Stuttering is sort of like....

How can fluent speakers begin to appreciate what it is like to stutter? How can children who stutter find ways to express what it is like to speak? Luc Tielens wrote about metaphors for the 2004 International Stuttering Awareness Day online conference. * Since I own a box of 50 or so dominos and my students sometimes enjoy playing with them, here is a metaphore we came up with:

… when a chain of toppling dominos - stops. The smooth clickety-clickety sound of the dominos stops. The chain is broken. Like in a sentence when the smooth consonant-vowel-syllable sound of the words - stops.

Word fears, sound fears are like great big dominos you see ahead. You are on the lookout for them. When you spot trouble ahead – how do you feel ? What do you do? Maybe you think you know when the dominos could stop. If you think that the chain of dominos might stop falling at any time, your body might get anxious. Positive anxiety is called excitement. Negative anxiety is called fear. If the dominos feel out of control and frustration leads you to put them away, this is called avoidance. When talking gets too unpredictable and frustrating, sometimes children who stutter say, “Nevermind.” And they give up.

Finish this thought with your own ideas: Stuttering is sort of like…



Down's Syndrome & Cluttering

One of my favorite tasks is searching the speech/language pathology journals for answers to specific questions posed by SLPs and by parents. I truly enjoy reading journal articles! I allow myself the luxury of wallowing in this kind of reading when I need to locate information regarding treatment choices for individual students.

A school-based SLP recently asked me about a student with Down’s syndrome. I could find only a few articles specifically about Down’s syndrome and stuttering with the kind of credibility necessary to support treatment decision making.

Judith Eckardt wrote an article for the International Stuttering Awareness Day online conference (1) in which she explained that her observation was that stuttering emerged around 8-10 years of age, about the same time these children were combining 2-3 word utterances and had rapid vocabulary development. This would be the time for “normal developmental stuttering” given the language delay. She also observed “shame of stuttering” in older Down’s students. She recalls, “I still remember the look of surprise and then a smile from the 17 year old, when I told her ‘It’s OK to stutter’ and ‘It’s NOT your Fault.’” (p.3)

There was also a presentation at the 2006 ASHA Convention specifically about stuttering and Down’s children. (2) I was not at the presentation, the handouts available on line make an explicit connection between Down’s and cluttering.

David Daley wrote an article for the 2007 International Stuttering Awareness Conference (3) in which he provides a checklist called the Predictive Cluttering Inventory. The checklist has 33 items divided into four categories: pragmatics, speech-motor, language-cognition, and motor coordination-writing problems. Each item is rated on a 7-point scale. He suggests that the higher the score on this inventory, the higher the probability that the speaker is a clutterer. Scores of “120 or more are quite rare. Typically, clients we have seen present with scores between 80 and 120. These scores we believe are indicative of a classification or diagnosis we call ‘Clutterer-Stutterer.’ One third of stuttering clients typically show some signs of cluttering.” (p.2) I have David Daley’s 1996 publication of The Source for Stuttering and Cluttering and in it he provides an extensive comparison of stuttering vs. cluttering.

The ASHALeader, an online publication of the American Speech Language Hearing Association, published an update on cluttering in 2003. (4) This article seemed to down play the role of language in the diagnosis. “Another vexing issue is the extent to which language planning and pragmatic problems are implicated in the diagnosis of cluttering. We do not currently include language difficulties in the definition because there appear to be at least a few clutterers for whom language problems are not evident.” (p.2) Rate problems are central to cluttering, says this article. “Clutterers also tend to slur or omit syllables of longer words, which compromise intelligibility during spurts of rapid speech.” (p.2) Many other optional symptoms include: lack of awareness of the problem, poor handwriting, confusing, disorganized language, temporary improvement when asked to ‘slow down,’ social or vocational problems, distractibility, hyperactivity, auditory perceptual difficulties, learning disabilities, and apraxia.

I think back upon 12 years of working exclusively with children and teens who stutter and realize that week after week, therapy activities often engaged my students in rate control, speech-motor practice, self-monitoring, educational counseling/mentoring, and language organization. These are relevant to both stuttering and cluttering. I recall how, eventually, so many of my students were found to have co-existing problems including Non-Verbal Learning Disorder, Attention Deficit, Sensory Integration Disorder, Dyslexia, Learning Disability and Temperamental Sensitivity. Others had family issues such as alcoholism, the birth of a sibling, moving to a new home, financial stress, and growing up in a multi-lingual environment.

