GAGAP

Stuttering

What is stuttering?

Stuttering affects the fluency of speech. It begins during childhood and, in some cases, lasts throughout life. The disorder is characterized by disruptions in the production of speech sounds, also called "disfluencies." Most people produce brief disfluencies from time to time. For instance, some words are repeated and others are preceded by "um" or "uh." Disfluencies are not necessarily a problem; however, they can impede communication when a person produces too many of them.

In most cases, stuttering has an impact on at least some daily activities. The specific activities that a person finds challenging to perform vary across individuals. For some people, communication difficulties only happen during specific activities, for example, talking on the telephone or talking before large groups. For most others, however, communication difficulties occur across a number of activities at home, school, or work. Some people may limit their participation in certain activities. Such "participation restrictions" often occur because the person is concerned about how others might react to disfluent speech. Other people may try to hide their disfluent speech from others by rearranging the words in their sentence (circumlocution), pretending to forget what they wanted to say, or declining to speak. Other people may find that they are excluded from participating in certain activities because of stuttering. Clearly, the impact of stuttering on daily life can be affected by how the person and others react to the disorder.

What are signs and symptoms of stuttering?

Stuttered speech often includes repetitions of words or parts of words, as well as prolongations of speech sounds. These disfluencies occur more often in persons who stutter than they do in the general population. Some people who stutter appear very tense or "out of breath" when talking. Speech may become completely stopped or blocked. Blocked is when the mouth is positioned to say a sound, sometimes for several seconds, with little or no sound forthcoming. After some effort, the person may complete the word. Interjections such as "um" or "like" can occur, as well, particularly when they contain repeated ("u- um- um") or prolonged ("uuuum") speech sounds or when they are used intentionally to delay the initiation of a word the speaker expects to "get stuck on."

Some examples of stuttering include:

• "W- W- W- Where are you going?" (Part-word repetition: The person is having difficulty moving from the "w" in "where" to the remaining sounds in the word. On the fourth attempt, he successfully completes the word.)
• "SSSS ave me a seat." (Sound prolongation: The person is having difficulty moving from the "s" in "save" to the remaining sounds in the word. He continues to say the "s" sound until he is able to complete the word.)
• "I'll meet you - um um you know like - around six o'clock." (A series of interjections: The person expects to have difficulty smoothly joining the word "you" with the word "around." In response to the anticipated difficulty, he produces several interjections until he is able to say the word "around" smoothly.)

How is stuttering diagnosed?

Identifying stuttering in an individual's speech would seem like an easy task. Disfluencies often "stand out" and disrupt a person's communication. Listeners can usually detect when a person is stuttering. At the same time, however, stuttering can affect more than just a person's observable speech. Some characteristics of stuttered speech are not as easy for listeners to detect. As a result, diagnosing stuttering requires the skills of a certified speech-language pathologist (SLP).

During an evaluation, an SLP will note the number and types of speech disfluencies a person produces in various situations. The SLP will also assess the ways in which the person reacts to and copes with disfluencies. The SLP may also gather information about factors such as teasing that may make the problem worse. A variety of other assessments (e.g., speech rate, language skills) may be completed as well, depending upon the person's age and history. Information about the person is then analyzed to determine whether a fluency disorder exists. If so, the extent to which it affects the ability to perform and participate in daily activities is determined.

For young children, it is important to predict whether the stuttering is likely to continue. An evaluation consists of a series of tests, observations, and interviews designed to estimate the child's risk for continuing to stutter. Although there is some disagreement among SLPs about which risk factors are most important to consider, factors that are noted by many specialists include the following:

• a family history of stuttering
• stuttering that has continued for 6 months or longer
• presence of other speech or language disorders
• strong fears or concerns about stuttering on the part of the child or the family

No single factor can be used to predict whether a child will continue to stutter. The combination of these factors can help SLPs determine whether treatment is indicated.

For older children and adults, the question of whether stuttering is likely to continue is somewhat less important, because the stuttering has continued at least long enough for it to become a problem in the person's daily life. For these individuals, an evaluation consists of tests, observations, and interviews that are designed to assess the overall severity of the disorder. In addition, the impact the disorder has on the person's ability to communicate and participate appropriately in daily activities is evaluated. Information from the evaluation is then used to develop a specific treatment program, one that is designed to:

• help the individual speak more fluently,
• communicate more effectively, and
• participate more fully in life activities.

What treatments are available for stuttering?

Most treatment programs for people who stutter are "behavioral." They are designed to teach the person specific skills or behaviors that lead to improved oral communication. For instance, many SLPs teach people who stutter to control and/or monitor the rate at which they speak. In addition, people may learn to start saying words in a slightly slower and less physically tense manner. They may also learn to control or monitor their breathing. When learning to control speech rate, people often begin by practicing smooth, fluent speech at rates that are much slower than typical speech, using short phrases and sentences. Over time, people learn to produce smooth speech at faster rates, in longer sentences, and in more challenging situations until speech sounds both fluent and natural. "Follow-up" or "maintenance" sessions are often necessary after completion of formal intervention to prevent relapse.

