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Acknowledgments
Thank you to all my clients and students. You taught me as much as I taught
you.
And thanks to my colleagues in Communication Sciences and Disorders
and in Psychological Sciences whose writings and conversations, in person
and via e-mail, have helped me become woke.
A round of applause for Andrea Klingler, Mike Nobel, Kerry McShane,
and Amy Millholen, whose editorial talents made this book what it is.
Cheers for Bot Roda—the talented illustrator who gave life to all my
notions about what might be helpful to put in visual form.
Kudos to Adinarayanan Lakshmanan Sivakumar (Siva) and his team who
have done a wonderfully thorough job of compositing my manuscript into the
printed page.
Hooray! Rebecca McCauley and Charlie Barasch, who have edited each
chapter, making them more readable, updated, and cogent than my original
drafts.
As with all the earlier editions, I bestow love and appreciation to my
wife, Carroll. She has used her librarian and literary skills to edit, find
references, keep databases, get permissions, help with videos, and keep me
moving so this edition will finally see the light of day.
Contents
Preface
Acknowledgments
References
Author Index
Subject Index
I
Nature of Stuttering
1
Introduction to Stuttering
Perspective
The Words We Use
People Who Stutter
Disfluency
Overview of the Disorder
Do All Cultures Have Stuttering?
What Causes People to Stutter?
Can Stuttering Be Cured?
Definitions
Fluency
Stuttering
General Description
Core Behaviors
Secondary Behaviors
Feelings and Attitudes
Functioning, Disability, and Health
The Human Face of Stuttering
Basic Facts about Stuttering and Their Implications for the Nature of
Stuttering
Onset
Prevalence
Incidence
Recovery from Stuttering
Recovery versus Persistence of Stuttering
Sex Ratio
Variability and Predictability of Stuttering
Anticipation, Consistency, and Adaptation
Language Factors
Fluency-Inducing Conditions
An Integration
Chapter Objectives
After studying this chapter, readers should be able to:
Explain why it is good practice to use the term “person who stutters”
rather than “stutterer”
Describe factors that may (1) predispose a child to stutter, (2)
precipitate stuttering, and (3) make stuttering persistent
Name and describe the core behaviors of stuttering
Name and describe the two major categories of secondary stuttering
behaviors
Name and describe different feelings and attitudes that can accompany
stuttering
Describe the elements of the new International Classification of
Functioning, Disability, and Health (ICF) system that are most relevant
to stuttering
Discuss the age range of stuttering onset and the types of onset, and
explain why the onset of stuttering is often difficult to pinpoint
Describe the meanings of the terms “prevalence” and “incidence,” and
give current best estimates of each of these characteristics for stuttering
Give an estimate of the number of children who recover without
treatment, and describe factors that predict this recovery
Give an estimate of the sex ratio in stuttering at onset and in the
school-age population
Explain what is meant by “anticipation,” “consistency,” and
“adaptation” in stuttering
Explain some relationships between stuttering and language, and
suggest what they mean about the nature of the disorder
Describe several conditions under which stuttering is usually reduced
or absent, and suggest why this may be so
Key Terms
Adaptation: The tendency for speakers to stutter less and less (up to a
point) when repeatedly reading a passage
Anticipation: An individual’s ability to predict on which words or
sounds he or she will stutter
Attitude: A feeling that has become a pervasive part of a person’s
beliefs
Avoidance behavior: A speaker’s attempt to prevent stuttering when
he or she anticipates stuttering on a word or in a situation. Word-
based avoidances are commonly interjections of extra sounds, like
“uh,” said before the word on which stuttering is expected.
Block: A disfluency that is an inappropriate stoppage of the flow of air
or voice and often the movement of articulators as well
Consistency: The tendency for speakers to stutter on the same words
when reading a passage several times
Core behaviors: The basic speech behaviors of stuttering—repetition,
prolongation, and block
Developmental stuttering: A term used to denote the most common
form of stuttering that develops during childhood (in contrast to
stuttering that develops in response to a neurological event or
trauma or emotional stress)
Disfluency: An interruption of speech—such as a repetition, hesitancy,
or prolongation of sound—that may occur in both individuals who
are developing typically and those who stutter
Escape behavior: A speaker’s attempts to terminate a stutter and finish
the word. This occurs when the speaker is already in a moment of
stuttering.
Fluency: The effortless flow of speech
Heterogeneity: Differences among various types of a disorder
Incidence: An index of how many people have stuttered at some time
in their lives
Normal disfluency: An interruption of speech in a typically developing
individual
Prevalence: A term used to indicate how widespread a disorder is over
a relatively limited period of time
Prolongation: A disfluency in which sound or air flow continues but
movement of the articulators is stopped
Repetition: A sound, syllable, or single-syllable word that is repeated
several times. The speaker is apparently “stuck” on that sound or
syllable and continues repeating it until the following sound can be
produced.
