Stuttering and Normal Non-Fluency: Onset and

Development

Presenter: Ramya Maitreyee II M.Sc (SLP)

DefinitionIncidence and prevalenceStuttering and Normal Non Fluency -Differential diagnosisOnset of StutteringDevelopment of Stuttering Patterns of Development The need for early identification and treatment of

stuttering

    

Van Riper (1982) defines “Stuttering” as a deviation in the ongoing fluency of speech, an inability to maintain the connected rhythm of speech” .

Wingate (1964):Disruption in fluency of verbal expression .Characterized by involuntary audible or silent

repetitions or prolongations in the utterances of short speech elements namely sound syllables.

These disruptions usually occur frequently or are marked in character .

Are not readily controllable.

Accompanied by accessory activities involving speech apparatus, related or unrelated body structure or stereotyped speech utterance.

Indications or reports of presence of emotional state ranging from general condition of “excitement” of “tension” to more specific emotions of negative nature such as fear, irritation.

Incidence and prevalencePercentage of general population that stutter vary but

seem to center around 0.7 to 1.0% (Milsen, 1957).

Common among children less than 12 years age (1%) than among adults (0.8%) (Andrews & Harris, 1964).

Males: Females = 3:1 to 10:1 (Hull &Timmons, 1969).

Stuttering is three times more common in families of stutterers than in families of non-stutterers (Wepman, 1939; Johnson, 1961).

There may be a slightly higher prevalence among lower socioeconomic groups than among higher ones (Morgenstern, 1956).

Stuttering may be more prevalent among retarded in particular among children with Down’s syndrome (Gens, 1951; Edson, 1964)

Stuttering and Normal Non-Fluency

Stuttering can be associated particularly in children with variety of speech and language problems.

Phonological problems (Louko, Edwards and Conture 1990; Nippold 1990).

Approximately 1/3rd of children who stuttered have DSL(Van Riper ,1971 & Bloodstein ,1981) .

BIGGEST CHALLENGE

Deciding not only if child is currently stuttering but also to decide if child’s speech problems are likely to continue if child receives speech and language therapy.

There are 2 major problems with regard to definition or classification of stuttering in children (Conture,1990)

•There is no known objective, listener independent criteria for identifying instances of stuttering or classifying children as stutterers vs normally fluent.

•There is no consensus among experienced clinician and researchers regarding behavior of stuttering in children or classification of children stutterers.

Differential diagnosis of children who stutter from normally fluent :

Considerable overlap in number and nature of speech dysfluencies exhibited by two talker groups (Johnson & Associates 1959; Meyers, 1986 Yairi & Lewis, 1984; Zebrowsky, 1991).

No known behavior, speech or otherwise that young stutterers exhibit that young non stutterers never exhibit.

No published evidence that speech dysfluency of young stutterers is categorically different from their fluent peers (Conture, 1990).

If stuttering is severe or has been chronic problem for some period of time, accurate diagnosis is seldom a problem.

Most of such children can be easily distinguished from

non stuttering children.

Nevertheless, speech of many preschool age children who are just beginning to stutter often sound very much like that of other children of their age.

Their stuttering may be episodic and vary substantially in frequency and severity from day to day and situation to situation.

So, identifying stuttering among these children can pose a significant diagnostic challenge for even experienced, expert clinicians (Curlee, 1993).

Gorden and Luper (1992)

•Limited data base for the diagnostic procedures used to identify beginning stuttering .

•There are multiple behaviors to simultaneously consider.

• It is not the mere presence, but the relative amount of frequency and type of a child’s dysfluency that help us to determine whether the child should be considered a “stutterer”.

There is no purely objective means for determining whether a child is stutterer any more than there is for deciding which sound, syllable or word is stuttered.

Clinically any child who exhibits both 10% of overall dysfluency and who produces 3 or more within word dysfluencies per 100 words is highly likely to be at risk for stuttering.

It is not hard to decide that a child’s is “stutterer” if he or she produces 10 more instances of stuttering per 100 words spoken.

Clinician does not find difficulty in deciding that a child is normally fluent if he or she exhibits extremely fluent speech.

• It is however hard for clinician to decide about a child whose behavior falls between those youngsters representing a sizeable portion of all children who stutter and who may be at low to moderate risk of stuttering.

•Tests like SSI (Riley, 1980) or SPI (Riley, 1981) help but are still less than adequate when describing these ‘in between’ children (Conture, 1990).