What can I do to communicate better with people who stutter?

Often, people are unsure about how to respond when talking to people who stutter. This uncertainty can cause listeners to do things like look away during moments of stuttering, interrupt the person, fill in words, or simply not talk to people who stutter. None of these reactions is particularly helpful, though. In general, people who stutter want to be treated just like anybody else. They are very aware that their speech is different and that it takes them longer to say things. Unfortunately, though, this sometimes leads the person to feel pressure to speak quickly. Under such conditions, people who stutter often have even more difficultly saying what they want to say in a smooth, timely manner. Therefore, listeners who appear impatient or annoyed may actually make it harder for people who stutter to speak.

When talking with people who stutter, the best thing to do is give them the time they need to say what they want to say. Try not to finish sentences or fill in words for them. Doing so only increases the person's sense of time pressure. Also, suggestions like "slow down," "relax," or "take a deep breath" can make the person feel even more uncomfortable because these comments suggest that stuttering should be simple to overcome, but it's not!

Of course, different people who stutter will have different ways of handling their speaking difficulties. Some will be comfortable talking about it with you, while others will not. In general, however, it can be quite helpful to simply ask the person what would be the most helpful way to respond to his or her stuttering. You might say something like, "I noticed that you stutter. Can you tell me how you prefer for people to respond when you stutter?" Often, people will appreciate your interest. You certainly don't want to talk down to them or treat them differently just because they stutter. However, you can still try to find a matter-of-fact, supportive way to let them know that you are interested in what they are saying, rather than how they're saying it. This can go a long way toward reducing awkwardness, uncertainty, or tension in the situation and make it easier for both parties to communicate effectively.

What other organizations have information about stuttering?

This list is not exhaustive and inclusion does not imply endorsement of the organization or the content of the Web site by ASHA.

• National Stuttering Association
• Stuttering Home Page Chat Room
• University of Wisconsin Family Village Stuttering Page
• Stuttering Home Page
• Stuttering Foundation of America
• The Canadian Stuttering Association
• International Stuttering Association
• K12 Academics Stuttering Page
• University College London's Archive of Stuttered Speech (UCLASS) Speech samples from children who stutter

What causes stuttering?

The exact cause of stuttering is unknown. Recent studies suggest that genetics plays a role in the disorder. It is thought that many, if not most, individuals who stutter inherit traits that put them at risk to develop stuttering. The exact nature of these traits is presently unclear. Whatever the traits are, they obviously impair the individual's ability to string together the various muscle movements that are necessary to produce sentences fluently.

Not everyone who is predisposed to stutter will develop the disorder. For many, certain life events are thought to "trigger" fluency difficulty. One of the triggers for developmental stuttering may be the development of grammar skills. Between the ages of 2 and 5 years, children learn many of the grammatical rules of language. These rules allow children to change immature messages ("Mommy candy") into longer sentences that require coordination to produce fluently ("Mommy put the candy in my backpack"). A child who is predisposed to stutter may have no difficulty speaking fluently when sentences are only one or two words long. However, when the child starts trying to produce longer, more complex sentences, he or she may find himself or herself not quite up to the challenge-and disfluent speech results.

After stuttering has started, other factors may cause more disfluencies. For example, a child who is easily frustrated may be more likely to tighten or tense speech muscles when disfluencies occur. Such tension may increase how long a disfluency lasts. Listeners' responses to stuttering (e.g., teasing) can aggravate fluency difficulties as well. People who stutter vary widely in how they react to the disfluencies in their speech. Some appear to be minimally concerned. Others-especially those who have encountered unfavorable reactions from listeners-may develop emotional responses to stuttering that hinder speech production further. Examples of these emotions include shame, embarrassment, and anxiety.

How common is stuttering and when does it typically start?

Usually, the symptoms of developmental stuttering first appear between the ages of 2½ and 4 years. Although less common, stuttering may start during elementary school. Stuttering is more common among males than females. Among elementary school-age children, it is estimated that boys are three to four times more likely to stutter than girls. Preschoolers may show little or no awareness of their speech difficulties, particularly during the early stages of the problem. Throughout the school years and beyond, however, most people who stutter become increasingly aware of their speech difficulties and how others react when they do not speak fluently.

The development of stuttering varies considerably across individuals. Some children show significant difficulty with speech fluency within days or weeks of onset. Others show a gradual increase in fluency difficulties over months or years. Furthermore, the severity of children's stuttering can vary greatly from day to day and week to week. With some children, the disfluencies may appear to go away for several weeks, only to start again for no apparent reason. For teens and adults who stutter, the symptoms of stuttering tend to be more stable than they are during early childhood. Still, teen and adult speakers may report that their speech fluency is significantly better or worse than usual during specific activities.

