Journal of Fluency Disorders 44 (2015) 1–15

Contents lists available at ScienceDirect

Journal of Fluency Disorders

Review

Anticipation in stuttering: A theoretical model of the nature

of stutter prediction
Mauricio A. Garcia-Barrera a,∗ , Jason H. Davidow b
a
Department of Psychology, University of Victoria, PO Box 1700 STN CSC, Victoria, British Columbia, Canada V8W 2Y2
b
Department of Speech-Language-Hearing Sciences, Hofstra University, 110 Hofstra University, Hempstead, NY 11549, United States

a r t i c l e i n f o a b s t r a c t

Article history: The fact that some people who stutter have the ability to anticipate a stuttering moment
Received 8 February 2014 is essential for several theories of stuttering and important for maximum effectiveness of
Received in revised form 18 March 2015 many currently used treatment techniques. The “anticipation effect,” however, is poorly
Accepted 19 March 2015
understood despite much investigation into this phenomenon. In the present paper, we
Available online 26 March 2015
combine (1) behavioral evidence from the stuttering-anticipation literature, (2) speech
production models, and (3) models of error detection to propose a theoretical model of
Keywords:
anticipation. Integrating evidence from theories such as Damasio’s Somatic Marker Hypoth-
Speech monitoring
esis, Levelt’s Perceptual Monitoring Theory, Guenther’s The Directions Into Velocities of
Stuttering
Error prediction Articulators (DIVA) model, Postma’s Covert Repair Hypothesis, among others, our central
Anticipation thesis is that the anticipation of a stuttering moment occurs as an outcome of the inter-
Somatic marker actions between previous learning experiences (i.e., learnt associations between stuttered
utterances and any self-experienced or environmental consequence) and error monitoring.
Possible neurological mechanisms involved in generating conscious anticipation are also
discussed, along with directions for future research.

Educational Objectives: The reader will be able to: (a) describe historical theories that
explain how PWS may learn to anticipate stuttering; (b) state some traditional sources of
evidence of anticipation in stuttering; (c) describe how PWS may be sensitive to the detec-
tion of a stuttering; (d) state some of the neural correlates that may underlie anticipation
in stuttering; and (e) describe some of the possible utilities of incorporating anticipation
into stuttering interventions.
© 2015 Elsevier Inc. All rights reserved.

Contents

1. Stuttering and anticipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2. Evidence of the ability to predict stuttering moments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3. Our theoretical approach to anticipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3.1. Foundations of anticipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3.2. Anticipation of a stuttering moment during speech production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
4. Learning to anticipate stuttering moments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
4.1. Re-occurrence and learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
4.2. Valence tagging in associative learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

∗ Corresponding author. Tel.: +1 250 472 5067; fax: +1 250 721 8929.
E-mail addresses: mgarcia@uvic.ca (M.A. Garcia-Barrera), Jason.davidow@hofstra.edu (J.H. Davidow).

http://dx.doi.org/10.1016/j.jfludis.2015.03.002
0094-730X/© 2015 Elsevier Inc. All rights reserved.
2 M.A. Garcia-Barrera, J.H. Davidow / Journal of Fluency Disorders 44 (2015) 1–15

5. How does prediction of stuttering emerge into consciousness? The role of interoceptive awareness and somatic markers . . . . . . 7
5.1. The somatic marker hypothesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
6. Speech monitoring and error detection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
6.1. Monitoring during speech production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
6.2. The Directions Into Velocities of Articulators (DIVA) model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
6.3. Domain general monitoring and the role of the anterior cingulate cortex (ACC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
6.4. Sensitivity to speech errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
7. Discussion and future directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
7.1. Limitations and future research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
7.2. Anterior cingulate cortex and awareness of errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
7.3. Other structures possibly involved in conscious anticipation of errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
7.4. Problems identifying neurocorrelates of anticipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1. Stuttering and anticipation

One of the more interesting phenomena in regard to developmental stuttering is the ability of the speaker to anticipate
stuttering moments. This “anticipation effect” has been studied extensively and is central to several theories of stuttering,
particularly those that Bloodstein and Ratner (2008) placed under the term “Anticipatory Struggle Hypothesis” that purport
anxiety, fear, or avoidance as a critical component; in fact, these authors stated that the anticipation of stuttering is a causal
factor for stuttering (Bloodstein & Ratner, 2008). Examples of well-known theories placed in this category include Sheehan’s
Approach-Avoidance Conflict (i.e., stuttering results from the opposing desires to speak and be silent; Sheehan, 1953), Van
Riper’s Preparatory Set (i.e., persons who stutter anticipate a stutter and place themselves in a physical and psychological
state that inhibits fluent speech; Van Riper, 1937), and Johnson’s Anticipatory Avoidance Theory (i.e., stuttering is the result
of trying to avoid anticipated stuttering; Johnson, 1938).
The ability to anticipate stuttering is also important for currently used stuttering treatment techniques, particularly those
that utilize fluency skills to avoid upcoming stuttering moments on difficult or feared words (see Guitar, 2014, chaps. 13–14,
for a review). For example, easy onsets (gentle voicing when starting a sound, syllable, or word) and light articulatory contacts
(placing relaxed articulators together softly) are often taught as ways to place the speech structures in a preset position in
order to avoid the tension and struggle that often accompanies a stutter. Maximum effectiveness of these techniques requires
the ability to anticipate stuttering moments. The ability to anticipate a stutter may also be beneficial to treatment programs
focused on reducing the frequency of stuttering moments, as even clients completing a standard fluency shaping treatment
would likely encounter situations in which they need to exaggerate the “blending of words together” or “stretching out
of syllables or words” in order to get through a stutter (Guitar, 2014, chap. 14). Anticipating the stutter would allow the
speaker to impart the strategy before, and possibly avoid, an overt stuttering moment. Therefore, inquiry into the anticipation
phenomenon may provide insight into the nature and treatment of stuttering.
In the following pages, we present a theoretical model for the anticipation of stuttering moments. In order to support our
model, we first summarize evidence of the ability to predict stuttering moments. Next, we present our theoretical model.
After the model is explained, we discuss how one may learn to anticipate stuttering moments, outline speech monitoring
and error detection models, and explain how anticipation may emerge to consciousness (including possible neurological
mechanisms). Finally, we provide conclusions and directions for future research. It should be noted that as we are focused
on examining anticipation, we are not interested in developing etiological explanations of stuttering itself. However, we will
discuss etiological models that are relevant to our hypotheses.

