Stuttering: Why we need a broader view to help children (and adults) who stutter

By Nan Bernstein Ratner, Ed.D., University of Maryland, College Park

If you remember your original “intro” text to communication sciences and disorders, it probably was divided into broad sections, such as Speech, Language and Hearing. Indeed, that was the actual title of my own intro text[i]. In such texts, stuttering was always covered in the section on Speech Disorders.

Separating speech, language and hearing was conventional for many years, including old record keeping of practicum and classroom experiences for ASHA certification, and is an example of what is now called “modularity”, the assumption that an ability or skill is encapsulated in some way, cognitively or even physically, as in a discrete area of the brain. But few scientists these days are convinced of the modularity of speech, language or hearing – these skills overlap in major ways in everyday function. They are also increasingly documented as having impacts that overlap within individual disorders, such as stuttering.

Is stuttering a speech disorder? Certainly, it involves speech. One hears the behavioral features of stuttering, which are present in the speech signal. But increasingly, stuttering has been shown to have features that intersect with language: recent literature shows rather compellingly that children who stutter tend to have less good language skills[ii], and that both adults and children who stutter appear to process language differently than fluent peers, as measured by brain responses, even when passively listening to well-formed and poorly formed utterances[iii][iv].  Some studies suggest that profiles of linguistic processing at first diagnosis may predict which children spontaneously recover[v] [vi], with less good performance on phonological, language and nonword repetition tests taken shortly after onset associated with a risk for persistence [vii] [viii]. As in many other disorders, being diagnosed with one communication impairment, such as stuttering, carries elevated risk for having a second concomitant disorder, such as language or phonological delay/impairment[ix] [x].  Not all children who stutter have weak language skills[xi], but a number do. Others appear to have inconsistent language profiles, with more discrepancies among areas of skill than typical peers.[xii]

Even if we prefer to consider stuttering a motor movement disorder, its features are not confined to the speech system: both AWS and CWS find it more difficult to learn and master not only novel sequences of sounds[xiii] [xiv]but perceiving and producing gestures as well (such as tapping a rhythm [xv] [xvi]). While coordination for even basic speech tasks may appear impaired relative to fluent speakers, speech motor coordination in both children and adults who stutter is adversely impacted by the linguistic complexity of the utterance they are trying to produce [xvii] [xviii]. Finally, many studies continue to show that PWS find it much more difficult than other speakers to “multi-task” or respond to two tasks at once, if one involves speech [xix] [xx]. Under such conditions, the experimental performance of PWS tends to slow and/or decline more than we would see in their fluent peers [xxi]. Language formulation appears to be particularly resource demanding for AWS. [xxii] and, to the extent that any language production skill is modularized, less modularized in AWS. However, for some adults who stutter, diverting attention from speech may actually increase fluency, perhaps because it interferes with maladaptive speech planning or responses. [xxiii]

Even hearing may interact with stuttering in ways that are as yet poorly understood. Neuroimaging appears to suggest that adults who stutter have depressed function in areas that tend to be associated with self-monitoring [xxiv]. One study suggests that AWS demonstrate an atypical profile of activity in circuits that are meant to monitor one’s own speech while speaking [xxv], as distinguished from the circuits used in listening to others. Certainly, one unique feature of stuttering in young children is the high degree of awareness that most CWS have of their speech difficulties – compare any young CWS, even close to onset, on your caseload with a child who has an articulation or language problem. The differences are obvious and somewhat startling, especially because young typically developing children don’t tend to notice errors in their speech when they talk. The heightened sensitivity that many CWS show to their own speech, as well as potentially to the reactions of others around them, is clearly a factor in the development of the so-called affective and cognitive components of stuttering that also distinguish it in major ways from other developmental communication disorders.

Why is any of this research important in working with children who stutter? It’s valuable, in our opinion, to understand that a PWS may be working with a language formulation and motor execution system that has challenges that go well beyond the speech motor system, and may well require us to integrate best practices from other areas of the field in order to achieve best outcomes. Even if your goal is to teach your client new ways of “smooth talking” or “sliding out” of disfluent moments, basic research that has broadened our understanding of stuttering suggests that considering linguistic, motor, cognitive and affective components of your client’s profile may aid in achieving more optimal outcomes.