According to Wingate (1976) it is well documented that children between 3-5 year experience periods of dysfluency, which vary often depending upon emotional and linguistic load present in community interaction.

However only small percentage of these children actually becomes stutterers.

3 views of seemingly different hypothesis regarding 2 types of dysfluencies (normal and stuttering) are prevalent in literature.

1. Normal dysfluencies have a place on same continuum as stuttering

• It is simply a more severe and frequent manifestation of former.

Johnson (1942) expanded this concept and created

“Diagnosogenic theory of stuttering”.

He speculated that word and part word repetition were common to all children and stuttering develops from parents mislabeling of normal dysfluency as stuttering.

Johnson (1967) observed that listeners were unable to appropriately identify samples of speech of stutterers and non stutterers and concluded that there is no clear evidence and sharp line of demarcation between speech of stutterers and non stutterers.

2. Bloodstein(1918) proposed continuity hypothesis; which supposes that normal non-fluency of early childhood utterances change over time and evolve into tense utterances and fragmentation of words that are perceived by listeners as dysfluent or stuttering.

3. Other view holds that stuttering is different from NNF.

Certain speech traits are characteristics of stuttering specifically syllable repetition and prolongation.

Yairi and Clifton (1972) and Silverman (1972b) observed dysrhythmic phonation and tense pauses to occur least frequently in normal dysfluent speakers.

Van Riper (1971) cited research employing spectrographic and cineflurographic analysis to conclude that dysfluencies of stuttering and non-stuttering differed along several dimensions.

Arnold and Decicco (1982) compared supraglottal and laryngeal muscular events during stuttering and non stuttering disfluencies.

They concluded that 2 types of dysfluencies are similar on supraglottal level but significantly different on laryngeal level giving support that larynx is core of stuttering moment.

Guidelines for differentiating Normal from Abnormal disfluency

{From Van Riper, C. The nature of stuttering (2nd edition)}

BEHAVIOR STUTTERING NORMAL

DISFLUENCY

Syllable

repetitions

a. Frequency /wordb.Frequency for 100 wordsc.Tempod.Regulartiye.Schwa vowelf.Airflowg.Vocal tension

More than twoMore than two

Faster than normalIrregularOften presentOften interruptedOften apparent

Less than twoLess than two

Normal tempoRegularAbsent or rareRarely interruptedAbsent

Prolongations

h. Duration

i. Frequency

j. Regularity

k. Tension

l. When voiced

m. When unvoiced

n.Termination

Longer than 1 sec

More than 1 per 100 words

Uneven/interrupted

Important when present

May show rise in pitch

Interrupted airflow

Sudden

Less than one second

Less than 1 per 100 words

Smooth

Absent

No pitch rise

Airflow present

Gradual

Gaps (silent pauses)

o. Within word boundary

p. Prior to speech attempt

q. After the disfluency

May be present

Unusually long

May be present

Absent

Not marked

Absent

Phonation

r. Inflections

s. Phonatory arrest

t. Vocal fry

Restricted;

monotone

May be present

May be present

Normal

Absent

Usually absent

Articulatory postures

u. Appropriateness May be inappropriate Appropriate

Reaction to stress

v. Type More broken words Normal

dysfluencies

Evidence of awareness

w. Phonemic consistency

x. Frustration

y. Postponements

z. Eye contact

May be present

May be present

May be present

May waver

Absent

Absent

Absent

normal

Yairi (1997) compared children who are beginning to stuttering with their non stuttering counter parts:

2 1/2 to 3 times as many total instances of dysfluencies.

5 to 6 times as many instances of Stuttering Like Dysfluencies (SLDs).

Proportions of SLDs to total dysfluency that are twice as large.

Six times as many dysfluency clusters.Repetitions in which intervals between interactions

are shorter.Twice as many head and neck movements

accompanying dysfluencies.

Zebrowski (1995) provided summary of selected research in topography of early stuttering and how this might differ these children from normally fluent peers.

Specific features includes:

a. Frequency of Speech Dysfluency:- Refers to how often a child produces dysfluent

speech units within sample of predictable size or duration.

• Johnson (1956) obtained speech samples of 89 young stuttering children and compared them with age and gender matched non-stuttering children.

They indicated that children who stuttered were more than twice as dysfluent overall than their normally fluent peers and produced more of almost every type of speech dysfluency.

b. Type of proportion of dysfluency:-

Type and frequency of dysfluency overlaps between stuttering and normal dysfluent children.