About 75% of preschoolers who begin to stutter will eventually stop. Many children who "recover" from stuttering do so within months of the time their stuttering started. Nonetheless, there are some people who have stuttered for many years and then improve. Why some people recover is unclear, and it is not possible to say with certainty whether the stuttering symptoms for any particular child will continue into adulthood. Children's recovery from stuttering may happen when they receive speech therapy. The role of speech therapy in the recovery process needs to be studied further, however, because some preschoolers appear to recover without ever having seen an SLP. It is hoped that, with continued research, SLPs will someday be able to precisely answer questions about why and how recovery takes place, both with and without speech therapy.

How effective are treatments for stuttering?

ASHA produced a treatment efficacy summary on stuttering [PDF] that describes evidence about how well treatment works. This summary is useful not only to individuals who stutter and their caregivers but also to insurance companies considering payment for much needed services for stuttering.

What do SLPs do when working with individuals who stutter?

SLPs work to help people who stutter lessen the impact or severity of disfluency when it occurs. The goal is not so much to eliminate disruptions in fluency-which many people find difficult to do-but to minimize their impact upon communication when they do occur. People may be taught to identify how they react to or cope with breaks in speech fluency. They learn other reactions that will lead to fluent speech and effective communication. For instance, a person who often produces long, physically tense disfluencies would learn to modify these disfluencies so that they become fleeting, relatively effortless breaks in speech. As people become better at managing fluency in therapy, they practice the newly learned skills in real-life situations.

People usually find that these behavioral strategies are relatively easy to implement during therapy activities. In contrast, people may find that day-to-day fluency management-at least in the early stages of treatment-is hard work! Use of the various fluency management techniques requires mental effort. It is one thing to manage or monitor speech rate in a quiet, controlled setting like a therapy room, but quite another in a noisy, fast-paced office or classroom. For this reason, SLPs often work with family members, teachers, and others on what to expect from therapy. Generally, it is not reasonable to expect that a person who stutters will be able to monitor or control his speech fluency at all times of the day in all situations.

Traditionally, there has been some reluctance to treat stuttering during the preschool years. This reluctance has stemmed from at least two sources: the observation that many children "outgrow" stuttering, and the belief that therapy heightens a child's awareness of fluency difficulty which in turn increases the child's risk for persistent stuttering. Current thinking is somewhat different from these traditional views, however. It is now generally agreed that early intervention for stuttering is desirable. That said, an SLP still may recommend a "wait and see" approach for children who have been stuttering for only a few months and who otherwise appear to be unconcerned and at low risk for persistent stuttering. If treatment is recommended for preschoolers, the approaches taken usually are somewhat different from those used with older children and adults. For example, parents may be trained to provide youngsters with feedback about their speech fluency, praising the fluent speech ("That was very smooth!"), and occasionally highlighting instances of disfluent speech ("That sounded a little bumpy"). Parents and/or SLPs may model smooth speech. SLPs teach parents when, where, and how to implement these treatments. Recent research suggests that intervention programs like these are quite effective at reducing, if not eliminating, the symptoms of stuttering with preschoolers.

In addition to the approaches described above, a variety of assistive devices have been developed to help those who stutter speak more smoothly. Most of these assistive devices alter the way in which an individual hears his or her voice while speaking. The devices often are small, so that they fit in or behind a speaker's ear. Laboratory research suggests that some individuals who stutter speak more fluently when they hear their voice played back to them at a slight delay or at a higher or lower pitch, or when "white noise" is played into their ear as they speak. How effective these devices are in real-life settings continues to be studied. Early findings suggest that some people find some auditory feedback devices very helpful, while others do not. Research is ongoing to identify:

• why some people benefit from the devices more than others
• whether the devices can be made to be more effective
• how much improvement one might expect in fluency when a device is used either alone or with speech therapy
• whether the benefits last over time

More information on the role of the SLPis available:

• The Preferred Practice Patterns for the Profession of Speech-Language Pathology outline the common practices followed by SLPs when engaging in various aspects of the profession. The Preferred Practice Patterns for fluency disorder assessment and intervention are outlined in sections 30 and 31.
• ASHA developed a document outlining the role of the SLP in the treatment of stuttering. Guidelines for Practice in Stuttering Therapy also highlights what an SLP should know and be able to do in this area of practice.

In addition to treatment provided by SLPs, some people who stutter have found help dealing with their stuttering through stuttering self-help and support groups. In general, stuttering support groups are not therapy groups. Instead, they are groups of individuals who are facing similar problems. These individuals work together to help themselves cope with the everyday difficulties of stuttering.

Many such groups exist around the world. In the United States stuttering support groups have a long-standing and strong tradition of helping people overcome the burden of stuttering. Support groups often have local chapters that consist of anywhere from a few to a few dozen members who meet regularly (e.g., weekly or monthly) to discuss issues related to their stuttering. Some groups also have e-mail lists and chat rooms, newsletters and books, and annual conferences that bring together hundreds of people who stutter and their families.

Many support group members report that their experiences in the support group improve their ability to use techniques learned in therapy. Others report that the support group meets needs that their formal speech therapy did not meet. Thus, many people benefit from participating in treatment provided by an SLP and a stuttering support group. Indeed, most support groups have developed strong partnerships with the speech-language pathology community to promote and expand treatment options for people who stutter.