2. Evidence of the ability to predict stuttering moments

The present paper is concerned with a speaker’s ability to anticipate stuttering on specific words or sounds, given the
feeling of a particular instance of stuttering approaching, as opposed to a more general anxiety (see Craig & Tran, 2014, for
a recent review) or sense that stuttering may be intensified in a given situation (e.g., on the telephone or while speaking
to a large audience). We also center our discussion on anticipation during spontaneous speech production as it is the most
ecologically valid form of communication, and the fact that the established speech production models that provide the
structure for our hypothetical construct are based on spontaneous speech production.
Perhaps the strongest evidence regarding a speaker’s ability to anticipate moments of stuttering are studies in which
persons who stutter (PWS) predict the specific words on which they will stutter. Methodologies for these investigations
have included (a) speakers reading through a text silently and identifying which words they believed they would stutter on
followed by an oral reading of the passage (e.g., Brutten & Janssen, 1979; Martin & Haroldson, 1967), and (b) signaling the
anticipated stutter while reading aloud (e.g., Avari & Bloodstein, 1974; Milisen, 1938) or before each individually presented
word (e.g., Brocklehurst, Lickley, & Corley, 2012; Silverman & Williams, 1972). Most recently, Brocklehurst et al. (2012)
reported that under experimental conditions, the likelihood of PWS self-reporting stuttering on words increased exponen-
tially from those words they had predicted they would maybe stutter (9.9 times as likely) to those words they had predicted
 M.A. Garcia-Barrera, J.H. Davidow / Journal of Fluency Disorders 44 (2015) 1–15 3

they would definitively stutter (46.5 times as likely). Overall, the literature reveals that, on average, PWS can predict a high
percentage of their stutters (80–95%; see also Bloodstein & Ratner, 2008, Table 10-1), but there is great variability and this
variability occurs at all ages examined. For example, Silverman and Williams (1972) studied 8- to 16-year olds and reported
that they predicted 0% to 100% of their stuttering, and approximately 50% of the participants could not predict more than half
of their stutters. They also had a participant who accurately predicted all stutters and never stuttered when he thought he
would not stutter. It should also be noted that despite the individual variation at all ages, the ability to anticipate stuttering
moments improves with age (Bloodstein, 1960; Silverman & Williams, 1972; see Section 4.1).
The next four sections of the present paper propose our hypothetical model and the foundations and mechanisms for the
ability to anticipate a moment of stuttering that supported its conception. The literature reviewed prompted the following
assumptions for our model:

1. Re-occurrence, associative learning (including valence tagging and generation of somatic markers), and autonomic arousal
(including interoceptive awareness) are underlying mechanisms for the development of the ability to anticipate. The
theories explaining these mechanisms are discussed in Sections 4 and 5.
2. Although identification of errors in speech production may occur without the speaker’s awareness, we define anticipation
as a prediction of an upcoming error made conscious. That is, in our model, anticipation requires an expectation or
knowledge by the speaker. This assumption allows for measurement of anticipation and covers the majority of cases,
because as just mentioned, the evidence shows that PWS can predict approximately 80–95% of their stutters.
3. The speaker is sensitive to upcoming stuttering moments via their speech monitoring system. These mechanisms are
discussed in Section 6.
4. Finally, we assume that anticipation of stuttering on a word or sound can only occur after at least one previous experience
of a stuttering moment on that word or sound has occurred, allowing those phonemes, lemmas, or words to be subjectively
tagged as errors during production of future utterances.

3. Our theoretical approach to anticipation

Despite the extensive research on the anticipation of stuttering, we still wonder, how is anticipation possible? When
does it occur? Here we produce a theoretical explanation of such a phenomenon, borrowing from the literature outlined in
sections to follow and applying it to the context of speech production in stuttering. We present our model using two figures:
foundations of anticipation (Fig. 1) and anticipation of a stuttering moment during speech production (Fig. 2).

3.1. Foundations of anticipation

The basic structure of Fig. 1 resembles the speech production process, from early processing at the conceptualizer level
to the outcome of audible speech. This process is supported by an external loop and three internal loops (Arrows #1, #2
and #3 in Fig. 1) going to the monitoring system (Postma, 2000). Overall, Fig. 1 outlines a potential explanation to the origin
of PWS’s ability to anticipate. Stuttering moments often occur on the same words and sounds, creating memories for each
speaker’s set of difficult words and sounds. In fact, PWS are able to provide the words that they are likely to stutter on (Van
Riper, 1971), sounds that they would most likely avoid (Martens & Engel, 1986), and sounds they fear (Bowers, Saltuklaroglu,
& Kalinowski, 2012; Brown, 1938; Van Riper, 1971). The avenue for this knowledge acquisition is identified in Fig. 1 by the
external loop. This perception-based external loop is going from the overt stutter to the monitoring system and then to the
“Neural representations & valence tagging” box. The monitoring system would also be involved in tagging prepositional
pre-verbal messages at the formulator level that would likely activate the problem words or sounds (Arrow #1), tagging the
selected word or sound as an “error” (Arrow #2) and/or identifying an aberrant phonetic plan or motor command (Arrow
#3). In this model, by ‘errors’ we mean words, sounds, or motor commands subjectively tagged as incorrect during speech
production due to the fact that they were stuttered on. These inputs would become part of the neural representation of
the experience of producing this word. The neural representations serve as memories, which become more robust with
reoccurrence of the same stuttered word or sound, or weaker if the troublesome word or sound is not stuttered.
In addition, we have learned from the literature on the cognitive neuroscience of error prediction that outcomes (in this
case, fluent utterance or stutter) are tagged to a positive or negative valence depending on the consequences associated with
the outcome (Holroyd & Coles, 2002). The outcome (in this case, the stutter) might be accompanied by an autonomic arousal
response (e.g., increased skin conductance; identified via “Autonomic arousal” box) that is either identified by PWS (via
interoceptive awareness as discussed in Section 5) or not identified. Whether or not the speaker was aware of the autonomic
arousal response, this information is processed via the Arrow going from the “Autonomic arousal” box to the monitoring
system. A third possibility is that the autonomic response is not registered by the monitoring system, as explained by the
direct Arrow from the “Autonomic arousal” box to the “Neural representations & valence tagging” box. A memory trace or
neural representation of the experienced autonomic arousal is formed, what is called a somatic state. This somatic state
is further associated to the neural map for these utterances and to a valence tag (positive or negative). The term ‘somatic
marker’ refers to this particular type of valence tagging, the coupling of a somatic state with a valence during a specific
experience (see Section 5.1 for discussion of the Somatic Marker Hypothesis).
4 M.A. Garcia-Barrera, J.H. Davidow / Journal of Fluency Disorders 44 (2015) 1–15

Fig. 1. Schematic representation of the manner in which the neural representations for moments of anticipation during speech production are solidified.
See Section 3.1 for a description of this display.

Thus, once this form of learning is in place, an association is likely established between the reoccurring stutter and its
perceived negative consequences due to the overt disruption in speech flow. At times, the outcome (e.g., stutter) may also
be followed with negative environmental feedback that aids to the generation of a negative valence. For example, a word
may be stuttered on and receive a negative response from a listener. This reaction may cause feelings of embarrassment
or anxiety in the speaker, such that these feelings now surface each time the word is uttered. These negative emotions
may aid in the anticipation of stuttering on that word in the future. Further, this negative valence tag is later employed as
the subjective criterion for the appraisal of a word or sound selection as an “error.” This knowledge (from repetition and
valence tagging) is represented across neural networks that, once active, may have bidirectional influences on the speech
monitoring system, as shown by the “Sensitivity to errors” Arrow going toward the monitoring system in Fig. 1. In other
words, and as discussed in Section 6.4, it is possible that activation and reactivation of these neural representations would
also have a sensitizing effect on the monitoring system over time, which likely results in a lower error threshold for these
flagged utterances in the future, identifying them as problematic even prior to articulation via the inner loops represented
by Arrows #1, #2, and #3.