Children, who stutter relatively close to onset of problem, produce more within word speech dysfluency (Conture, 1999a, Zebrowsky and Conture 1989).

•Four most frequently produced dysfluencies for boys who stuttered were

Sound and syllable repetition Whole word repetition Interjection Prolonged sounds.

•For non-stuttered boys Interjections Revisions Whole word and sound syllable repetition

(Johnson and Associates, 1959).

c. Duration of Instances of stuttering:-

A widely used protocol for identifying early stuttering includes some measures of estimation of stuttering duration.

They directly or indirectly specify that instances of stuttering of one sec, or longer help to distinguish stuttering from normal dysfluency (Cooper and Cooper 1985; Pindzola 1987; Van Riper 1982).

d. Number of repeated units within sound, syllable and word repetition:-

Adams (1980) and Pindzola (1987) contend that sound, syllable or part word repetition consisting of more than 2 repeated units reflects beginning stuttering.

e. Associated non-speech behavior:-

The presence, type, variety and magnitude of speech and non speech behavior associated with stuttering has been used in identifying and rating its severity (Riley 1980).

Conture and Kelly (1991) measured non speech behavior of 3-7 year old children who stutter and found more head turns, eye blinks and upper lip rising during their stuttered words than non stuttering children.

•Several protocols (Gorden & Luper, 1992) have been published that are designed to help SLPs to distinguish who are typically fluent from those children who stutter (Adams, 1977; Pindzola & White, 1986).

However fewer instruments (Cooper & Curlee, 1985) helped clinician to distinguish among children who stutter.

•One widely used protocol designed to differentiate children at risk for continuing to stutter from those likely to discontinue stuttering is Stuttering Prediction Instrument (SPI).

• It examines aspects of children’s assessing children who stutter or who are expected to stutter (Yaruss & Conture, 1993).

•Conture (1991) stated that complex and dimensional nature of early stuttering makes its diagnosis a consideration of probabilities not absolute.

•Geetha Y V (1996) devised Dysfluency Assessment Procedure for Children (DAPC) to assess dysfluent children in age range of 2.3-6 years. It consisted of

Questionnaire: - It consisted of 40 questions which was prepared on basis of SSI, SPI, and Stuttering chronicity prediction Instrument and literature on factors associated with stuttering onset and development.

Test Battery: - Consisted of tests of articulation and language. Diagnostic Kannada Picture Articulation Test and Kannada Language Test was used.

SSI was used to assess severity of stuttering.Assessment of speech and non speech

characteristics: - Speech samples were elicited using recitation, narration, conversation.

Comprehensive crucial for identifying differentiation of dysfluencies. A detailed questionnaire was prepared incorporating

which consisted of •Historical, Attitudinal and behavioral factors•Motor, speech, language development•Scholastic history

• Items which were more important were given more weightage in scoring yielding a score of 50.

• It was found that Historical and Attitudinal factors overlap in scores between NNF and very mild stuttering.

•NNF had scores less than 5 and Stuttering children had 5-15.

•Attitudinal factors were important in determining stuttering dysfluencies as more negative attitude of self.

• Behavioral factors clearly differentiated Stuttering and NNF and scores were directly related to severity of problem.

•NNF had 0 score and it ranged from 0-20 for stuttering.

Onset and Development of stuttering.

•Stuttering at or near onset not only differs from that of the ‘typical’ adult who stutters but also that of the ‘typical’ school age child who has it.

•The disorder following onset tends to develop over a period of years in a fairly predictable way along a continuum or track.

•According to Van Riper (1982) he believes that there is more than one track along which it can develop.

Onset of stutteringCan begin at any age.

Onset -2-5 years (Darley, 1955, Johnson & Associates, 1959; Yairi 1983).

The mean ages of onset that have been reported range from 28 months (Yairi, 1983) to 46 months (Darley, 1955).

The age of onset age at which an informant reports that he or she first concluded that a child’s repetitions and/or other hesitations were abnormal.

Information about stuttering at onset

Reports by informants who are not SLPs. Information is incomplete Based on what can readily be observed by a layperson

through vision and hearing.

There are undoubtedly physiological and psychological events associated with it that either cannot be observed without instrumentation or even if observed would be unlikely to regard as related to the onset of the disorder.

Nature of onset

Difficult to answer Most of the data relevant to it (Johnson & Associates,

1959) are from reports by parents and other laypersons, reported months (or years) after the disorder is thought to have begun.