Secondary behaviors: A speaker’s reactions to his or her repetitions,
prolongations, and blocks in an attempt to end them quickly or
avoid them altogether. Such reactions may begin as random
struggle but soon turn into well-learned patterns. Secondary
behaviors can be divided into two broad classes: escape and
avoidance behaviors.
PERSPECTIVE
No one is sure what causes stuttering, but it is an age-old problem that may
have its origins in the way our brains evolved to produce speech and
language. Its sudden appearance in some children is triggered when they try
to talk using their just-emerging speech and language skills. Its many
variations and manifestations are determined by individual brain structure
and function, learning patterns, personality, and temperament. It also
provides lessons about human nature: the variety of responses that stuttering
provokes in cultures around the world is a reflection of the many ways in
which humans deal with individual differences.
This description of stuttering makes it seem like a very complicated
problem—one that will take a long time to learn about. It’s true that you
could spend a lifetime and still not know everything there is to know about
stuttering. But you don’t need to understand everything in order to help
people who stutter. If you read this book critically and carefully, you will get
a basic understanding of stuttering and a foundation for evaluating and
treating people who stutter and their families. And once you start working
with people who stutter, your understanding and ability will expand
exponentially.
If you continue to work with stuttering, you will soon outgrow this book
and begin to make your own discoveries. You will experience the satisfaction
of helping children, adolescents, and adults regain an ability to communicate
easily. Someday you may even write about your therapy procedures and
measure their effectiveness. Those of us who have spent many years engaged
in stuttering research and treatment all began where you are right now, at the
threshold of an exciting and rewarding profession that can have a major
impact on others’ lives.
Disfluency
In our literature, “disfluency” is used to denote interruptions of speech that
may be either normal or abnormal. That is, it can apply to pauses, repetitions,
and other hesitancies in individuals who are typical speakers. It can also
apply to moments of stuttering. This makes it a handy term to use when
describing the speech of young children whose diagnosis is unclear.
When someone’s speech hesitancies are unequivocally not stuttering, I’ll
use the term “typical disfluency.” I won’t use the older term for the abnormal
hesitations in stuttering—“dysfluency” with a “y”—because it can easily be
mistaken for “disfluency” when you see it on the page and because the two
are indistinguishable when spoken.
DEFINITIONS
Fluency
By beginning with a definition of fluency rather than stuttering, I am pointing
out how many elements must be maintained in the flow of speech if a speaker
is to be considered fluent. It is an impressive balancing act. Little wonder that
everyone slips and stumbles from time to time when they talk.
Fluency is hard to define. In fact, most researchers have focused on its
opposite, disfluency. (As I mentioned earlier in this chapter, I use the term
disfluency to apply both to stuttering and to typical hesitations, making it
easier to refer to hesitations that could be either typical or abnormal.) One of
the early fluency researchers, Freida Goldman-Eisler (1968), showed that
typical speech is filled with hesitations. Other researchers have acknowledged
this and expanded the study of fluent speech by contrasting it with disfluent
speech. Dalton and Hardcastle (1977), for example, distinguished fluent from
disfluent speech by differences in the variables listed in Table 1.1. Inclusion
of intonation and stress in this list may seem unusual. It could be said that
speakers who reduce stuttering by using a monotone are not really fluent. We
would argue that it is not their fluency but the “naturalness” of their speech
that is affected. Nonetheless, both aspects will be of interest to the clinician
working to help clients with all areas of their communication.
Stuttering
General Description
At first, stuttering may appear to be complex and mysterious, but much of it
is based on human nature and can be easily understood if you think about
your own experiences. In some ways, it is like a problem you might have
with a cell phone.
Imagine that you have a cell phone with intermittent problems, such as
not holding a charge, dropping calls, and dropping words in the middle of a
conversation. The listener may say, in an impatient voice, “What did you
say? I can hardly hear you.” Then momentarily the connection may clear up
and you feel relief, only to be followed by exasperation when the call gets
noisy again or is completely dropped (Fig. 1.2).
Figure 1.2 Stuttering can be like having a cell phone that doesn’t
always work.
Core Behaviors
I have adopted the term “core behaviors” from Van Riper (1971, 1982), who
used it to describe the basic speech behaviors of stuttering: repetitions,
prolongations, and blocks. These behaviors seem involuntary to the person
who stutters, as if they are out of her control. They differ from the “secondary
behaviors” that a stutterer acquires as learned reactions to the basic core
behaviors.