3.2. Anticipation of a stuttering moment during speech production

Fig. 2 outlines the process of anticipation during the speech production process; that is, it addresses how anticipation
occurs while speaking and outlines where the process of anticipation may be triggered by the monitoring system. The
monitoring system is continuously evaluating and detecting errors and this sensitivity is critical for the detection of errors
at several points during the speech production process. The system’s previous knowledge of problematic words and sounds
is being constantly compared to the selection of sounds and words. This process is represented by the “Sensitivity to errors”
Arrow and the “Output” Arrow going from the “Monitoring System” box to the “Comparison against neural representations
of previous stuttering experiences” box. When a word or sound that has a history of difficulty for a person who stutter is
selected during speech production, the process of anticipating a stutter for that word or sound is activated.
We will now explain where the triggering of a moment of anticipation can occur. The models discussed in the following
sections allow us to hypothesize that monitoring occurring at both earlier (e.g., formulation) and later (e.g., generation of
 M.A. Garcia-Barrera, J.H. Davidow / Journal of Fluency Disorders 44 (2015) 1–15 5

Fig. 2. Schematic representation of the anticipation of a stuttering moment during speech production. See Section 3.2 for a description of this display.

efferent commands sent prior to speech motor movements) stages of speech production would flag the selection of words,
sounds or efferent commands that have been previously learned to be problematic. This flagging would be initiated via the
inner loops (as per Postma’s speech production model; Postma, 2000), which is represented by Arrows #1, #2, and #3.
We begin with the hypothesized effect of the influence represented by Arrow #1 during the early stages of speech
production. Let’s take the example of a speaker who describes the word “Manhattan” as an error-prone utterance (stutter).
In a given conversation, interactions spontaneously lead to the question, “Where do you live?” and this question cues the
conceptualizer to activate semantic representations associated with living place or area, priming the formulator for the
possibility of a specific lemma activation (for instance the word “Manhattan”) and thus, the possibility of a stutter. Another
example is uttering one’s name, which has been an often-cited problem for PWS (Van Riper, 1971). For example, Dietrich
and Roaman (2001) found that introducing oneself at a party or at a meeting were the two situations (out of 20 situations)
that made PWS the most anxious. It is possible that the thought of these situations initiated the series of processes just
mentioned. We opted to draw this arrow with a dotted line to represent the lack of empirical evidence that self-monitoring
may be signaled by processing occurring as early as at the conceptualizer level.
The probability of the influence of Arrow #2 is supported by the findings presented above regarding the ability of PWS to
report words and sounds with which they struggle (Bowers et al., 2012; Brown, 1938; Martens & Engel, 1986). Certain words
and sounds trigger memories of stuttering moments. Thus, lemma selection and phonological encoding included in those
words and sounds previously flagged as subjective errors may trigger the monitoring system, and in turn, may activate the
neural representations (including the valence and the somatic markers) associated with the subjective error.
We also hypothesize a third possible trigger coming from the “Phonetic plan and Transfer of efferent commands” box
(Arrow #3). These later stages lay at the transition between planning and execution of speech, or the place where articulatory
instructions are transferred into articulatory gestures. There are three pieces of evidence that lead us to the possibility of this
trigger, discussed in detail in Section 6. First, according to Indefrey and Levelt’s (2004) meta-analysis of the timing of speech
production processes, self-monitoring is possible at this time period during speech production. Second, there is evidence
via computational simulations of activation of neural representations produced directly from motor efferent commands
after mediation via sensory systems ‘readout’ (DIVA, Guenther, Ghosh, & Tourville, 2006). Third, it is also reasonable to infer
that a repetitive motor command that has been associated to a negative outcome (e.g., stutter) may have created a neural
6 M.A. Garcia-Barrera, J.H. Davidow / Journal of Fluency Disorders 44 (2015) 1–15

somatosensory representation that may serve as a trigger source of anticipation. In fact, the concept of efference monitoring
suggests that a motor command itself has an influence on error detection: “The basic idea is that (copies of the) commands
leaving the central nervous system and traveling to the periphery are sent to some comparison centre, and may then be used
for some sort of control in addition to the control they already exert by energizing the effector organs” (Postma, 2000, p. 110).
This copy could be used to predict the consequences of the efferent commands prior to sensory feedback (Shadmehr, Smith,
& Krakauer, 2010), providing a source of error detection and the possibility of anticipation. It is expected that successful error
prediction and its emergence to consciousness in the form of anticipation will have an enhancing effect on the monitoring
system itself, which will become calibrated to faster detections of these problematic words and sounds in components of
speech production prior to execution.
Triggering and comparison of the neural representations against learned markers can produce a positive match. When
achieved, a primed somatic marker may become re-activated, producing an experience of autonomic arousal that could
arrive to consciousness as anticipation of the error to come via interoceptive awareness, or it could bypass consciousness
altogether given that not all PWS are able to explain how they arrive at their ‘feelings’ of anticipation (path A on Fig. 2). Path
B on Fig. 2 illustrates the absence of autonomic arousal activation, in which case anticipation is experienced without such
mediation.

4. Learning to anticipate stuttering moments

4.1. Re-occurrence and learning

Perhaps the most obvious way that PWS learn to anticipate stuttering on specific words or sounds is through re-
occurrence; that is, PWS tend to stutter on the same sounds and words on which they previously stuttered. Three sources of
evidence support re-occurrence as a foundation for learning which words may be stuttered. First, PWS anticipate more as
they get older and the ability to anticipate seems to improve with age. Bloodstein (1960) reported that 38% of 8–9-year olds,
45% of 10–11-year olds, 62% of 12–13-year olds, and 71% of 14–16-year olds reported anticipations of stuttering. Silverman
and Williams (1972) reported far less anticipations per speaker in a group of 8–9-year olds (2.23 anticipations per speaker)
than a group of 14–16-year olds (15.44 anticipations per speaker). In addition, Silverman and Williams (1972) data show
that the percentage of stuttered words anticipated was higher for 14–16-year olds (61.30%) than for 8–9-year olds (31.15%).
Second, Brown’s (1945) data reveal that stuttering often occurs in similar places in words and sentences. That is, stuttering
happens more often on (a) words beginning with consonants than those beginning with vowels, (b) content words than
function words, (c) the first words of a sentence than later words, and (d) longer words than shorter words. These findings
have essentially been corroborated in adult populations (Bloodstein & Ratner, 2008).
A third source of evidence for learning to anticipate stuttering on specific words or sounds is that PWS tend to stutter
on the same words in consecutive readings of a passage. This phenomenon, first outlined by Johnson and Knott (1937), is
termed the consistency effect and has been found in adults and school-age children who stutter (Neelley & Timmons, 1967;
Williams, Silverman, & Kools, 1969). Although the effect has been found to be somewhat variable, group data show that
approximately 50–70% of words that were stuttered in a previous reading were also stuttered in a subsequent reading.
In summary, the literature suggests that the location of stuttering within the utterance tends to be somewhat predictable
and that this re-occurrence facilitates the establishment of neural representations (i.e., memories). As these memories are
established over time, there is an increased likelihood of conscious anticipation of stuttering on similar words and sounds in
the future. It should be noted that while the stuttering population tends to conform to the general patterns just described,
there is substantial individual variation regarding the specific words and sounds where difficulty is anticipated (e.g., Bowers
et al., 2012; Brown, 1938; Martens & Engel, 1986). These individual differences are likely due to distinct personal experiences
with the specific words and sounds in question. The next section attempts to describe how these personal experiences might
arise.