Inaccurate reportsThe persons making them either were not aware of child’s earliest moments of stuttering or considered them to be normal hesitations.

This would tend to make the onset of disorder appear to have been more sudden than it really was.

•Though the data bearing on this question have to be interpreted with caution for the reasons indicated earlier, they do seem to indicate that the onset could be:

Sudden or gradual (Yairi, 1983) But usually is gradual (Van Riper, 1982).

•The percentage of cases reported by other investigators in which the onset was gradual are 86 (Ajuriaguerra, 1958), 92 (Morley, 1957) 76 (Preus, 1981), 69 (Berlin, 1954) and 90 (Van Riper, 1982)

Onset of stuttering in adultsRegarded as disorder of childhood

Onset almost always occurs before the age of 18, usually before the age of 5.

However there are number of reports of persons who began to stutter after the age of 18.

Some of these may be cases in which the person stuttered for at least a short time during childhood, stopped and began again as an adult, it seems unlikely that they all are. So probably stuttering can have its onset during adulthood.

•Some of the findings of onset of stuttering (Starkweather)

▫Most stuttering begins between the onset of speech and puberty median age of onset is 4 years (Andrews and Harris, 1964).

▫The dysfluencies of preschool children who stutter are primarily whole word repetitions and interjections (Westby, 1979).

▫In children, onset is typically gradual. Often there is nothing unusual in circumstances at the time of onset i.e. no shocks, fright, illness or injury (Van Riper 1971).

▫There is no systematic pattern of environmental events at the time of stuttering onset but many parents report that there was a source of emotional tension in the household at or around the time of onset such as illness of a family member, absence of parents etc.

Conditions contributing to onset

Less influential factors: These factors do not have a strong influence on precipitating the problem of stuttering

I. Physical development: - Same general physical make up as children who

speak normally. No evidence that children who stutter are distinctive

in terms of general developmental milestones (Andrews and Harris, 1984)

II. Illness: -

Silverman (1906) points out, if illness affects CNS, a cause and effect relationship between illness and onset of stuttering may be possible.

CWS do not appear to have more illness than those who do not (Andrews and Harris, 1964; Johnson and Associates, 1959)

III. Imitation: - This consideration of stuttering onset may be

influenced by culture of the speaker, E.g, Otsuki (1958) reported that in Japan, imitation was

viewed as a major casual factor in 70% of his cases.

Van Riper (1982) indicated that there were several instances where imitation appeared to be involved in onset of stuttering

IV. Shock or fright: - Parents may report the onset of stuttering following a

traumatic emotional event (Van Riper, 1982). Parents may report onset of stuttering associated with

an event without knowing that their child had been stuttering for some time in school and other locations.

Moreover Silverman indicates that almost in all cases the ‘traumatic’ events are not really very traumatic.

V. Emotional and communicative conflicts: -

Some parents suspect that a variety of interpersonal and family stresses can bring about stuttering.

There is no indication that children who stutter have a greater number of emotional conflicts than their normally speaking counterparts (Adams, 1993; Van Riper, 1982).

Again as with illness, shock or fright emotional or communicative stress undoubtedly enhances the possibly of breakdowns in the motor sequencing of speech (Van Riper, 1982)

VI. Socio economic status: - Few data available indicates that stuttering is present

in all socio economic groups. Van Riper (1982) reviewed several studies that

report varying amount of stuttering across both cultures and races.

Gillespie and Cooper (1973) and Dyker and Pindzola (1995) reported data showing a higher occurrence of stuttering in African populations.

Bloodstein (1987) suggest that occurrence of stuttering may be related to the imposition of high standards for achievement of status and prestige.

More influential factors:- These factors have greater influence on likelihood of

stuttering.

The following conditions may be best thought of as predisposing factors that can place a child at greater risk for both precipitating and maintaining stuttering (Silverman, 1992)

I. Gender: –

Kent (1983) discussed the fact that higher occurrence of stuttering in males is one of the few consistencies about the disorder.

However, stuttering begins with approximately equal frequency with young boys and girls.

Females are much more likely to recover from stuttering during pre school years than males.

The reason why males consistently show a higher persistence of stuttering may relate to boys being less adept at language and speech activities or less able to adapt to communicative stress.

Based on result of several studies, Yairi and Ambrose (1999) suggest that gender and genetics interact in such a way that young females who stutter are much less likely to persist in stuttering than young males.