Repetitions are the core behaviors observed most frequently among
children who are just beginning to stutter. Repetitions consist of a sound,
syllable, or single-syllable word that is repeated several times. The speaker is
apparently “stuck” on that sound and continues repeating it until the
following sound can be produced. In children who have not been stuttering
for long, single-syllable word repetitions and part-word repetitions are much
more common than multisyllabic word repetitions. Moreover, children who
stutter will frequently repeat a word or syllable more than twice per instance,
li-li-li-li-like this (Yairi, 1983; Yairi & Lewis, 1984).
Prolongations of voiced or voiceless sounds also appear in the speech of
children beginning to stutter. They usually appear somewhat later than
repetitions (Van Riper, 1982), although both Johnson and associates (1959)
and Yairi (1982). In contrast to my use of the term, earlier writers include
stutters with no sound or airflow as well as stopped movement of the
articulators in their definitions of prolongations (e.g., Van Riper, 1982;
Wingate, 1964).
Repetitions and sound prolongations are usually part of the core
behaviors of more advanced stutterers, as well as of children just beginning to
stutter. Sheehan (1974) found that repetitive stutters occurred in every speech
sample of 20 adults who stuttered. Indeed, 66 percent of their stutters were
repetitions. Although many of their stutters were also prolongations, as
defined above, how many is not clear, because Sheehan’s definition of
prolongations seems to differ from mine.
Blocks are typically the last core behavior to appear. However, as with
prolongations, some investigators (Johnson and associates, 1959; Yairi, 1977;
Freeman & Ushijima, 1978; Kenyon, 1942; Schwartz, 1974). Others disagree
(Smith, Denny, Shaffer, Kelly, & Hirano, 1996).
As stuttering persists, blocks often grow longer and more tense, and
tremors may become evident. These rapid oscillations, most easily observable
in the lips or jaw, occur when someone has blocked on a word or sound. The
individual closes off the airway, increases air pressure behind the closure, and
squeezes her muscles particularly hard (Van Riper, 1982). You can duplicate
these tremors by trying to say the word “by” while squeezing your lips
together hard and building up air pressure behind the block. Imagine this
happening to you unexpectedly when you were trying to talk.
People who stutter differ from one another in how frequently they stutter
and how long their individual core behaviors last. Research indicates that a
person who stutters does so on average on about 10 percent of the words
while reading aloud, although individuals vary greatly (Bloodstein, 1944;
Bloodstein & Ratner, 2008). Many people who stutter mildly do so on fewer
than 5 percent of the words they speak or read aloud, and a few with severe
stuttering stutter on more than 50 percent of the words. The durations of core
behaviors vary much less, averaging around 1 second, and are rarely longer
than 5 seconds (Bloodstein, 1944; Bloodstein & Ratner, 2008).
Secondary Behaviors
People who stutter dislike stuttering, to put it mildly. They react to their
repetitions, prolongations, and blocks by trying to end them quickly if they
can’t avoid them altogether. Such reactions may begin as a random struggle
to get the word out, but soon turn into well-learned patterns. I divide
secondary behaviors into two broad classes: escape behaviors and avoidance
behaviors. I make this division, rather than follow the traditional approach of
dealing with secondary behaviors as “starters” or “postponements,” for
example, because my treatment procedures focus on the principles by which
secondary behaviors are learned.
The terms “escape” and “avoidance” are borrowed from behavioral
learning literature. Briefly, escape behaviors occur when a speaker is
stuttering and attempts to terminate the stutter and finish the word. Common
examples of escape behaviors are eye blinks, head nods, and interjections of
extra sounds, such as “uh,” which are often followed by the termination of a
stutter and are therefore reinforced. Avoidance behaviors, on the other hand,
are learned when a speaker anticipates stuttering and recalls (consciously or
unconsciously) negative experiences he has had when stuttering. To avoid
stuttering and the negative experience that it entails, he often resorts to
behaviors he has used previously to escape from moments of stuttering—eye
blinks or “uh”s, for example. But he employs these behaviors before
attempting to say the word he expects to stutter on. Or, he may try something
different, such as changing the word he was planning to say.
In many cases, especially at first, avoidance behaviors may prevent the
stutter from occurring and provide highly rewarding emotional relief from the
increasing fear that a stutter will occur. Soon these avoidance behaviors
become strong habits that are resistant to change. The many subcategories of
avoidances (e.g., postponements, starters, substitutions, and timing devices
such as hand movements timed to saying the word) are described in Chapter
7.