4.2. Valence tagging in associative learning

Overskeid once stated (2000, p. 288), “It is an old assumption in psychology (e.g., Wundt, 1893) that every experience falls
somewhere along a hedonic continuum [and] that such positive or negative feelings are evoked by most (if not all) words
and objects in an automatic fashion, very quickly, without conscious control and not infrequently without awareness.” In
other words, Overskeid is referring to the concept of valence tagging. Valence refers to the value attributed to every stimuli
experienced, which tends to be dichotomized as positive or negative, depending on the behavior it activates, approach or
avoidance, respectively (Larsen, Berntson, Poehlmann, Ito, & Cacioppo, 2008). This value becomes part of the identity of the
stimulus (intrinsic value), as part of our stored knowledge about it, creating a ‘tag’ to the memory trace of the stimulus
(Pollermann, 2002). As would occur with any memory trace, a new encounter with the stimulus would lead to activation of
the representation of the stimulus and its associated valence tag (Fiske & Pavelchak, 1986; Moors, De Houwer, Hermans, &
Eelen, 2005). Some postulate that computation of the valence take place in regions of the orbitofrontal cortex, particularly in
the right hemisphere (Schore, 1998). Some argue, however, that the dichotomy positive/negative is associated with left/right
hemispheres (respectively), particularly frontal and parietal regions (Heilman, 1997). Others criticized this cortico-centric
 M.A. Garcia-Barrera, J.H. Davidow / Journal of Fluency Disorders 44 (2015) 1–15 7

position because it fails to incorporate the subcortical contributions (Watt, 1998). Valence tagging is our convenient label
for the idea that there are positive or negative values associated with every stimulus or experience (e.g., stuttered words).
Therefore, another way that PWS may learn to anticipate stuttering on certain sounds or words is through associative
learning. That is, early re-occurrence of stutters may produce an association between the utterance and the high probability
of a stuttering moment, and a systematic negative-value association (i.e., valence tagging) between the utterance and its
outcomes (e.g., negative feedback, frustration). This association has been recently suggested in a study by Brocklehurst et al.
(2012). These authors manipulated the feedback provided to their subjects after single word productions, and observed an
increase in the likelihood of stuttering in later utterances of words that were labeled as ‘incorrectly produced’ despite the
true outcome.

5. How does prediction of stuttering emerge into consciousness? The role of interoceptive awareness and somatic
markers

A person who stutter’s typical response to the question, “How do you recognize that you are about to stutter?” is “I don’t
know.” Some PWS mention a tightening in the throat or a feeling in their stomach (Van Riper, 1971), but many cannot put into
words how they know. It is possible that re-occurrence produces a level of automaticity in which detection of upcoming
troublesome sounds or words occurs without knowledge of how this particular instance of anticipation is happening (i.e.,
awareness of a feeling without being able to identify its source). PWS may also be able to identify the sensation that leads to
anticipation of a particular stuttering moment. Identifying these sources seems important, as it would allow for more valid
measurement of the anticipation phenomenon and could potentially assist in treatment if clients can be taught to perceive
the source.
One avenue for recognition may be the perception of bodily changes prior to a stuttering moment; that is, the speaker
uses interoceptive awareness. Interoceptive awareness refers to our conscious ability to perceive the sensations arising from
different parts of our bodies, such as temperature, itching, thirst, hunger, breath, heartbeat, and gastrointestinal sensations
(Craig, 2002; Damasio, 2003; Wiens, 2005). This level of perception is particularly relevant when the autonomic system
produces physiological bodily changes (i.e., autonomic arousal, muscular changes) that are associated with our experience
of emotions and feelings (Bechara & Naqvi, 2004), and become part of our memory trace of every stimuli and experience,
in the same way as valence tags do (Damasio, 2003). For instance, we may experience rapid heartbeat changes, ‘butterflies’
in the stomach, and flushing skin when in the presence of somebody we love. If the feeling is welcome, we may tag the
experience with a positive valence. Some of the same sensations (e.g., heartbeat changes, stomach reactions, skin flush) may
be experienced when facing an uncomfortable situation, like when feeling embarrassed. In that case a negative valence will
be likely tagged to the memory trace of this experience.
Several studies have found a positive relationship between autonomic arousal measures prior to stuttering and stuttering
(e.g., increased vasoconstriction, Ickes & Pierce, 1973; increased skin conductance, changes in heart rate, respiration and
blood volume, Myers, 1978). A positive relationship has also been shown between muscular activity in the larynx, tongue
and lip before a stutter occurred and stuttering (e.g., Thürmer, Thumfart, & Kittel, 1983). Other investigations have reported
contrary findings, including no change or a slight reduction in heart rate prior to performing speech tasks in PWS, whereas
persons who do not stutter had no increase in heart rate (see Alm, 2004, for a review), and no difference between skin
conductance and heart rate measures between stuttered and fluent utterances (Bowers et al., 2012).
More important to the present paper is the relationship between measurements of bodily changes and anticipation; that
is, are bodily changes associated with the anticipation of a stuttering moment? Most recently, Bowers et al. (2012) reported
that conditions involving feared phonemes included higher skin conductance response frequency than those involving
“neutral” phonemes. Baumgartner and Brutten (1983) reported a weak relationship between heart rate and the anticipation
of specific stuttering moments, but for one of three PWS mean heart rate accounted for a statistically significant amount of
the variance in “yes” and “no” stuttering expectancy responses. Finally, Dietrich and Roaman (2001) found skin conductance
to be only weakly related to expectations of situational speech anxiety in PWS.
The inconsistent findings demonstrate that the relationships between anticipation and arousal and between stuttering
and arousal require further investigation. It is possible that the different findings are due to the fact that interoceptive
awareness ability varies widely across individuals (Jones, 1994). For those who have a high degree of interoceptive awareness,
the autonomic and muscular changes that are occurring prior to a stuttering moment may enhance their ability to anticipate.

5.1. The somatic marker hypothesis

To better explain the combined role of valence tagging and interoceptive awareness in the anticipation of stuttering,
we need to describe the concepts of somatic states and somatic markers as largely explained by Damasio (1996) in his
somatic marker hypothesis. Briefly, Damasio supports the idea that our experiences are coupled with an emotion and a
feeling (i.e., valence tagging). In the case of the somatic markers, the valence tagging takes effect not only from the acquired
knowledge about the experience itself (e.g., halting speech under unfamiliar situations), but also from the changes in the
body representations within the somatosensory cortex, or ‘somatic state’, which integrates the information perceived via
musculoskeletal, visceral, and other somatic components during those experiences (e.g., higher heart rate, sweat, heat
temperature rise; Damasio, 1995). According to Damasio, the experience-valence association is embodied in such a way that
8 M.A. Garcia-Barrera, J.H. Davidow / Journal of Fluency Disorders 44 (2015) 1–15