II. Age: -

Children who are approximately 2 to 7 years of age are much more likely to begin stuttering than older children, adolescents or adults.

There is a much greater clearance of stuttering onset before age 5 than after age 7 years.

Andrews (1984) suggests that the risk of developing stuttering drops by 50% after age 4, 75% after age 6 and is virtually nil by age 12.

Onset of stuttering during middle or later adult years is extremely a rate is likely to occur only in cases of neurological or psychological origin.

Yairi and Ambrose (1992b) found that boys begin stuttering an average of 5 months later than girls.

III. Genetic factors-Bloodstein (1995) review indicates that percentage

of persons who have relatives on maternal or paternal side who stuttered ranges from 30 to 69%.

Studies concerning stuttering have focused on occurrence of stuttering in families, particularly in instances where there is density of stuttering in 1st and 2nd degree relatives.

Research during past few decades has indicated a genetic component in selected groups of people who stutter (Cox, Seider and Kidd, 1984)

IV. Twinning: - The relationship of twinning to stuttering is of

course, closely connected to genetic factors. Approximately 1/3rd of all twin pairs are

monozygotic pairs and are genetically identical. The remaining twin pairs are dizygotic and share

about half of their polymorphic genes. A child is more likely to stutterer if he is a member

of a twin pair in which the other twin also stutters (Howie, 1981).

This is especially true if twins are monozygotic. It is less likely that both members of fraternal twin pair will stutter5 (Howie, 1981)

V. Brain injury – Van Riper (1982) summarizes findings that report

considerably greater than 1% occurrence of stuttering with brain injury, especially for speakers with CP and epilepsy.

However it can sometimes be difficult to distinguish motor speech and language problems (part word finding) from fluency breaks.

In addition, speakers who are developmentally delayed often have a higher than usual occurrence of stuttering especially those with Down’s syndrome.

Van Riper (1982) summarized results of 7 independent studies indicating prevalence figures ranging from low of 7% (Schaeffer and Shearer 1968) to a high of 60% for clients with Down’s Syndrome (Preus 1973).

Averaging all 7 studies and 2 reported categories of general retardates and monogloids results in prevalence figure of 24%.

In addition developmental delays and neuro-pathological influences can mask identification of fluency disorders.

Studies indicate that both verbal and non verbal intelligence is slightly lower in speakers who stutter in contrast to control subjects.

VI. Speech and language development:- As series of studies of Andrews and Harris (1964) ;

Berrty (1938); Guitar (1998); Kloine and Starkweather (1979); Wall (1980); Peters and Guitar (1991) concluded that children who stutter typically achieve lower scores than their peers on measures of receptive vocabulary, age of speech and language onset, MLU and expressive and receptive syntax.

Recent investigations suggest that relationship of stuttering and expressive language and phonological abilities is far from simple.

Watkins, Yairi and Ambrose (1999) studied 62 pre school children who recovered from stuttering and 22 who still persisted, on language skills and found that both groups of children displayed expressive language scores well above normative values. These results counter the frequently expressed opinion that young children who stutter demonstrate delays in expressive language.

Paden, Yairi and Ambrose (1999) studied phonological abilities of these same children and concluded that preschool children who stutter and are slow to develop phonologically are usually in the group whose stuttering will be persistent.

VII. Motor coordination: - There is some evidence that adults who stutter have

greater difficulty in fine motor coordination (Riley & Riley, 1984; Starkweather, 1987, Van Riper, 1982).

A significant part of act of speaking is a motor skill and any delay or deficit in this aspect could certainly adversely affect development of normal fluency.

There is some indication of a lack of appropriate interaction between laryngeal and supralaryngeal behaviors during fluent speech in young children who stutter (Conture, 1985).

Development of stuttering

There have been several attempts to describe how symptomatology of stuttering in preschool children evolves into that evinced by most adults.

The most traditional view of stuttering development is one of gradual increase in awareness and struggle, and thus severity.

Bluemel’s primary and secondary stages

One of the first attempts to describe the development of disorder was by Dr.Charles Bluemel (1932, 1957).

He referred to stuttering evinced during first stage as “primary” stuttering and that evinced during the second as “secondary” stuttering.

He described primary stuttering as consisting of relatively effortless repetitions and prolonged articulatory postures. This type would be exhibited by most children at or near onset.

Secondary stuttering Marked by conscious struggle to articulate while

mental process of speech is momentarily halted. The stammerers breathing is disturbed like wise his

vocalization and articulation. He uses starters to get the speech going. He becomes conditioned against difficult words and

situations and he develops speech aversion and avoidance.