When working on fluency skills, have you considered the strength of your client’s sentence formulation and word retrieval skills? Given the impact that linguistic challenge may have on speech motor coordination in stuttering, have you tried to teach new fluency skills in conversational contexts that begin at simple levels and then gradually increased language (and cognitive) demand to more challenging levels? Given the robust association of vocabulary skills with eventual school achievement [xxvi], probably every child on your caseload can benefit from vocabulary enrichment in the course of therapy for other targets. The relatively weaker profiles of CWS when learning new sequences or gestures implies that it may take much more practice to create “expertise” in using fluency skills, just as it appears to take much more exposure to new words to learn them for children who have SLI [xxvii].  Every child (and adult) finds that the most challenging multi-tasking in speech (or even sports performance) is thinking about others’ reactions or evaluations, which is why public speaking is universally feared by most fluent speakers [xxviii]. Consider how hard it is for your client to balance language formulation, speech execution and monitoring for their own and others’ reactions. A simple way to appreciate it for those who don’t stutter is to ask yourself to repeat (or “cancel”) each time you say “um”, “uh”, or any other favorite filler – invite a family member to watch and see how well you are doing with this task. Then stop and ask how long it might take you to change your speech patterns, and make that change durable.

Finally, I believe that the most disservice that has been done in considering stuttering to be “just” a speech disorder is in how we tend to view the pace of stuttering therapy. I was once asked by a superintendent of a school system to provide a stuttering workshop for her SLPs. She explained that clearly they needed such a workshop because, to quote her, “the stuttering kids never get off the caseload.” This stopped me in my tracks. I asked her whether or not the “language kids” ever got off the caseload. She acknowledged that students’ language problems tend to require ongoing work, as the challenges of the curriculum evolve over the child’s development. Then why, I asked, should stuttering be any different? You already know the answer: because it’s a speech problem. The children who misarticulate get off the caseload rather quickly; by analogy, so should the children who stutter. Most newsletter readers will see the failure in reasoning here. But it’s really just one more consequence of seeing stuttering in our old intro text’s table of contents as a speech disorder. Perhaps taking a broader view will help not only to understand stuttering better, but to treat it better as well.

Author note: this essay is not intended to exhaustively review the literature

[i] Minifie, F. D., T. HIXON, & F. WILLIAMS. Normal Aspects of Speech, Hearing and Language,Englewood Cliffs: Prentice-Hall, (1973).

[ii] Ntourou, K, EG Conture, & MW Lipsey. Language abilities of children who stutter: A meta-analytical review. American Journal of Speech-Language Pathology 20, no. 3 (2011): 163-179.

[iii] Weber-Fox, C., A. Hampton Wray, & H. Arnold. "Early childhood stuttering and electrophysiological indices of language processing." Journal of Fluency Disorders 38, (2013): 206-221.

[iv] Cuadrado, E. M., & C. M. Weber-Fox. Atypical Syntactic Processing in Individuals Who Stutter: Evidence From Event-Related Brain Potentials and Behavioral Measures. Journal of Speech, Language, and Hearing Research 46, (2003): 960-976.

[v] Usler, E., & C. Weber-Fox. Neurodevelopment for syntactic processing distinguishes childhood stuttering recovery versus persistence. Journal of Neurodevelopmental Disorders 7, (2015): 1.

[vi] Mohan, R., & C. Weber. Neural systems mediating processing of sound units of language distinguish recovery versus persistence in stuttering. Journal of Neurodevelopmental Disorders 7, 2015): 1.

[vii] Ambrose, N. G., E. Yairi, T. M. Loucks, C. Seery, & R. Throneburg. Relation of motor, linguistic and temperament factors in epidemiologic subtypes of persistent and recovered stuttering: Initial findings. Journal of Fluency Disorders 45 (2015): 12-26.

[viii] Spencer, C., & C. Weber-Fox. Preschool speech articulation and nonword repetition abilities may help predict eventual recovery or persistence of stuttering. Journal of Fluency Disorders 41 (2014): 32-46.

[ix] Arndt, J., & E. C. Healey. Concomitant disorders in school-age children who stutter. Language, Speech, and Hearing Services in Schools 32, (2001): 68-78.