re-occurrence of the situations that formed the somatic state can effectively reactivate the somatosensory memory trace
that best represents the specific somatic state (Damasio, 1995). These activations are used to mark scenarios as good or bad
(e.g., stuttering moments or utterances) and can operate as alarm and biasing signals. The term ‘somatic marker’ refers to
this particular type of valence tagging, the specific coupling of a somatic state with a valence during a specific experience.
Research based on Damasio’s somatic marker hypothesis has revealed an important role of the ventromedial prefrontal
cortex (PFC) in the storage of those links (experiential knowledge and bioregulatory states), and the relevance of this area
in facilitating their retrieval during complex processes such as decision-making, estimation and prediction of outcomes
(Bechara, 2004; Bechara, Damasio, Tranel, & Damasio, 1997; Bechara, Tranel, & Damasio, 2000; Damasio, 1995). Some reviews
of the somatic marker hypothesis have also demonstrated the participation of other regions of the PFC (i.e., dorsolateral PFC)
and insular cortex in poor performance during tasks designed to elicit the activation of the somatic markers (Dunn, Dalgleish,
& Lawrence, 2006). One could expect that activation of these somatic markers within the PFC and insular regions might lead
to anticipation. Interestingly, a study by Pollatos, Schandry, Auer, and Kaufmann (2007) reported associations between
detection of one’s heartbeat (interoception) and enhanced activation patterns in bilateral cortical brain regions such as the
insula and inferior/middle frontal gyrus, medial frontal/dorsal cingulate gyrus, right inferior parietal lobule, and several
thalamic nuclei, a system of brain areas that overlaps and interconnects with those involved in error monitoring and the
valence tagging implied by the somatic marker hypothesis.
Interoceptive awareness during speech production may occur in the following manner. At some point prior to speech
execution, priming occurs due to prior learning of the associations between specific lemmas or phonemes that are difficult
and error-prone (i.e., with a high likelihood of stutter) and the somatic experience that was coupled with the stuttering
moments. The robustness of these associations could be made possible via basic Hebbian principles (Hebb, 1949); that is,
neurons associated with the lemma and phoneme selections end up firing at about the same time as those associated with
the somatic markers, wiring together into a full interoceptive experience.
In summary, the literature reviewed demonstrates that re-occurrence, valence tagging and the somatic markers, are
possible mechanisms for the ability to anticipate stuttering moments before overt articulation. That is, each instance of
stuttering leads to a negative valence tag for a particular word or sound. This repeated negative tagging produces a memory
trace of a problematic word. In addition to the negative valence that occurs with every utterance of the word, the memory
trace may be further impacted by the somatic state (e.g., sweating, higher heart rate) and the interoceptive awareness
ability of the speaker. The experience of a somatic state and the perception of bodily changes become associated with the
problematic word and produce a memory trace incorporating these factors. We propose that this memory trace allows for
anticipation of an upcoming stutter (subjectively tagged as an error) and is signaled during the planning of speech (before
execution).
It is worth noting that in our proposed model we emphasized the conscious experience of the somatic marker via inter-
oceptive awareness prior to a stutter moment; however, it is also important to note that these associations are not always
conscious (Damasio, 1996), which could explain instances of anticipation of a stuttering moment in which the person is
not conscious of the word associated to the somatic marker (i.e., the speaker does not know why they are anticipating a
particular stuttering moment). Finally, our proposed mechanism suggests a monitoring of the speech sequence that results
in the ability to detect an upcoming stutter. Therefore, our focus now turns to speech monitoring models to understand the
possible process for detecting stuttering moments.

6. Speech monitoring and error detection

There are two types of errors that are relevant to the discussion of speech production. First, an utterance can be considered
incorrect or to be an error if it does not meet the external criteria imposed by a consensus. For instance, in Standard American
English (SAE) the combination “you was” can be considered an error, detected by those familiar with SAE grammatical rules.
Second, utterances may be tagged as “errors” by the individual producing them, based on subjective criteria; that is, the
outcome (i.e., overt utterance) did not match the desired or planned outcome. This second form of error tagging is private
and subjective. As Postma (2000) stated, “The conviction that a certain action is wrong arises from a conflict between what
the actor believes to be true and what he or she perceives to be the case” (p. 101). Stutters may fit this category of error
tagging, as they might be subjectively tagged as “errors” by the speaker (Vasiç & Wijnen, 2005). For our purpose, we refer
in our hypothetical model to this later type of error; that is, lemma or phoneme selections subjectively tagged as incorrect
during speech production. Therefore an “anticipated error” would refer here to words, sounds, or efferent commands with a
high self-perceived likelihood that they will be stuttered. At times, we may refer to errors that do not fit this category solely
for the purpose of clarification of general mechanism of detection, self-correction, and prediction of errors.

6.1. Monitoring during speech production

Monitoring is an essential executive process in the regulation of behavior (Holroyd & Coles, 2002; Jurado & Rosselli, 2007).
Consideration of the role of monitoring systems during speech planning and production has become an essential compo-
nent of speech production models (e.g., Civier, Tasko, & Guenther, 2010; Ganushchak & Schiller, 2006; Levelt, 1983, 1992),
and examination of these systems has yielded to two main types of monitoring mechanisms: perceptual monitoring and
 M.A. Garcia-Barrera, J.H. Davidow / Journal of Fluency Disorders 44 (2015) 1–15 9

production monitoring. The perceptual monitor is relatively slow and partially under conscious control, whereas production
monitors (there may be several of them) are fast, automatic and largely unconscious (see Postma, 2000, for more details).
An important conclusion resulting from research on speech monitoring that is relevant to our purposes is the idea that
monitoring of speech can occur before overt utterances are produced (Indefrey & Levelt, 2004; Postma, 2000; Wheeldon
& Levelt, 1995). On the basis of a meta-analysis of studies investigating the time course of speech production, Indefrey
and Levelt (2004) established a set of temporal signatures. From the presentation of an image (0 ms baseline mark) the
lexical concept is formed within the first 175 ms post picture onset, target lemma retrieval and selection occurs within
the first 250 ms, and phonological retrieval and syllabification occurs between 250 ms and 330 ms post presentation. Later
stages include phonological word encoding (around 455 ms) and articulatory programming (around 600 ms post image cue).
Based on empirical evidence, the authors postulated that it is possible to initiate self-monitoring as early as 25 ms following
phonological code retrieval (Indefrey & Levelt, 2004). It is worth noting that these authors also concluded that there is not
enough available evidence to accept or reject the idea that one of the outcomes of self-monitoring is reformulation at the
level of the conceptualizer (Indefrey & Levelt, 2004).