He resorts to synonyms and circumlocutions to avoid his stammering.

Bluemel’s Theory

Characteristics.simple disturbance in speech

.effortlesscore behaviors

Secondary behaviorsavoidancestruggle

But Bluemel’s scheme has been criticized for several reasons.

Behaviors which he indicates as being symptomatic of primary stuttering can be observed in speech of normal speaking preschool age children.

It does not adequately describe symptomatology of disorder in school age children, particularly in those of elementary school age.

Stuttering does not always begin with relatively relaxed hesitations of which person is unaware. It has been reported that children evinced behavior characteristics of secondary stuttering immediately following onset of disorder.

It does not describe in sufficient detail the transition between beginning stuttering and fully developed form of disorder.

Bloodstein’s four phases

Bloodstein (1960) has proposed 4 stage scheme that includes aspects of symptomatology of disorder in school age children as well as in preschool age ones and adults.

He appropriately points that there is considerable variation in the age at which a person evinces symptomatology associated with each phase.

Phase 1 (Pre schooler)oEpisodic.

oStuttering is still in its rudimentary form. oAppears for periods of weeks or months

between long internals of normal speech.

oThere is apparently high percentage of spontaneous recovery.

oChild stutters most when excited or upset when seeming to have great deal to say or under condition of communicative pressure.

oDominant symptom is repetition. Much of the repetitions consist of repetition of initial syllables as it does in older stutterers, there is usually a conspicuous tendency to repeat whole words.

oThere is a marked tendency for stuttering to occur at the beginning of the sentences, clause or phrase.

o In contrast to more advanced stuttering, interruptions occur not only on content words, but also on function words of speech pronouns, conjunctions articles and prepositions.

oMost of the time children in first phase of stuttering show little evidence of concern about interruption in their speech.

Phase II (Elementary school)

oChronic. oThere are few, if any, intervals of normal

speech.oChild has a self concept of stuttering.

oStuttering occurs chiefly on major parts of speech nouns, verbs, adjectives and adverbs.

oFewer tendencies to stutter only on initial words of sentences and phrases and whole word repetitions are no longer quite as common.

oDespite a self concept as a stutterer, child usually evinces little or no concern about the speech difficulty.

oThere is absence of features of advanced stuttering as anticipation of stuttering, substitution, avoidance of speaking circumlocution, word sound and situation fears.

oStuttering increases chiefly under conditions of excitement and when the child is speaking rapidly.

PHASE III (Late childhood and early adolescence)

oStuttering comes and goes largely in response to specific situations.

oPerson often reports difficulty in situations like classroom recitation, speaking to strangers, using telephone.

oCertain words or sounds are regarded as more difficult than others.

o In varying degrees, word substitutions and circumlocutions are seen.

o It tends to be done only occasionally and more often as reaction to frustration.

oNo avoidance of speech situations and no evidence of fear.

Phase IV (Adulthood)

oVivid, fearful, anticipations of stuttering

oFeared words, sound and situations

oVery frequent word substitutions and circumlocution.

oAvoidance of speech situation, evidence of fear and embarrassment.

Van Riper’s tracks of stuttering

Van Riper (1982) agreed with Bloodstein that the process through which symptomatology of disorder in preschool children evolves into adult form.

However he concluded that continuum along which it developed was not same for all persons.

He indicated that there at least 4 tracks along which it can develop.

Track I---Typical Development of Stuttering

•Previously fluent Gradual onset•Cyclic long remissions•good articulation normal rate• syllabic repetitions no tensions• loci: first words, function words•no awareness no frustration

Track II---- Cluttering•Often late, at time of first sentences•never very fluent, gradual onset•no remissions•poor articulation fast spurts•gaps, revisions, syllable and word repetitions•no tensions, no tremors• loci: first words, long words scattered throughout

sentence•variable pattern•no awareness, no frustration

Track III--- “Shocks and Frights”

•Any age previously fluent• sudden onset, often after trauma•Steady few short remissions•normal articulation• slow careful rate•much tension• tremors•beginning of utterance, after pauses•highly aware much frustration

Track 1, suggest more than 50% of cases follow, quite similar continuum defined by Bloodstein’s 4 phases.

As such, it has the same limitation as scheme proposed by Bloodstein symptoms that define beginning of this track also are exhibited by some normal speaking preschool age children.

