Stuttering Midterm

stuttering sex ratio

Sex ratio beings at 1:1 at onset, by school age reaches 3:1 (male:female)

Typical onset of stuttering

• Between 2-3.5 years

• Gradual increase in normal disfluencies

• Sudden appearance of severe block 

• Between 70-80% of children who begin to stutter recover without treatment

• If they persist past about 8 yrs old, it is likely they will persist for their entire life

Developmental factors of stuttering

• Limited speech motor skills

• Increases emotional reactivity

• Decreases in emotional regulation

• Rapidly developing motor cognitive, and speech and language skills may compete for neural resources so that language and speech production are affected

• Stuttering onset often coincides with complex language development (Evaluation of young children who stutter should include all components of language)

secondary behaviors

Learned behaviors that are triggered by the experience of stuttering or the anticipation of it.

escape behaviors in stuttering

to actions or strategies that a person who stutters might use to avoid or get out of a difficult speaking situation. These behaviors typically happen when the individual is experiencing a moment of stuttering and feels anxious or unable to complete their speech fluently. Escape behaviors can help them temporarily avoid the stuttering moment, but they don't resolve the underlying speech difficulty.

Example: A common escape behavior is eye blinks or head jerks. When a person feels that they are about to stutter on a word, they might quickly blink their eyes or jerk their head to distract from the stutter or to "break" the stuttering moment, allowing them to move past it more quickly. While this might help in the short term, it can contribute to the persistence of stuttering over time if used frequently.

avoidance behaviors in stuttering

the actions a person takes to prevent situations where they might stutter. These behaviors are typically driven by fear or anxiety about stuttering in certain situations and can involve avoiding specific words, people, or speaking scenarios altogether.

Example: A common avoidance behavior is avoiding certain words. For instance, a person might steer clear of words they know are likely to cause stuttering, such as difficult consonant clusters or longer words, by substituting them with simpler words or rephrasing their sentences. This avoidance can lead to reduced fluency in everyday conversations and may limit communication opportunities. Another example may be someone avoiding certain social situations, which may be very isolating for the individual.

Listeners tend to…

• Feelings of discomfort

• Avoid eye contact

• Help finish utterance

• Interrupt when there is a pause

• Try to help by saying phrases such as “it’s olay, take your time” “slow down”

genetic influences

• when one twin stutters, the other often stutters as well (but not always, shows there are biological and environmental influences)

• No single gene or mutation has been shown to be associated with stuttering

• Relieve parent’s guilt about “causing” their child’s stutter

• Just because a relative has persistent stuttering does not assure that stuttering will occur

• the hereditary factors that may contribute to the likelihood of developing stuttering. Research indicates that stuttering can run in families, suggesting a genetic component, but it also involves complex interactions with environmental factors.

brain structure differences- white matter tracts

Density of white matter tracts in areas of left operculum were less dense in PWS. information flow between brocas and wenicke’s area may be affected with this less myelinated white matter

brain structure differences- overactivation

•  increased brain activity in the right hemisphere

• PWS are using less efficient side of the brain for speech 

• Compensation for deficient left hemisphere

brain structure difference- deactivation

decreased brain activity in left hemisphere

Underactivity in auditory areas used to monitor one’s own speech output. Delayed auditory feedback 

Children and adults who stutter show reduced connectivity within brain regions associated with speech motor control

environmental influences

• Behaviors, attitudes, events at home

• Family’s anxiety about child’s speech

  • Conversational style in home

    • Rapid rate

    • Complex syntax

    • More than 1 language in home

    • Polysyllabic vocab

    • Competition for speaking

    • Frequent interruptions

    • Demand for display speech

    • Loss of listener attention

    • Hurried when speaking

    • Frequent questions

    • Excited when speaking

    • Many things to say

  • Peer/family reactions to stuttering

  • Parenting style

  • Life changes

    • Moving

    • Parent separation/divorce

    • Death in family

    • Hospitalization (family member or child)

    • Parent loss of job

    • New person in house

    • Parents leaving frequently or long-term

    • Holidays, changes in routine, etc.

