state. The majority of respondents perceived stutterers as having psychosocial problems and believed that client and parental counseling were essential aspects of treatment. These views were relatively unaffected by student training and clinical exposure. In addition, most of the assumptions of Johnson's diagnosogenic theory of stuttering were held by the majority of the students surveyed. Most of the respondents believed that stuttering was difficult to modify and that speech clinicians were neither adept nor comfortable treating stutterers. These latter attitudes were significantly affected by training, i.e., the more advanced the students' training, the more pessimistic their views on clinician competence. Other professional attitudes and the effect of training on them are also discussed.     

Mindfulness training in stuttering therapy: a tutorial for speech-language pathologists

The use of mindfulness training for increasing psychological well-being in a variety of clinical and nonclinical populations has exploded over the last decade. In the area of stuttering, it has been widely recognized that effective long-term management often necessitates treatment of cognitive and affective dimensions of the disorder in addition to behavioral components. Yet, mindfulness based strategies and their possible usefulness in stuttering management have not been described in detail in the literature. This article seeks to engage professionals who treat stuttering in a conversation about the possible usefulness of incorporating mindfulness training into stuttering management. A review of the literature reveals that there is a substantial overlap between what is required for effective stuttering management and the benefits provided by mindfulness practices. Mindfulness practice results in decreased avoidance, increased emotional regulation, and acceptance in addition to improved sensory-perceptual processing and attentional regulation skills. These skills are important for successful long-term stuttering management on both psychosocial and sensory-motor levels. It is concluded that the integration of mindfulness training and stuttering treatment appears practical and worthy of exploration. Mindfulness strategies adapted for people who stutter may help in the management of cognitive, affective, and behavioral challenges associated with stuttering.Educational objectives: Readers should be able to: (1) describe what mindfulness is and how it is cultivated; (2) identify the benefits that can be produced from mindfulness practice; (3) summarize how the benefits of mindfulness practice parallel what is often required for effective long-term stuttering management; and (4) identify specific mindfulness techniques that can be taught in stuttering therapy and explain their rationale.     

Social anxiety in stuttering: measuring negative social expectancies

Much research has suggested that those who stutter are likely to be anxious. However, to date, little research on this topic has addressed the role of expectancies of harm in anxiety, which is a central construct of anxiety in modern clinical psychology. There are good reasons to believe that the anxiety of those who stutter is related to expectancies of social harm. Therefore, in the present study, 34 stuttering and 34 control participants completed the Fear of Negative Evaluation (FNE) Scale and the Endler Multidimensional Anxiety Scales-Trait (EMAS-T). The FNE data showed a significant difference between the stuttering and control participants, with a large effect size. Results suggested that, as a group, a clinical population of people who stutter has anxiety that is restricted to the social domain. For the EMAS-T, significant differences between groups were obtained for the two subtests that refer specifically to people and social interactions in which social evaluation might occur (Social Evaluation and New/Strange Situations) but not for the subtests that contained no specific reference to people and social interactions (Physical Danger and Daily Routines). These results were taken to suggest that those who stutter differ from control subjects in their expectation of negative social evaluation, and that the effect sizes are clinically significant. The findings also suggest that the FNE and the EMAS-T are appropriate psychological tests of anxiety to use with stuttering clients in clinical settings. The clinical and research implications of these findings are discussed, in terms of whether social anxiety mediates stuttering or is a simple by-product of stuttering. Possible laboratory explorations of this issue are suggested, and potential Cognitive Behavior Therapy packages for stuttering clients who might need them are discussed. EDUCATIONAL OBJECTIVES: The reader will be able to: (1) explain why expectancy of social threat or harm may be associated with stuttering; (2) name and describe two psychological tests that are suitable for assessment of the social threat or harm that may be associated with stuttering; and (3) explain how findings for the EMAS-T test in the present results suggest that expectancy of social threat or harm, but not other kinds of negative expectancy, are associated with stuttering.     

Middle school students' perceptions of a peer who stutters

Little is known about how middle school students perceive a similar-aged peer who stutters. Therefore, the purpose of this study was to examine the influence of stuttering frequency, Likert statement type (affective, behavioral, cognitive), and the gender of the listener on middle school students' perceptions of a peer who stutters. Sixty-four middle school students (10-14 years) individually viewed a video sample of a teen telling a joke at one of four stuttering frequencies (<1%, 5%, 10%, 14%). After the students viewed one of the video samples, they were asked to rate 11 Likert statements that reflected their affective, behavioral, and cognitive perceptions of a peer who stuttered. The results revealed an interaction between stuttering frequency and Likert statement type. Ratings of behavioral statements (speech production characteristics) were significantly more positive for the sample containing <1% stuttering than 10% and 14% stuttering. Ratings for cognitive statements (thought and beliefs) were significantly more positive for the sample containing <1% stuttering than 10% and 14% stuttering. The stuttering frequency of the peer did not significantly influence how students rated affective statements (feelings and emotions). It was also found that male and female middle school students did not significantly differ in their perceptions of a male peer who stutters. Clinical implications are discussed relative to peer teasing, friendship, listener comfort, and social acceptance within a middle school setting for a student who stutters. Future research directions are also discussed. EDUCATIONAL OBJECTIVES: The reader will be able to: (1) summarize how middle school students perceive stuttering; (2) explain how the frequency of stuttering influences middle school students' perceptions of a peer who stutters; and (3) provide clinical implications of the data from this study.     