6.2. The Directions Into Velocities of Articulators (DIVA) model

Although Levelt’s perceptual loop theory of speech monitoring has been widely accepted (Nozari, Dell, & Schwartz,
2011), an alternative explanation to error detection and correction at the articulatory level is proposed by Guenther and his
colleagues in the DIVA model (Guenther, 2006; Guenther et al., 2006). DIVA is a computational model of a neural network
for the control of speech movement, which integrates feedback controllers with feedforward control strategies that make
possible a biologically supported explanation of syllable speech production. During the initial stages of speech acquisition,
errors in the motor programs involved in the articulation of phonemes and syllables may need detection and correction.
According to the DIVA, there are at least two mechanisms for error detection and correction. First, some of these errors may
originate during the activation of the speech sound map in the left ventromedial premotor cortex, which would then send
parallel inputs to the auditory error map in the superior temporal cortex and the somatosensory error map in the inferior
parietal cortex. These auditory and somatosensory error maps would, in turn, generate inputs in the form of feedback
commands to the articulatory velocity and position maps in the motor cortex (for a detailed description and illustration see
Guenther, 2006). It is worth noting that under the DIVA framework, these errors are production errors and have an objective
nature, as opposed to the subjective error tagging we discussed in our model. However, it is discussed here as it supports the
inclusion of a production-based inner loop that transfers inputs to the generic monitoring system.
A second error detection mechanism in the DIVA account is engaged after production of sounds or utterances is achieved.
The control subsystem in this model involves interactions between motor and sensory systems in order to provide feedback
about successful articulatory mapping and sequencing. The cascade of neural processes underlying speech production in the
DIVA model includes a basic level of error monitoring. That is, once the speech sound maps are activated, the somatosensory
cortex (and the anterior supramarginal gyrus) compares the sensory feedback to an original learned somatosensory target
arriving from the speech sound map, facilitating detection of articulatory errors (i.e., sounds that do not match to the desired
command). Error detection would lead to subsequent programming of corrective motor commands (Golfinopoulos, Tourville,
& Guenther, 2010). This feedback mechanism for error detection is complemented by a feedforward control system, which
is learning from the corrections made to motor commands (Guenther et al., 2006). This second mechanism supports the
inclusion of an external loop from the audible speech to the generic monitoring system in our model.

6.3. Domain general monitoring and the role of the anterior cingulate cortex (ACC)

It has been widely postulated that the frontal lobes play an important role in monitoring (Stuss, 2007), and in particular,
the right dorsolateral areas of the PFC serve as a neural base for performance monitoring (Stuss et al., 2002). Neurons in the
PFC connect to other neuronal systems forming networks involved in monitoring. More specifically, a circuit between the
PFC and the ACC has been demonstrated to be involved in generic error monitoring. It is worth noting that these studies do
not necessarily make a distinction between the mechanisms for monitoring objective and subjective errors. Also, by ‘generic’
it is meant that it functions independently of the type of outcome (Holroyd, Dien, & Coles, 1998). These findings suggest
a possible central role of the ACC and multi-modal generic monitoring in integrating the outcomes of the various types of
monitoring (e.g., perceptual and production) discussed earlier. Further, the ACC appears to be involved in identification of
errors via conflict monitoring (Botvinick, Nystrom, Fissell, Carter, & Cohen, 1999) and in the evaluation and prediction of error
likelihood (Brown & Braver, 2005; Hester, Foxe, Molholm, Shpaner, & Garavan, 2005). Error monitoring and error-likelihood
monitoring (i.e. error prediction) are two related but distinctive processes, both possibly involving the ACC. Brown and
Braver (2005) proposed an ‘error likelihood hypothesis’ that explains these differences. Neurons in the ACC appear to code
errors of any modality (e.g., visual processing, motor movement, language production) via error monitoring mechanisms
(Holroyd et al., 1998). However, and according to this hypothesis, these ACC neurons may actually be coding information in a
more dynamic way, associating stimulus representations with error signals that were active simultaneously, via an adaptive
and competitive reinforcement learning mechanism that facilitates coding of error likelihood by the ACC neurons, while
training them for future error prediction (Brown & Braver, 2005).
10 M.A. Garcia-Barrera, J.H. Davidow / Journal of Fluency Disorders 44 (2015) 1–15

In his thesis introducing the Speech and Monitoring Interaction (SAMI), Arenas (2012) proposed that “the error likelihood
hypotheses of monitoring provides an elegant biologically plausible explanation for how learned associations between
stuttering (as problem words or subjective errors) and contextual cues can negatively influence speech production” and
hypothesizes that “subjective ratings of stuttering expectancy to cues (words, sounds or situations) reflects a conscious
awareness of underlying error likelihood representations in the brain.” (p. 35). The SAMI framework assumes that in the
interactions between the speech production systems and monitoring systems, an increase or decrease in stuttering is a result
of increased inhibition from the monitoring system to motor plans. Although it is an etiological account of stuttering, some
of Arenas’ postulates resonate with our model.
Therefore, it is reasonable to assume that monitoring during speech and coding of error likelihood involve this single,
generic system, as was postulated earlier by Levelt (1983, 1989), hypothesized by Postma (2000), and later demonstrated by
others using electrophysiological markers (e.g., Ganushchak & Schiller, 2006; Riès, Janssen, Dufau, Alario, & Burle, 2011) and
model simulations versus patient data (e.g., Nozari et al., 2011). Thus, for the purpose of our model, we have implemented
a single monitoring system, possibly associated with the Anterior Cingulate Cortex (ACC), and that is responsible for the
supervision of several aspects of the speech production process.

6.4. Sensitivity to speech errors

Due to the subjective nature of error tagging and the re-occurrence of stuttering moments, PWS may become sensitized
to upcoming difficulties. A new question then arises: Is this sensitivity affecting the speech monitoring system in PWS? In this
regard, Vasiç and Wijnen (2005) developed a hypothesis for stuttering based on the assumption that the speech monitoring
system is overly engaged in error detection. These authors suggest that PWS place extreme focus on the temporal or rhyth-
mic components of an utterance and apply overly strict acceptability criteria. That is, PWS have improperly set effort (more
than is needed by normally-fluent speakers), focus and threshold (lower threshold for errors) parameters for acceptable
speech output, resulting in the correction of normal discontinuities and temporal variations (e.g., stoppage of airflow during
production of a plosive). These discontinuities and variations are perceived as the start of a disfluency by PWS, resulting in an
interruption to prevent the disfluency. These new interruptions are also labeled as disfluencies, resulting in further interrup-
tions, and ultimately repetitions or blocks. The continuous identification of interruptions that result in further interruptions
places the monitoring system in a “vicious circle” that stops speech production. Part of this hypothesis, specifically the
possibility of highly active (yet, not impaired as suggested by Vasiç and Wijnen) monitoring, detecting potential subjective
errors at speech production stages before speech execution, is relevant to our purpose.

7. Discussion and future directions

We presented here what we believe is a feasible and testable model of anticipation in stuttering, from a comprehensive
theoretical perspective including a diversity of empirical evidence and theories (e.g., Damasio’s Somatic Marker Hypothesis,
error monitoring and speech monitoring models) to support this model. As stated before, our model is by no means an
etiological theory of stuttering. It is our belief that a better understanding of the mechanisms of anticipation may facilitate
testing classic (e.g., Anticipatory Struggle Hypothesis), current (Variable Release Threshold Hypothesis, Brocklehurst, Lickley,
& Corley, 2013) and future etiological models of stuttering.