[x] Blood, G. W., V. Ridenour, C. D. Qualls, & C. Scheffner Hammer. Co-occurring disorders in children who stutter. Journal of Communication Disorders 36, (2003): 427-448.

[xi] Nippold, M. Concomitant Speech and Language Disorders in Stuttering Children: A Critique of the Literature. Journal of Speech and Hearing Disorders 55, (1990): 51-60.

[xii] Coulter, C., J. Anderson, & E. G. Conture. Childhood stuttering and dissociations across linguistic domains: A replication and extension. Journal of Fluency Disorders 34, (2009): 257-278.

[xiii] Namasivayam, A., & P. van Lieshout. Investigating speech motor practice and learning in people who stutter. Journal of Fluency Disorders 33, (2008): 32-51.

[xiv] Byrd, C., M. Vallely, J. Anderson, & H. Sussman. Nonword repetition and phoneme elision in adults who do and do not stutter. Journal of Fluency Disorders 37, (2012): 188-201.

[xv] Wieland, E., J. D. McAuley, L. Dilley, & S-E Chang. Evidence for a rhythm perception deficit in children who stutter. Brain and Language 144 (2015): 26-34.

[xvi] Falk, S., T. Müller, & S. Dalla Bella. Non-verbal sensorimotor timing deficits in children and adolescents who stutter. Frontiers in Psychology 6 (2015).

[xvii] Kleinow, J., & A. Smith. Influences of length and syntactic complexity on the speech motor stability of the fluent speech of adults who stutter. Journal of Speech, Language, and Hearing Research 43, (2000): 548-559.

[xviii] MacPherson, M., & A. Smith. Influences of sentence length and syntactic complexity on the speech motor control of children who stutter. Journal of Speech, Language, and Hearing Research 56, (2013): 89-102.

[xix] Smits‐Bandstra, S., & L. De Nil. Speech skill learning of persons who stutter and fluent speakers under single and dual task conditions. Clinical Linguistics & Phonetics 23, (2009): 38-57.

[xx] Bosshardt, H.‐G. Cognitive processing load as a determinant of stuttering: Summary of a research programme. Clinical Linguistics & Phonetics 20, (2006): 371-385.

[xxi] Jones, R., R. Fox, & E. Jacewicz. The effects of concurrent cognitive load on phonological processing in adults who stutter. Journal of Speech, Language, and Hearing Research 55, (2012): 1862-1875.

[xxii] Maxfield, N.., W. Olsen, D. Kleinman, S. Frisch, V. Ferreira, & J.Lister. Attention demands of language production in adults who stutter. Clinical Neurophysiology 127, (2016): 1942-1960.

[xxiii] Eichorn, N., K. Marton, R. Schwartz, R. Melara, & S. Pirutinsky. Does Working Memory Enhance or Interfere With Speech Fluency in Adults Who Do and Do Not Stutter? Evidence from a Dual-Task Paradigm. Journal of Speech, Language, and Hearing Research (2016): 1-15.

[xxiv] Fox, P., R J. Ingham, J. Ingham, T. Hirsch, J. Hunter Downs, C.Martin, P. Jerabek et al.. A PET study of the neural systems of stuttering. (1996): 158-162.

[xxv] Cai, S., D. Beal, S. Ghosh, M. Tiede, F. Guenther, & J. Perkell. Weak responses to auditory feedback perturbation during articulation in persons who stutter: evidence for abnormal auditory-motor transformation. PLoS One 7, (2012): e41830.

[xxvi] Sohr‐Preston, S., L. Scaramella, M. Martin, T. Neppl, L Ontai, & R.Conger. Parental Socioeconomic Status, Communication, and Children's Vocabulary Development: A Third‐Generation Test of the Family Investment Model. Child Development 84, (2013): 1046-1062.

[xxvii] Gray, S. (2003). Word-learning by preschoolers with specific language impairment: What predicts success? Journal of Speech, Language, and Hearing Research, 46(1), 56–67.

[xxviii] Pull,C. Current status of knowledge on public-speaking anxiety." Current Opinion in Psychiatry 25, (2012): 32-38.