Stuttering: a dynamic motor control disorder

The purpose of this review is to determine what neural mechanisms may be dysfunctional in stuttering. Three sources of evidence are reviewed. First, studies of dynamic inter-relationships among brain regions during normal speech and in persons who stutter (PWS) suggest that the timing of neural activity in different regions may be abnormal in PWS. Second, the brain lesions associated with acquired stuttering are reviewed. These indicate that in a high percentage of cases, the primary speech and language regions are not affected but lesions involve other structures, such as the basal ganglia, which may modulate the primary speech and language regions. Third, to characterize the motor control disorder in stuttering, similarities and differences from focal dystonias such as spasmodic dysphonia (SD) and Tourette’s syndrome (TS) are reviewed. This review indicates that the central control abnormalities in stuttering are not due to disturbance in one particular brain region but rather a system dysfunction that interferes with rapid and dynamic speech processing for production.

Educational objectives: The reader will be able to describe: (1) the similarities and differences between stuttering and other speech motor control disorders, (2) which brain lesions are most likely to produce acquired stuttering in adults, and (3) what type of brain abnormality most likely underlies stuttering.     

Evidence-based treatment of stuttering: I. Definition and application

The philosophy guiding evidence-based treatment and its application to decision-making in stuttering treatment is described. Limitations to the use of evidence-based treatment principles to guide stuttering treatment, namely the lack of a substantial treatment research literature that can serve as the basis for meta-analyses and systematic reviews of effective treatment studies, are bemoaned. Guidelines are provided to aid clinicians in their own conduct of critical evaluations of treatment research. EDUCATIONAL OBJECTIVES: The reader will learn about and be able to (1) describe the four steps that characterize evidence-based practice, (2) evaluate previous efforts to develop practice guidelines for stuttering, (3) assess the importance of an evidence-based approach to stuttering treatment, and (4) discuss the need for more research that will contribute to the evidence base.     

A rapid method of eliminating stuttering by a regulated breathing approach

The Habit Reversal Procedure for eliminating nervous habits was applied to the problem of stuttering. In the new procedure the speaker interrupted his speech at moments of actual or anticipated stuttering and at natural pause points, and resumed speaking immediately after breathing deeply during the pause. In addition to this regularized pausing and breathing, the program included other factors such as formulation of one's thoughts prior to speaking, identification of stutter-prone situations, identification of mannerisms associated with stuttering, speaking for short durations when tense or nervous, daily breathing exercises, relaxation procedures for anxiety, immediate display of improved speaking, and enlisting family support for progress. Fourteen stutterers were given training in the program during a single counseling session of about two hours duration. The next day, the average number of stuttering episodes decreased by 94 per cent, by 97 per cent at the end of one month, and by 99 per cent during the extended follow-up. Each of the clients was improved by at least 93 per cent. The new procedure appears to be more rapid and effective than alternative procedures.     

The effects of self-disclosure and non self-disclosure of stuttering on listeners' perceptions of a person who stutters

The aim of this study was to examine listener perceptions of an adult male person who stutters (PWS) who did or did not disclose his stuttering. Ninety adults who do not stutter individually viewed one of three videotaped monologues produced by a male speaker with severe stuttering. In one monologue, 30 listeners heard the speaker disclose stuttering at the beginning and in another monologue, 30 listeners heard the speaker disclose stuttering at the end. A third group of 30 listeners viewed a monologue where no disclosure of stuttering occurred. After listeners viewed a monologue, they were asked to rate a set of six Likert scale statements and answer three open-ended questions. The results showed that only one of six Likert statements was significantly different across the three conditions. The only statement that was different was that the speaker was perceived to be significantly more friendly when disclosing stuttering at the end of the monologue than when not disclosing stuttering. There were no significant differences between the percentage of positive and negative comments made by listeners across the three conditions. Listeners' comments to each open-ended question showed they were comfortable listening to stuttering with or without disclosure and slightly more than half of the listeners believed their perceptions of the speaker did not change when he disclosed stuttering. The results also showed that the speaker who disclosed stuttering at the beginning of the monologue received significantly more positive listener comments than when he disclosed stuttering at the end of the monologue. Results are discussed relative to comparisons with the study, the clinical relevance of acknowledging stuttering as a component of treatment, and future research on the self-disclosure of stuttering. Educational objectives: The reader will be able to: (1) describe how different groups of listeners perceive and respond to two conditions of self-disclosure of stuttering and one condition involving non self-disclosure of stuttering; (2) summarize the range of listener responses to and benefits of self-disclosure of stuttering; and (3) describe the value of self-disclosure of stuttering for the listener and the speaker.     

A case study of mediated learning, delayed auditory feedback, and motor repatterning to reduce stuttering

A case study of DW, an 11-yr. old monolingual, English-speaking boy who exhibits stuttering, language delay, and ADHD is presented. DW experienced only limited improvement during stuttering therapy received in public schools, according to parents and the public school clinician. The purpose of this case study was to assess whether fluency treatment which incorporated Mediated Learning, Delayed Auditory Feedback, and Speech Motor Repatterning would enhance progress. Therapy was delivered in two treatments, with each treatment being 5 wk. of intense therapy, separated by one year. Treatment 1 of combined Mediated Learning and Delayed Auditory Feedback yielded improvement in fluency, judged by parents and the teacher to be clinically significant. The improved fluency was maintained for one year when DW was pretested for participation in Treatment 2, which combined Mediated Learning, Delayed Auditory Feedback, and Speech Motor Repatterning Exercises. As no conclusions are possible, further study is needed.