Stuttering and its management

By

Dr. T. Balasubramanian M.S. D.L.O.




Definition:  Stuttering is defined as a disorder of language fluency.  This is characterised by excessive amounts of dysfluencies in general and these dysfluencies are also excessive in their durations.    The stutterers in addition may also demonstrate associated motor behaviors while they speak.  These motor behaviors include:
1.  Excessive muscular effort while speaking
2. Facial grimafces
3. Hand and feet movements

Brian's classification of dysfluencies: 
1. Part word repetitions:  Classic example being (ta-ta-ta- time).  The patient while saying the word time will keep saying ta ta ta before articulating the full word time. 
2. Whole word repetition: Example (I - I - I ).  The patient when saying the word I will keep on repeating the word I atleast three or four times before continuing.
3. Phrase repetition: Example (why are you-why are you-why are you).
4. Sound prolongations: Example (sssssoup).  The patient speaks the word soup as indicated.  There is prolongation of the sound S.
5. Interjections of  sounds syllables or phrases:
    Example:
    Sound interjection: "um ... um I had a problem this morning."
    Whole word interjection: "I had well problem this morning"
    Phrase interjection: " I had a you know problem this morning"

6. Silent pauses:  A silent duration within speech is considered abnormal.  Example:
     " I am going to the (Pause) store.
7. Broken words:  A silent pause within words: "It was won(pause)derful".



How to diagnose stuttering?
Even normal speakers can manifest the various forms of dysfluencies listed above in varying degrees.  No one is probably 100% fluent all the time.  Pauses of varying durations are also fairly common in normal individuals.  To distinguish a stutterer from a non stutterer the following three issues are considered:
1. The frequency of dysfluencies
2. Type of dysfluencies
3. Duration of dysfluencies

Frequency of dysfluencies:  A normal speaker may be dysfluent depending upon the speaking situation, the topic being discussed, and other factors like the response of listners.  It has been estimated that on an average a stutterer stutters on about 10% of spoken words.  Hence a frequency of 10% dysfluency is considered abnormal.  This is the minimum percentage of dysfluency necessary to diagnose a stutterer. 

Listener's judgement of stutterer:  When ordinary people are asked to listen to speech samples and requested to assess for stuttering they are known to pick up 5% of dysfluencies easily.  They even classify this group as stutterers.   Some speech pathologists hence would go for the figure of 5% dysfluency as an indicator for stuttering.  It is always better to err on the side of caution, and 10% dysfluencies in language may be used to diagnose stutterer.

Types of dysfluencies:  This is again one important aspect in the assessment of stutterer.  Eventhough all types of dysfluencies are seen in normal individuals, some types are rare in them.  They are part word repetitions, speech sound prolongations and word or phrase repetition.  If these types of dysfluencies are present in an individual then they must be labelled as a stutterer. 

Duration of dysfluencies:  Most speech pathologists diagnose stuttering if the duration of dysfluency lasts for more than a second. 

Presence of associated motor behavior:
     A majority of motor behaviors associated with stuttering are seen in the facial muscles.  Most adult stutterers tend to blink their eyes and wrinkle their noses and forehead while speaking.  Some of the stutterers have trembling lips.  They even have a tendency to keep their mouth open even when they are not talking.  
     Muscle tension associated with speech is also significant.  Most stutterers report tightness in their throat, jaws, stomach muscles while speaking in a dysfluent way.  Sometimes the whole body may become tense.  They may also manifest certain abnormal breathing behaviors.  Normal speakers stop and breathe often during their speech, a stutterer may keep talking even when the air supply is exhausted.   Some stutters may stop speaking and inhale air inappropriately. 

Circumlocution:  In lay terms it is known as beating around the bush.  This is a common statergy used by a stutterer to mask stuttering.  They tend to beat around the bush till the listner says the word they have been avoiding.  This is also known as avoidance behavior. 

Almost all the stutter experience painful emotions associated with stuttering.  These emotional responses get stronger as the individual grows older.   The presence of consistent stuttering on certain words and in certain speaking situations can create apprehension and anxiety about speaking the word and about the speaking situation.  Most adult stutters can predict a certain amount of their suttering even before they stutter.

Incidence:
    Roughly 1% of general population are stutterers.   It may be found in all walks of life, and in different individuals be it a mentally retarded or a mentally gifted individual.  Males out number females by a ratio 4:1.  Girls recover from stuttering better than boys. 