I reflect on how experts in the field of stuttering have wondered aloud exactly why some treatment approaches seem effective with some individuals and not others. This has led to two stunning generalizations: 1. The client-clinician relationship matters more than the treatment approach; and, 2. Stuttering is a heterogeneous disorder with subtypes requiring different treatment approaches. Are these two concepts consistent with one another?!

All this causes me to pause and wonder, in the end, what separates me from the ‘snake oil salesman.’ All professional literature at my fingertips still leaves me with abiguity. Evidence Based Practice is not only literature based, but values clinician judgment. My judgments regarding client treatment are based on professional knowledge, ethical practice, and family feedback. Unlike 2+2, there is no single right answer in speech pathology.

(1) Judith Eckardt (2008) “Treating Down’s Children Who Stutter” http://www.mnsu.edu/comdis/isad11/papers/eckardt11.html
(2) Kurt Eggers & Chris De Bal (2006) Speech Dysfluencies in People with Down’s Syndrome Nov. 17, ASHA, Miami Beach http://convention.asha.org/2006/handouts/855_1304Eggers_Kurt_090842_112206071130.pdf
(3) David Daley (2007) “Cluttering: Characteristics Identified as Diagnostically Significant by 60 Fluency Experts” http://www.mnsu.edu/comdis/isad10/papers/daly10.html
(4) St. Louis, K, Myers, F.L., Bakker, K. (2003) “Cluttering Updated” (2003, Nov. 18) The ASHA Leader, pp 4-5, 20-22; http://www.asha.org/about/publications/leader-online/archives/2003/q4/f031118a.htm


Nonverbal Communication

Persons who stutter (PWS) face the challenge of ‘carryover’ from the very beginning of fluency therapy. The speech language pathologist (SLP) must offer guidance to the PWS regarding how to approach real life with new speech skills. One way to go about this can be to tap into the wealth of information available in the field of social-pragmatic communication. Research in the field of autism spectrum disorders provides detailed descriptions of social skills that will help in the design of carry over treatment goals. For example, I attended a workshop on Asperger’s Syndrome (2) in 2006 that included a 110 point Conversational Effectiveness Profile. Checklists such as this one provide the SLP and PWS with very specific choices from which to craft carry over goals.

Speech therapy for stuttering often emphasizes learning new speech skills along linguistic and speech-motor continuums. This means that practicing easy onset, for example, begins with syllables. Syllables are presumably easy to say because they are brief and have little/no semantic or syntactic demand. I suppose this would be similar to learning finger positions on an instrument. Gradually, the PWS practices his new speech skills in single words, then phrases, then sentences and longer speech tasks. This would be similar to learning chords, then short musical pieces and finally long, complex solos on an instrument.

The social-pragmatic literature draws our attention to the non-verbal aspects of communication that may be equally important in stuttering therapy. (3) Someone learning an instrument may want to play in a concert or jazz band, a string ensemble or perform solo in front of an audience. It seems to me that this requires more than musical talent and technical expertise. Likewise, the PWS wants more than fluency; he wants to communicate with others. He needs to appreciate the larger picture of effective communication. SLPs employed in multi-cultural settings also need to be sensitive to the different communication styles. (4)

Nonverbal communication is “body language.” A more encompassing, professional definition is “nonverbal communication includes those behaviors that are mutually recognized and socially shared codes and patterns with a focus on message meaning.” (1) Subtle and not-so-subtle behaviors communicate specific meanings to our listeners. A subtle raised eyebrow could indicate surprise. Hand waving could mean ‘Hi, I’m glad to see you.’ It depends on the situation, how these are combined with other gestures and perhaps what the speaker is also saying. PWS are sometimes extremely sensitive to the nonverbal signals being sent by listeners. They have seen "the look" so often, that they sometimes expect and percieve rejection from the subtlest of cues. Perhaps a greater understanding of nonverbal communication would help PWS gain a healthier, more resilianet perspective on listeners.