    • Discipline issues with kid

speech motor skills approach

• (Van Lieshout, Hulstijn, Peters)

• Stuttering result of limited speech motor skills

• PWS have less efficient, less flexible, less adaptive speech motor system; increasing demands of speech motor system may destabilize motor control

• PNS start to receive benefits from motor practice, PWS have more difficulty and motor practice does not improve

multifactorial dynamic pathway theory

• Smith and Weber

• Constellation of stuttering

• There is no one cause of stuttering

• Many factors interact to result in stuttering

  • Psychosocial/emotional stress

  • Linguistic stress

  • Cognitive stress

• Unique to the individual 

• The 80% of children who recover experience brain adaptations, allows them to compensate for the atypical neural activity underlying the stuttering disfluencies

• The 20% of children who don't recover dont have adequate brain adaptations

capacities and demands

• Stuttering exacerbated by demands from attention, language, emotion, motoric processes (Chang, Sheehan, Andrews, Starkweather)

• Capacities:

  • Ability to plan and program for language while making fast, coordinated movements for speech

• Demands:

  • Advanced conceptual and linguistic abilities: attempting to model rapid and complex speech and language in environment; emotionally stressful situations

2-stage theory of stuttering

• Primary stuttering

  • Occurs because neural circuits for speech and language may be:

    • Working in an “underdeveloped” area

    • Reorganized and moved to an area not naturally suited to rapid speech and language functions (e.g. right hemisphere)

    • Reorganized so that major functions are at some distance from each other

    • Slower in processing because of less dense pathways

• Secondary stuttering

  • Some kids may be more reactive temperamentally

  • Reactivity causes responses to unpleasant/threatening stimuli such as

    • Increasing tension

    • Speeding up

    • Escaping

    • Avoiding

  • Reactive temperament causes emotional arousal, events causing the emotion are more deeply engrained (learning enhances emotion)

  • Emotional conditioning may result in cognitive changes

2-stage theory of stutterin for dummies

In the primary stage, stuttering happens because the brain’s neural circuits for speech and language may not be fully developed or may not be in the ideal areas for smooth speech. For example, the circuits might be working in an “underdeveloped” part of the brain or be reorganized to a less efficient area (like the right hemisphere), making it harder for the person to speak quickly and smoothly. The pathways for speech might also be less dense, leading to slower processing of language.

In the secondary stage, the stuttering becomes more pronounced because of a child’s emotional reactions. Some children may have a temperament that makes them more sensitive or reactive to stress, and this can lead to feelings of anxiety or frustration when they try to speak. This emotional reaction often increases tension, causes them to speed up their speech, or leads them to use escape and avoidance behaviors (like avoiding certain words or situations). Over time, these emotional responses become deeply ingrained, and they can make stuttering worse, creating a "fear" pattern that leads to persistent difficulties.

In simple terms, stuttering doesn't have just one cause. Biological differences in the brain can make speech less efficient, and emotional reactions to stuttering can create a cycle of fear and avoidance that makes the problem worse over time.

normal disfluencies

Ages 2-5

• Part word repetition

• Single-syllable word repetitions

• Multisyllabic word repetition

• Phrase repetition “I wanna I want a ice-cream

• Interjection “uh”

• Revision-incomplete phrase- “I lost my…where’s mommy going”

• Repetitions are more common in younger children, revisions are more common in older children

• Most children have these at these ages

how to differentiate normal disfluencies

1. No more than 10 disfluencies per 100 words

2. Typically one-unit repetition

3. Most common disfluency types are interjections, revisions, and word repetitions. 

Normal/other disfluencies- fillers, interjections, revisions, multisyllabic word repetitions 

• Children with normal disfluencies don't react to them, they seem unaware of them

younger preschool: borderline stuttering

• More than 10 disfluencies per 100 word

• Often more than two units in repetition

• More repetitions and prolongations than revisions or incomplete phrases

• Disfluencies loose and relaxed, no frustration/embarrassment, moves through quicker

• Rare for child to react to disfluencies

olderpreschool children: beginning stuttering

• signs of muscle tension and hurry

• pitch rise may be present some escape behaviors emerging

• awareness of difficulty and feelings of frustration are present, but there are no strong negative feelings about self as a speaker

school aged: intermediate stuttering

• most frequent core behaviors are blocks, repetitions, and prolongations

• uses escape behaviors to terminate blocks

• can anticipate block, and will engage in avoidance behaviors

• fear before stuttering, embarassment during stuttering, and shame after stuttering

word avoidance techniques

• Starters

• Substitutions

• Circumlocutions

• Postponements- waiting a few beats or putting in a filler before starting a word on which stuttering is expected 

• Anti-expectancy devices- using an odd manner or funny voice to avoid stuttering (whispering, accents)

adults/adolescents: advanced stuttering

• longer, tense blocks

• stuttering may be suppressed through extensive avoidance behaviors

• fear, embarassment, shame feelings are very strong

• have negative feelings of self

A married couple come to you for advice. They tell you they are thinking of having a child but are worried because each has a relative who stutters. What would you tell them about the likelihood that they would have a child who stutters and whether they should be concerned?