Another question raised is whether the disorder that develops along tracks II, III and IV is same as that which develops along track 1.

Though all are labeled as “stuttering’, it might not be the same disorder.

The symptomatology evidenced by children on tack II seems to be that of cluttering (Silesman, 1992).

Conture (1991)

a. Alpha Behaviors:- They are brief, subtle inefficiencies in speech

production characterized by short within word pauses, laryngeal catches and articulatory arrests at the beginning of an utterance or at the transition between sounds and syllables.

These subtle breaks appear to occur as a result of interplay between child’s capacity for producing fluency and environmental stimuli or demands.

b. Beta behaviors:-They are oscillatory movements of speech

mechanism which are characterized by brief to lengthy repetitive productions.

These are compensatory or copying reactions to the original alpha factors and take the form of syllable repetitions, laryngeal adduction and nostril flaring.

c. Gamma behaviors: - They are speech movements that are relatively tense,

fixed or both and are viewed as coping reactions to the beta activities.

These behaviors take the form of fixed laryngeal adductory postures, labial contacts and lingual posturing.

They result in inaudible sound prolongations or cessation of airflow or voicing.

This stage is a significant step in development of stuttering, marking a reduced likelihood that spontaneous recovery will take place.

d. Delta Behaviors: -

They are both nonverbal and verbal reactions to beta, gamma and possibly alpha behaviors and are seen as reactive speech and non speech behaviors.

These coping reactions are in the form of such responses as pharyngeal muscle constrictions, vocal fold lengthening and shortening, blinking of eye lids and eyeball movements.

Although this pattern of development assists in understanding how stuttering may sometimes evolve, there is a growing body of data that suggests that such development is not always the case.

The longitudinal data accumulated by Yairi and his associated concerning onset and development (Yairi & Ambrose 1992a, 1992b, 1999) suggest that stuttering in young children can reach an advanced form soon after onset.

The most interesting finding is the observation that a substantial number of children show a dramatic decline in both frequency and severity of stuttering within first six months after onset (Yairi & Ambrose 1992; Yairi, Ambrose & Nirmann, 1993).

Peters and Starkweather (1989) in their study on “Development of stuttering throughout Life” provided a comprehensive view of development of normal and abnormal fluency from perspective of three aspects of human development.

Speech motor behavior, linguistic behavior, social, emotional and cognitive behavior.

They have divided life span into 5 phase as preschool, early school years, puberty and adolescence, late adolescence and early adulthood.

According to them, stuttering develops most dramatically in early years of life and continues to change in less dramatic ways throughout life.

They concluded that human beings grow in predictable ways throughout life.

Most importantly, certain aspects of stuttering change be seen as particularization of human development.

Development of stuttering during middle age and

beyond

There is an implicit assumption that once stuttering has reached its most severe form, usually during adolescence or early adulthood it ceases to develop in predictable manner.

Research pertaining to this assumption began during 1980s.

There is some evidence that personality and attitudes tend to change in predictable ways during adult life cycle (Sheehy, 1976).

Since personality attributes and attitudes influence stuttering severity it would not be particularly surprising if stuttering did change during middle age and beyond.

Peters and Starkweather (1989) reported the following changes tend to occur after age of 30 years:-

During this period, a gradual decline in the severity of stuttering is seen.

New behaviors are no longer acquired.Tendency for a reduction of abnormality has largely

stopped.Increased self confidence maturity seems to reduce

the frequency with which all stuttering behavior occur.

Occasionally there is complete remission.

Some findings for development of stuttering:There is tendency for the amount and frequency of

dysfluency in normal speakers to decrease with age during the second year of life (Yairi, 1981) and presumably throughout the preschool period.

During school years, there is a continued but slight decrease in the frequency of dysfluency in normal children.

Stuttering changes over time. The pace of this change is highly variable and course of development is also variable but some common characteristics are identifiable as trends of development in young stutterers (Bloodstein, 1960)

There is tendency for dysfluencies of stuttering children to fragment briefer units of speech (Bloodstein, 1960) and for the rate of repetition to increase (Van Riper, 1984)

There is a tendency for the amount of tension and forcing to increase (Bloodstein, 1960)

Early stuttering is likely to be episodic over time. With development, this changes to fluctuations in severity over time (Bloodstein, 1960)

Early stuttering is as likely to occur in one circumstances as in any other but with continued development it tends to become associated with specific speaking situations (Bloodstein, 1960)

There is a tendency for children who stutter to recover spontaneously (Ingham, 1985)

Females are more likely to recover than males (Andrews, et al. 1983)

Stutterers are late in passing speech milestones. (Andrews et al., 1983)

Reductions of parental speech rate are significantly correlated with the extent of improvement in children’s stuttering during treatment (Starkweather & Gottwald, 1984).