7.1. Limitations and future research

We hope that as a theoretical model our approach inspires experimentation to better understand the complexity of
speech production, specifically in regards to monitoring and anticipation. Several limitations of our model provide avenues
for future experimentation. First, we have only weak evidence supporting the loop between the conceptualizer and early
stages of formulation and monitoring systems, represented with our Arrow #1 in Figs. 1 and 2. The existing evidence is mostly
emerging from Levelt’s perceptual theory and the role of the conceptualizer loop in speech monitoring. Second, there is a lack
of experimentation directly examining the relationships between interoceptive awareness and the anticipation of a stutter.
By integrating several theories and based on our reasoning, we made what we believe is a sound, yet hypothetical, connection
between two known phenomena: the formation of somatic markers and the experience of anticipation. We are currently
examining this connection in our lab. Third, as discussed earlier, Indefrey and Levelt’s (2004) meta-analysis demonstrated
when self-monitoring can occur during speech production. Our model is based on self-monitoring, so we would expect
anticipation to happen in a similar time frame. However, to the best of our knowledge, there are no data on this issue. Fourth,
the issue of speaking task needs to be addressed. Our model was focused on spontaneous speech production, and due to
the differences between spontaneous speech and reading (e.g., reading does not permit the substitution of words, provides
visual perception of the word, requires no discourse formulation), parts of the model may not be applicable to reading.
In addition, the attention and effort involved in anticipating stuttering events may vary across tasks. For example, since
substitution occurs in spontaneous speech, a speaker may put more effort into anticipation during this task. The frequency
of stuttering can also differ between tasks for many PWS (e.g., Davidow, Bothe, Andreatta, & Ye, 2009), possibly resulting in
varying levels of anticipation. Lastly, and relatedly, the data-based studies cited in Section 2 used reading continuous text
 M.A. Garcia-Barrera, J.H. Davidow / Journal of Fluency Disorders 44 (2015) 1–15 11

or single words to examine rates of anticipation. Data-based evidence of the ability to anticipate stuttering moments during
spontaneous speech is needed to strengthen our model.
We also trust that our model can aid some of the recent approaches used to understand the neural markers of speech
production. For instance, the DIVA model offered by Guenther et al. (2006) and its related iterations for modeling stuttering
(e.g., GODIVA by Bohland, Bullock, & Guenther, 2010; Civier, Bullock, Max, & Guenther, 2013; Civier et al., 2010; Max,
Guenther, Gracco, Ghosh, & Wallace, 2004) might serve as a potential neural foundation to explain some of our hypotheses.
The DIVA network involves mostly primary motor, premotor and sensory (i.e., temporal and parietal) areas specifically
involved in the stages of motor control over speech production. The DIVA model also acknowledges the role of the cerebellum
as part of a feedforward command projection. It is our opinion that the approach we presented here picks up where the DIVA
model stops, rather than competing against it, as we are concerned here with the nature of the subjective anticipation of
utterances tagged as errors, including the anticipatory signals produced during discourse formulation to initiation of efferent
commands.

7.2. Anterior cingulate cortex and awareness of errors

Recent developments in cognitive experimentation have revealed an interesting association between the ACC and aware-
ness of error detection. Originally, it was hypothesized that the ACC was actively engaged in the detection of errors and in
dealing with the conflict that two competing responses are generated within the system (Botvinick, Braver, Barch, Carter,
& Cohen, 2001). Interestingly, a network between ventral frontal cortex, insular regions, and ACC has been documented to
play a relevant role in the process of positive and negative emotional valence tagging in connection to somatic sensations
(Bechara & Damasio, 2005), and particularly, in the context of uncertainty. Neuroimaging research in the area of probabilis-
tic decision-making under uncertainty has demonstrated the involvement of a functional network integrated by prefrontal,
parietal and insular cortices (Huettel, Song, & McCarthy, 2005). It is worth noting that the flow of speech-language commu-
nication in any given spontaneous verbal interaction could involve a high degree of unpredictability and uncertainty as of the
specific utterances that the conversation may evoke. Computational and functional neuroimaging models of error prediction
in a context of uncertainty have postulated the relevant role of the bilateral insula in both risk prediction and risk prediction
errors (e.g., Preuschoff, Quartz, & Bossaerts, 2008). These authors posed the hypothesis that the insular activation associated
with risk prediction may serve as an anticipatory signal even before risk is fully computed. The association between the
insular activation and anticipation has also been studied in the context of emotional valence processing (Critchley, Mathias,
& Dolan, 2001). Thus, the element of novelty and uncertainty may be an additive factor to the hyper-engagement of the
insula during these tasks.
Some patterns of hyperactivity of the ACC and insular cortex have been described in the stuttering literature. However,
neuroimaging findings in stuttering appear to be inconsistent with respect to the role that these structures play during speech
production (Brown, Ingham, Ingham, Laird, & Fox, 2005; Chang, Kenney, Loucks, & Ludlow, 2009). In an earlier review of the
neuroimaging studies, Ingham (2001) postulated that hyperactivation of the ACC was observed only under the uncertainty
of unfamiliar speech production tasks, not in the context of familiar speech tasks, suggesting that this differential pattern
may be associated with the task and not with stuttering per se. There is yet the possibility that the hyper-engagement of
the monitoring systems (e.g., ACC) in stuttering occurs only in the early stages of associative learning, which is conducive to
later prediction of errors and its subsequent emergence to consciousness, that is, anticipation. One recent fMRI study by den
Ouden, Montgomery, and Adams (2013) suggested that activation patterns observed in the anterior components of the ACC
might be associated with awareness of an upcoming stutter, making the ACC a potential neural correlate of the subtracts of
stuttering and possibly, anticipation. There are, however, other brain structures that may be involved.

7.3. Other structures possibly involved in conscious anticipation of errors

Some have demonstrated that the ACC involvement in the anticipation of errors may be better explained in terms of
its role in the evaluation process, as part of a monitoring system that facilitates the prediction of error likelihood (Hester
et al., 2005). This level of ACC engagement appears to occur in the presence of relevant contexts, where the level of attention
is higher. However, it has been proposed that activation of the ACC alone cannot explain the emergence of error aware-
ness (Nieuwenhuis, Ridderinkhof, Blom, Band, & Kok, 2001). Both prefrontal and parietal areas appear to be concomitantly
involved. Relevant biological markers have been used to examine this hypothesis. For instance, studies using ERP to examine
error prediction and awareness have looked at the localization of source of the Pe/P300 component, and found a diffuse scalp
distribution, including posterior and anterior areas (Overbeek, Nieuwenhuis, & Ridderinkhof, 2005). This neural association
between the Pe and activation of PFC, ACC, and parietal cortex has been successfully replicated in fMRI studies (Hester et al.,
2005).
The engagement of PFC in this network appears to play a crucial role not only in attentional control, but also in facilitating
monitoring by means of awareness of error detection. The PFC is known for its role in executive control, and this association
is particularly meaningful in the context of self-correction often observed after conscious error detection. Detection of an
error implicates the engagement of prefrontal systems to initiate changes in the faulty pattern of action. This problem solving
process requires the engagement of pyramidal networks within the PFC, which has the flexibility to quickly address issues
with the program of action and make modifications using the feedback from internal and external speech monitoring loops.
12 M.A. Garcia-Barrera, J.H. Davidow / Journal of Fluency Disorders 44 (2015) 1–15

This perception-action cycle requires the involvement of associative cortex within the parietal lobes and its connections
to their anterior counterparts in the PFC (Fuster, 2008). However, the type of awareness that has been associated with
anticipation seems to involve both the conceptual and the inner loops postulated by Postma (2000), as awareness of error
detection seems to occur before the individual initiates the articulation of an utterance, which in turn explains the relevant
role that parietal somatosensory cortex and its connections to associative intraparietal cortex play in triggering anticipation.