Genetic hypothesis:  Since stuttering tends to run in families has lent credence to this hypothesis.  It has also been demonstrated in concordant monozygotic twins.  Both heredity and environmental factors play a role in the etiopathogenesis of stuttering. 

Myths about stuttering:

Greek philosopher Aristotle thought that a tongue too thick and sluggish caused stuttering in a stutterer.
Hippocrates father of modern medicine attributed a dry tongue as the cause of stuttering.

Theories on stuttering:

Laryngeal dysfunction:  It has been postulated that the laryngeal muscles are too tense in stutterers.  These muscles were also found to be excessively active.  Opposing pairs of laryngeal muscles may be simultaneously active.  The vocal cords may vibrate in an irregular manner.  Laryngeal dysfunctions have been observed in video laryngoscopy done on stutterers. 

Brain and speech mechanism:  Since brain controls the intricate mechanism of speech, it has been postulated that stuttering could be due to faulty functioning of brain.  It has been demonstrated that regardless of handedness, the left side of the brain is dominant for speech.  The right side of the brain is dominant for musical and other non verbal activities.  The left hemisphere of the brain is slightly larger than its right counterpart because of the importance and complexity of speech.  If for some reason one of the hemispheres is not dominant for language, then stuttering could occur. 

Diagnosogenic theory:  This theory was first propounded by Wendell Johnson.  He explained stuttering on the basis of environmental events.  He even said that stuttering is not in the mouth of the child but in the ears of the listner. 

Anticipatory struggle theory:  This is a modification of diagnosogenic theory.  This was proposed by Bloodstein.  He suggested that stuttering is due to a belief in a child that speech is a difficult task.

Theories based on conditioning and learning:  It has been observed that a stutterer speaks some words fluently, in some speaking situations, but speaks dysfluently on other words, in other speaking situations.  This behavior could be possible if one considers stuttering to be a learned avoidance behavior. 

Treatment of stuttering:

Psychological methods:
     These methods include psychoanalysis, psychotherapy and counselling.  In psychoanalysis the emphais is on unconsious sexual urges suppressed by the individual.  In psychotherapy the emphasis is on emotional conflicts.  The psychological methods of treating stuttering are at the most indirect ways of managing the situation.   In order to successfully counsel these patients the counseller should be a good listener.  He should listen to the problems of the patinet and counsel accordingly. 

Speech therapy:

Van Riper's procedure:  He called this procedure fluent stuttering.  Riper beleived that normal fluency is not possible in stutterers.  He suggested the used of the term fluent stuttering.  He changed the form of stuttering in such a way that it became less abnormal.    He taught stutterers to reduce the muscular tension and to speak without associated bizarre facial expressions.  He also taught stutterers to repeat and prolong words in an easy and effortless manner.  This therapy ofcourse falls short of normal speech.

Modified air flow technique:  This method concentrates the irregular breathing behaviors in stutterers.  The stutterer is taught to inhale sufficient air before saying something.  The air is also exhaled in a controlled manner.  These skills are meticulously taught in these patinets by breathing exercises. 

Gentle initiation of sound:  This procedure helps to reduce the chance of stuttering.  A stutterer is taught to start a word gently, softly and in a relaxed manner.  A stutterer is taught to slow down the rate of speech.  They are also taught to stretch the syllables to prolong them.  This prolongation reduces the chance of stuttering.  Ofcourse this type of speech is monotonous and excessively slow. 

Delayed auditory feed back:  Electronic instruments can be used to slow down the rate of speech in a stutterer.  This device is known as the vocal feedback device.  It converts the movements of vocal folds into vibrations that could be felt in the throat.  Through headphones the patient is able to hear his sound with a fraction of a second delay.  This in a way slows down the rate of speech.
























Image of a portable delayed feed back equipment.



Soft contacts of articulators:

     Teaching soft contacts of articulators makes speech more relaxed.  Many stutterers jam their tongue against the hard / soft palate.  Their lips may be closed too tightly.  If these defects could be rectified it will go a  long way in reducing stuttering in these individuals. 

It is only a multi dimensional approach management modality which will work satisfactorily in the treatment of stuttering.  It includes psychoanalysis, counselling and speech therapy.








 





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