Stuttering can have a genetic component, as research shows it sometimes runs in families, suggesting that inherited factors may increase a child's risk. However, no single gene has been identified as solely responsible, indicating that stuttering is likely polygenic, with multiple genes contributing to the risk. Given that both individuals in the couple have relatives who stutter, their child may have a slightly higher chance of stuttering, but genetic predisposition alone doesn’t guarantee it. Stuttering can also arise from complex interactions between genetic, neurophysiological, developmental, and environmental factors, as outlined by the Multifactorial Dynamic Pathway Theory (Smith & Weber, 2017).

The theory emphasizes that while genetics may contribute to susceptibility, stuttering is influenced by a variety of forces, including developmental milestones, brain function, and environmental stressors. Even if a child is genetically predisposed, stuttering may not manifest unless specific developmental or environmental factors trigger it. Moreover, early intervention and a supportive environment can significantly help a child manage or overcome stuttering. I would reassure the couple that, while their family history may slightly raise the likelihood of stuttering, many children with a family history of stuttering do not develop it, and supportive, low-stress environments can mitigate any challenges.

Why do you think it is important for you to understand genetic and brain differences in people who stutter?

By understanding the neurological and genetic factors involved, we can better support clients and their families, offering strategies that account for both the speech production process and potential cognitive or emotional influences.

Research has shown that individuals who stutter may have differences in brain hemisphere activation, particularly when it comes to speech and language processing. Typically, the left hemisphere is dominant for language, but in people who stutter, there can be altered activation patterns, with both hemispheres being involved in speech production. This could lead to difficulties in coordinating the motor and cognitive aspects of speech. Additionally, the amygdala, which is involved in processing emotions like anxiety and fear, may be more activated in people who stutter, contributing to the emotional and social challenges they experience. Finally, differences in white and gray matter have been observed, particularly in areas related to speech motor control. These structural differences may impact the efficiency and coordination of speech movements. By understanding these brain-based differences, we can adopt more personalized, neurodevelopmentally informed approaches to therapy, addressing not just the speech itself, but also the emotional, cognitive, and developmental aspects of stuttering.

Knowing some of the developmental and environmental pressures that impact stuttering in young children, how might you counsel a parent to promote a supportive environment?

When counseling a parent, it's crucial to acknowledge the complexity of environmental and developmental factors that contribute to stuttering in young children. In homes with rapid speech, complex syntax, and multiple languages, it's essential to slow down communication, provide ample time for the child to respond, and create an atmosphere where the child feels relaxed and unpressured. Avoiding frequent interruptions and competition for speaking space can help reduce anxiety and promote more fluent speech. Also, parents should be mindful of their reactions to the child's stuttering, ensuring that they remain calm and supportive rather than correcting or drawing attention to the stutter, which may increase stress for the child. If there are multiple changes in the home, such as moving or family illness, these stressors should be addressed in a sensitive, open manner, as the child’s environment plays a key role in their speech development.

Additionally, ensuring a stable and predictable routine can help reduce pressure around speaking. If the child is excited, hurried, or feeling rushed when speaking, it’s important to encourage slow, relaxed conversation and avoid demanding overly formal or display-like speech. Parents should prioritize listening attentively, even if the child’s speech is disfluent, and reassure the child that their thoughts and words are valued. In situations where there are significant life changes, like a divorce or family death, the child may need extra emotional support to cope, which can, in turn, alleviate the impact of stress on their speech. Parenting styles that are warm, patient, and understanding, combined with a calm, structured environment, can significantly reduce stuttering-related anxiety and foster a supportive atmosphere for the child’s speech development.

Explain to a parent, using a classical conditioning approach, why their child’s stuttering has changed from easy, loose repetitions, to tightly squeezed blocks?

When a child starts stuttering, it may initially appear as easy, loose repetitions without much tension. However, through classical conditioning, these disfluencies can become associated with negative responses from others, such as a frown, mocking, or stern correction. Over time, these reactions (unconditioned stimuli, or UCS) trigger a stress response (unconditioned response, or UCR), which creates tension during stuttering. As this pattern repeats, the child begins to associate certain words, sounds, people, or situations (previously neutral stimuli) with the uncomfortable feelings of tension and pressure, turning them into conditioned stimuli (CS). This repeated pairing leads to a shift in how the child stutters, causing the once easy repetitions to become tighter and more blocked as the conditioned response intensifies.

What are two indicators that point to developmental stuttering vs normal disfluency?

• Presence of secondary behaviors

• any sort of tension

• a child being aware of stutters

• any sort of negative feelings about talking

• Part-word, syllable, and word repetitions, prolongations, blocks