A narrow view of carry-over, one based on linguistic and speech-motor continuums, is unsatisfactory. The field of social pragmatics is within the scope of practice for SLPs and can be a part of speech therapy for stuttering.
(1) Cicca, A.H., Step, M., & Turkstra, L. (2003, Dec 16). Show me what you mean: Nonverbal communication theory and application. The ASHALeader, pp. 4-5, 34.
(2) Kowalski, Timothy (2006) http://www.socialpragmatics.com/
(3) Volden, J. (2002) Nonverbal Learning Disability: what the SLP Needs to Know
(4) Cheng, L.R. (2007), May 29) Codes and contexts: Exploring linguistic, cultural, and social intelligence. The ASHA Leader, 12(7), 8-9, 32-33.


Speech Development

Developmental disfluency emerges between 2 years and 6 years of age. This is a time of rapid speech and language growth. Research suggests that this growth is happening as the child’s brain and body mature. There is a sequence to this development. I was in a home this week where I observed a 5 year old ask his 17 month old brother to say “football.” While the younger boy may say something word-like to mean football, his ‘word’ cannot sound exactly like “football” because his oral-motor skills are too immature to pronounce the f-oo-t-b-a-ll sounds in just that way.

Yet we can listen to what a 17 month old child says and hear patterns common to child speech/language development. This blog entry is a brief review of speech development from birth – age 5. The information is adapted from a book by Ken M. Bleile. (1) The American Speech Language Hearing Association also provides information about speech/language development at http://www.asha.org/.

From birth to about 12 months of age, children begin to perceive the specific speech sounds of the language(s) they hear around them. When we talk, we create an acoustic signal, a sound wave full of information. The young child must decipher this signal. She has to find the individual ‘segments’ that are letter sounds and words. Imagine yourself listening to a language you don’t know; it sounds like a jumble of sounds, not an understandable sequence of words. “The acoustic signal of speech shows no distinctive boundaries that might mark where one segment ends and another begins, and the acoustic properties that can be associated with any particular segment are spread over fairly broad temporal regions.” (2) The young child listens to intonation patters, facial expressions, and watches his environment closely to discover the speech and language code hidden in the acoustic signal.

At the same time, brain and physical development are giving the child greater control over his body, including his jaw, tongue, lips, chest and lots of other muscles needed for saying sounds of his own. His babbling is his way of practicing these sounds. He tries out new sounds, combines them in different ways, hears his own voice and sees what affect it has on others. Gradually, he controls this babbling by starting and stopping it precisely enough that the people around him hear “words.” These beginning words don’t sound exactly like adult words. But they are close enough to give him a new kind of power. He can get what he needs with speech.

Once the child has figured out 1.) the acoustic signal actually made up of sound segments and 2.) she has greater control over saying sounds, she must learn the language rules of her community. A speaker of French must learn the rules of the French language. These rules are different than the rules of Spanish, or English, or any other language. And so the child must match her new physical ability to make sounds with a gradual understanding of how these sounds are combined in her native language. These two forces - the mechanics of speech and the rules of language – create some common “Error Patterns.” It is expected that children from the age of 2 years to 5 years will not speak like little adults! They will have natural, normal “error patterns” in their speech. A speech language pathologist listens carefully to a child and looks for these error patterns. It helps her decide if a child needs extra help learning to talk.

Note: “Regressions, small and large, occur commonly in speech development, especially during Stage 2, and may last from days to months. Parents sometimes notice larger, longer-lasting regressions, commenting that a child “used to say it correctly, but now doesn't” …Rather than proceeding in a straight line, speech development zigzags and sometimes even regresses… (3) While it may be normal to see regressions, we do want to take care that a child's regression is not due to hearing loss, environmental deprivation, or developmental delays. Consultation with the child's pediatrician, school district, or private clinician may be helpful.

(1) Manual of Articulation and Phonological Disorders: Infancy through Adulthood, 2nd Edition (© 2004, Clifton Park, NY: Thomson Delmar Learning, Inc.).
(2) Nittrouer, Susan (2002) From Ear to Cortex: A Perspective on What Clinicians Need to Understand About Speech Perception and Language Processing, Language Speech and Hearing Services in Schools,33, p. 238.
(3) Bleile p. 120
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.