7.4. Problems identifying neurocorrelates of anticipation

Another problem that we have identified is finding the best technology to localize in time the specific activation patterns
of error-monitoring networks (that some researchers have associated to anticipation in stuttering). The well-known time
resolution limitations associated with commonly used techniques such as traditional PET and fMRI are impairing our ability
to observe their engagement across small units of time, which is needed in order to isolate anticipatory signals during speech
monitoring of subjective errors. Thus, a possible solution to this constraint is the use of more time-sensitive technology,
such as electrophysiological markers. Although this reasoning is not original (Postma, 2000), we know of only a handful of
studies looking at potential neurophysiological markers of speech monitoring, such as the error negativity (Ne) or Error-
Related Negativity (ERN), an event-related brain potential associated with error monitoring (for an extensive review, see
Holroyd & Coles, 2002). The ERN has been associated with activity of the ACC during error monitoring-taxing tasks (Holroyd,
Nieuwenhuis, Mars, & Coles, 2004). In a similar fashion to action-monitoring research, the ERN has been elicited during
the application of verbal self-monitoring tasks (Ganushchak & Schiller, 2006), high versus low motivational manipulation
during speech production (Ganushchak & Schiller, 2007), and during semantic conflict paradigms (Ganushchak & Schiller,
2008). In the context of stuttering, we know of only one such study by Arnstein, Lakey, Compton, and Kleinow, 2011) looking
at differential ERN patterns between fluent controls and PWS. Arnstein et al. (2011) reported that their group of PWS
generated larger ERN amplitudes than controls. These findings are meaningful because they serve as: (a) a demonstration
of a differential pattern of activation of the ACC in stuttering using neuroimaging technology with higher time resolution;
(b) a demonstration of an overactive monitoring system as observed in larger ERN amplitudes, which are modulated by
the amount of dopamine released; and (c) a successful coupling of electrophysiological technology and phonological-based
error monitoring tasks, as evidenced by their ability to elicit the ERN, demonstrating the role of the ACC and its networks in
preverbal speech monitoring.
Inspired by the reported association between electrophysiological neural markers in the form of an ERN amplitude
difference (Arnstein et al., 2011), and by recent research demonstrating that the ERN reflects a generic, online speech
production monitoring mechanism, rather than speech error detection (Riès et al., 2011), our lab has engaged in the design of
a series of studies coupling the dopaminergic activity represented by the feedback ERN marker (fERN; Holroyd & Coles, 2002)
and supported by error prediction models. Our labs first empirical study (Moore, 2012; Moore, Garcia-Barrera, Davidow,
Baker, & Holroyd, 2015) involves the examination of the error monitoring system of PWS by using a T-maze paradigm for
action selection and prediction of reward/error (Baker & Holroyd, 2009), and guided by the question: Do PWS have an overly
sensitive generic error monitoring system? Our second study involves the relationship between language networks and error
monitoring systems: Do PWS have an overly sensitive generic error monitoring system when anticipating a stutter?
Error processing and cognitive control are fundamental to normal behavior in every day life, and thus differences in these
mechanisms are manifested in a wide variety of disorders, including addiction, attention deficit hyperactivity disorder, fetal
alcohol spectrum disorder, normal aging, schizophrenia, Parkinson’s disease, and most pertinent to the current proposed
model, developmental stuttering. Understanding reward processing in PWS could facilitate the development of treatments
that focus on modulating error-processing mechanisms via enhancement of interoceptive attention such as Buddhist
meditation, which is known to modulate the activity of the insular cortex in such a way that facilitates uncoupling of the
negative emotion from the behavior (Kirk, Downar, & Montague, 2011). Other methods that have been demonstrated to
increase self-awareness are mindfulness (Raffone & Srinivasan, 2010) and integrative body-mind training (Tang et al.,
2009). The idea of introducing mindfulness training as part of the treatment of stuttering is not new (Boyle, 2011), and the
effects of meditation on the electrophysiological modulation of the insula and PFC have also been demonstrated (e.g., see
Cahn & Polich, 2006 for a review). Furthermore, understanding how differential error processing can interact with verbal
systems to result in anticipatory signaling of stuttering will foster a more comprehensive understanding of error monitoring
mechanisms.

CONTINUING EDUCATION
Anticipation in stuttering: A theoretical model of the nature of stutter prediction
QUESTIONS

1. The following has been shown in regard to the ability to anticipate moments of stuttering:
a. Preschool children who stutter are more accurate than adults who stutter
b. School-age children who stutter are more accurate than adults who stutter
 M.A. Garcia-Barrera, J.H. Davidow / Journal of Fluency Disorders 44 (2015) 1–15 13

c. There is variability across all ages

d. Preschoolers who stutter are more accurate than school-age children who stutter
e. Age appears to have no effect on the ability to anticipate
2. At which of the following points during speech production was it hypothesized that anticipation of a stuttering moment
could not occur?
a. During conceptualization
b. After phonological encoding
c. During the transfer of efferent commands
d. During phonetic planning
e. After the stutter has been produced
3. Interoceptive awareness refers to:
a. Knowledge of one’s frequency of stuttering
b. The individual’s ability to perceive bodily changes
c. A stage of speech production
d. The ability to anticipate specific types of stutters
e. The ability to perceive the reactions of others
4. The term somatic marker refers to:
a. Interpretations of the emotional reactions to life events
b. A tag imposed to a situation based on reactivations of somatosensory patterns
c. A state produced by a prediction error such as an action-consequence mismatch
d. The awareness of an error (e.g., stutter)
e. Identifying the point of anticipation during speech production
5. One of the following structures appears to be involved in awareness of error detection:
a. Cerebellum
b. Striatum
c. Somatosensory cortex
d. Prefrontal cortex
e. Globus pallidus

Acknowledgements

We gratefully acknowledge the contributions of our students at the University of Victoria: William Rylie Moore, Justin
Karr, Emilie Crevier-Quintin, and Clifford Donovan; and our peers Drs. Ulrich Mueller and Clay Holroyd to conceptualizing,
editing and proofreading this manuscript. In addition, special thanks are due to our two anonymous reviewers and the
Associate Editor (Dr. Stephen Tasko). Your detailed reviews and thoughtful recommendations substantially improved the
quality of our model and how it is described in this paper.
Financial disclosures: Mauricio Alejandro Garcia-Barrera and Jason Davidow did not disclose any relevant financial rela-
tionships used in support of the research reported in this article.
Non-financial disclosures: Mauricio Alejandro Garcia-Barrera and Jason Davidow did not disclose any relevant non-
financial relationships used in support of the research reported in this article.

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Mauricio A. Garcia-Barrera, Ph.D., is an Associate Professor in the Department of Psychology at the University of Victoria, in Canada. He has been
working on developing biologically plausible models to better understand executive control mechanisms. Part of his current research examines neural
systems involved in error detection during speech monitoring.

Jason H. Davidow, Ph.D., is an Associate Professor in the Speech-Language-Hearing Sciences Department at Hofstra University. His main research
interests include stuttering treatment outcome and the measurement of speech production changes during fluency-inducing conditions in persons
who stutter.