When trying to decide if a secondary behavior is an escape or avoidance,
just remember that an escape behavior occurs only after a moment of
stuttering has begun, and an avoidance behavior occurs before the moment of
stuttering begins.
Case Examples
A Young Preschool Child: Borderline Stuttering
Ashley was a happy, outgoing child who was advanced in her language
development; she spoke in well-formed sentences when she was 18 months
old. Then suddenly, when she was 21 months old, she began to stutter. Her
stuttering took the form of multiple repetitions, most often at the beginnings
of sentences. For example she would say “I-I-I-I want some water” or “Ca-
ca-ca-ca-can you lift me up?” Despite the fact that she would sometimes
repeat a syllable 10 or more times before getting the word out, she didn’t
show obvious signs of frustration when she stuttered. She continued to
develop language rapidly, talk copiously, and socialize easily.
About 6 months after she started stuttering, her parents contacted a
speech-language pathologist who evaluated Ashley. The evaluation
indicated that Ashley’s language development was advanced for her age,
that her phonological development was also advanced, and that she stuttered
on 4 percent of the syllables she spoke. (This means that when a few
minutes of her speech were analyzed and the number of syllables she spoke
was counted, Ashley stuttered on 4 percent of those syllables.)
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planet itself, in proportion to the quantity of matter in each; and the
planets attract one another just as much as they attract the sun,
according to the quantity of matter.
“M. Le Verrier has mentioned for the new planet the name
Neptunus; and probably, deference to his authority as its discoverer,
will obtain general currency for this name.”
In truth, at the moment when this was uttered, the new Planet had
already been seen by Professor Challis; for, as we have said, he had
seen it in the early part of August. He had included it in the net which
he had cast among the stars for this very purpose; but employing a
slow and cautious process, he had deferred for a time that
examination of his capture which would have enabled him to detect
the object sought. As soon as he received M. Le Verrier’s paper of
August 31 on September 29, he was so much impressed with the
sagacity and clearness of the limitations of the field of observation
there laid down, that he instantly changed his plan of observation,
and noted the planet, as an object having a visible disk, on the
evening of the same day.
Not only did this law stimulate the inquiries for the Missing Planet,
and thus lead to the discovery of the Minor Planets, but it had also a
share in the discovery of Neptune. According to the law, a planet
beyond Uranus may be expected to be at the distance represented
by 388. Mr. Adams and M. Le Verrier both of them began by
assuming a distance of nearly this magnitude for the Planet which
they sought; that is, a distance more than 38 times the earth’s
distance. It was found afterwards that the distance of Neptune is only
30 times that of the earth; yet the assumption was of essential use in
obtaining the result and Mr. Airy remarks that the history of the
discovery shows the importance of using any received theory as far
as it will go, even if the theory can claim no higher merit than that of
being plausible. 51
51 Account of the Discovery of Neptune, &c., Mem. Ast. Soc., vol.
xvi. p. 414.
The rapidity with which these discoveries were made was owing in
part to the formation of star-maps, in which all known fixed stars
being represented, the existence of a new and movable star might
be recognized by comparison of the sky with the map. These maps
were first constructed by astronomers of different countries at the
suggestion of the Academy of Berlin; but they have since been
greatly extended, and now include much smaller stars than were
originally laid down.
I will mention the number of planets discovered in each year. After
the start was once made, by Hencke’s discovery of Astræa in 1845,
the same astronomer discovered Hebe in 1847; and in the same
year Mr. Hind, of London, discovered two others, Iris and Flora. The
years 1848 and 1849 each supplied one; the year 1850, three; 1851,
two; 1852 was marked by the extraordinary discovery of eight new
members of the planetary system. The year 1853 supplied four;
1854, six; 1855, four; and 1856 has already given us five. 560
I may add that it appears to follow from the best calculations that
the total mass of all these bodies is very small. Herschel reckoned
the diameters of Ceres at 35, and of Pallas at 26 miles. It has since
been calculated 53 that some of them are smaller still; Victoria having
a diameter of 9 miles, Lutetia of 8, and Atalanta of little more than 4.
It follows from this that the whole mass would probably be less than
the sixth part of our moon. Hence their perturbing effects on each
other or on other planets are null; but they are not the less disturbed
by the action of the other planets, and especially of Jupiter.
53 Bruhns, as above.
Tides.
The Tides of the Coast of Ireland have been examined with great
care by Mr. Airy. Numerous and careful observations were made with
a view, in the first instance, of determining what was to be regarded
as “the Level of the Sea;” but the results were discussed so as to
bring into view the laws and progress, on the Irish coast, of the
various inequalities of the Tides mentioned in Chap. iv. Sect. 9 of this
Book.