Children may also have traumatic onset, the mute period being reported in some of the cases (Van Riper, 1971).

Adult onset may also follow physiological trauma (Peacher & Harris, 1946).

Few cases of stuttering following brain injury have been reported. Diffuse brain injury has also been reported as a precursor to stuttering behaviors (Helm, Butler & Benson, 1978)

Stuttering has occasionally been reported as a sequel to aphasia (Helm, Butler & Benson, 1978)

Patterns of developmentFirst, the discontinuous behavior, pauses, repetitions

prolongations and broken words that take up time but do not convey information, become truncated.

The first noticed abnormal child’s fluency is excessive amount of whole words to parts of words. Eg: The child says “But, but, but, but I don’t want”. The repeated element may be shortened further ‘b-b-b-b-but’.

Hence, one characteristic of typical course of development is progressive truncation of repeated elements (Bloodstein, 1960).

•The next change in the most typical course of development is use of one or more behaviors that indicate there is tension in larynx.

•Three behaviors are common: Prolonged vowels with pitch rise Broken words Increased loudness.

Prolonged vowels with pitch rise is siren like e.g. the child says “May I have some?” and vowel in ‘may’ is prolonged like Maaaay and pitch of voice rises slowly and steadily and it continues as long as vowel is prolonged.

Increased tension in larynx leads to increased vocal loudness.

The voice becomes increasingly loud as vowel is prolonged.

Finally, the more elaborate secondary features develop, those designed to avoid stuttering :

Changing words Postponing the attempt on the word. Diverting attention from dysfluency. Avoiding talk altogether.

In beginning these tricks are effective but gradually these behaviors lose their effectiveness and change in form.

Avoidance is also important in development of disorder: -

Many who repeat whole word excessively manage to grow into normal speakers.

Those who do not are the ones who react to repetitiveness in their speech with struggle, forcing tension and avoidance.

Not only do they react in avoidant way, they incorporate this reaction into their habitual talking pattern.

THE NEED FOR EARLY IDENTIFICATION AND TREATMENT

Stuttering is a disorder of childhood, onset of which is more than 90% of the individuals is before the age of 6 years.

Clinicians are often apprehensive in counseling the parents regarding the need for intervention for young children with stuttering in terms of duration of treatment required, outcome expected, the techniques which facilitate recovery etc. This is more so with those who adhere to the Johnson’s Diagnosogenic Theory.

This is a serious problem when the current emphasis is more on early identification and intervention.

Stuttering has serious impact on the individual’s personal (self-esteem), psychological, social, educational, vocational and interpersonal relations.

There are some risk factors suggested in the literature for predicting recovery or to make decisions regarding intervention such as the presence of family history, chronicity and severity of the problem, associated phonological and language delays or defects, consistency of the problem, child’s and/or parental concern etc.

However, early identification and treating children close to onset of stuttering is increasingly emphasized by many authors for the following reasons:

It is easy, less time consuming and more long lasting (i.e., approximately 1-3 months or 20 hours for children (Starkweather & Gottwald, 1986) to one to several months/years or 140 hours for adults (Van Riper, 1973; Webster, 1974) and is reported to be dependent on the chronicity of the problem

Reported rates of success is higher (>90%) compared to that for adults (50-75%) (Franken, 1988; Starkweather, Gottwald & Halfond, 1990; Webster, 1974).

Relapsed rates for treated adults are reported to be around 50% (Franken, 1988); whereas for children it is close to zero (Starkweather, Gottwald & Halfond, 1990).

Adults who are treated are reported to have carefully monitored speech (Boberg & Kully, 1994) and diminished quality of speech (Franken, 1988) or may have residual stuttering behaviors (Prins, 1984) while the treated children are reported to be no different from their non-stuttering peers (Starkweather, Gottwald & Halfond, 1990).

Although it is reported that many children with stuttering spontaneously recover, nearly 20% would continue to stutter if not treated and it is not a small number when 1% of the total adult population who continue to stutter if not treated is considered.

The impact of stuttering problem on the young minds to live with it could be quite handicapping emotionally, socially, educationally and vocationally as reported by many persons with stuttering.