Stuttering and Cluttering (Second Edition)

Frameworks for Understanding and Treatment

David Ward

• Publisher: Psychology Press
• Year: 2017
• ISBN:
  9781317538820
• Edition: 2
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Stuttering and Cluttering provides a clear, accessible and wide-ranging overview of both the theoretical and clinical aspects of two disorders of fluency: stuttering and cluttering. This edition remains loyal to the idea that stuttering and cluttering can best be understood by first considering various overarching frameworks which can then be expanded upon, and provides a clear position from which to disentangle the often complex interrelationships of these frameworks.The book is divided into two parts, the first of which mainly deals with theory and aetiology, while the second focuses on clinical aspects of assessment, diagnosis and treatment. The book also provides frequent references across Parts I and II to help link the various areas of investigation together.This revised edition of Stuttering and Cluttering reflects the major changes in thinking regarding both theory and therapy that have taken place since the publication of the first edition. As well as those who stutter and clutter, the book will be invaluable for speech language therapy/speech language pathology students, practicing clinicians, psychologists and linguists around the world.

Part I

The Aetiology of Stuttering and Cluttering

1Definitions and epidemiology

1.1Introduction

Take a minute sometime to tune in to any radio phone-in show and listen to the callers. Notice how many participants um, err and repeat parts of words, whole words and phrases. Perhaps they change track halfway through a sentence, revising a phrase in the process. Particularly if they are flustered or agitated these disfluencies, on reflection, may be very obvious indeed. But, without stopping to think about it, actually, are they really obvious? Do you really think, ‘Wow, that caller has a speech fluency problem’? Unless you, yourself, are a person who stutters, I suggest that the speech fluency of these callers will have passed you by, unnoticed. It is also very likely to have gone unnoticed by the caller, too. Measure the disfluencies ‘objectively’ by taking a fluency count (see Chapters 9 and 10 for details), and you can arrive at a figure that, had there been a diagnosis of stuttering attached, might even have indicated moderate to severe impairment. Nevertheless, the caller finishes making their point, hangs up the phone and gets on with the next thing. Now consider a person who does have a diagnosis of stuttering and who also calls in to the radio show. (Actually, this person might very well have elected to avoid making the phone call in the first place, deciding in advance that doing so is simply unachievable.) Let’s assume, though, that this person does make the call. As the dialogue progresses our speaker becomes increasingly aware of the repetitions of part-words, words and phrases. He continues to make his point but ultimately puts the phone down feeling angry and frustrated that he got stuck, and that he ‘messed up’. To the listeners, the disfluencies may not have registered, and they will simply be digesting the caller’s message. To the PWS, though, the phone call has been a ‘disaster’.

So what does this tell us? Well, for a start, that people who stutter may well be more fluent than people who do not, but at the same time perhaps a whole lot more anxious. It also tells us that stuttering, ultimately, is not just about fluency but also control – or of ‘real versus perceived loss of control’. Those of us who do not stutter have the luxury of knowing we can get our speech right if we focus on it – but largely we choose not to focus on it simply because (with some exceptions) it doesn’t really bother us enough. And it doesn’t bother us because we know we can get it right without too much effort. It’s a happy circular issue. Contrast this with what can happen with the person who stutters – who perhaps cannot be sure exactly what is going to happen when they go to speak – whether there will be fluency or not. Some PWS may even be 100 per cent fluent while calling in to this radio show, but the same issue of a sense of loss of control still applies – the fear that, at any minute, the veneer of fluency could shatter and they might be seen or heard to stutter. For them, ‘There really could be nothing worse than that.’ So, it’s often a circular issue to the PWS, also. Now, though, the circle turns the opposite way and it is far from happy. From this sense of a loss of control (or sense of impending loss of control) springs increased anxiety. The anxiety leads to physical sensations, which in turn lead to emotional consequences – ‘uh-oh, I feel that I might stutter here…’ – which then result in stuttering itself, accompanied by a potential range of negative self-evaluations and speech-related reactions.

So what will the listener have been thinking? As mentioned earlier, we tune out disfluency. What we don’t tune out is anxiety. Negative listener reaction reflects the level of discomfort detected in the speakers we listen to. We tune out the multiple part-word repetitions and repeated fillers in one person precisely because the person shows no sign of discomfort. If we do notice disfluencies it is often because they are accompanied by a sense of struggle, anxiety or escape behavior. We listeners become concerned because the speaker appears concerned. Thus the apparent irony is that, from a listener’s perspective, too, stuttering is not so much about stuttering but the speaker’s reaction to it.

It’s important to emphasize that stuttering is many different things to many different people. It may be severe or mild (as measured by the frequency and duration of stuttered moments); it may have dire consequences for some, and very little or even no impact for others; and either a strong or weak association between severity and speech anxiety may exist. Regardless, it is important that, from the outset, we get away from the idea of stuttering as simply comprising disfluent speech. Again – stuttering is far more than getting stuck on words. So if that is the case, then what exactly do we mean by stuttering? A simple enough question, but actually not one that is simple to answer in any succinct form, implicating as it does not only a range of factors – motor speech, linguistic, psychological, environmental, neurological amongst others – but also the interaction between these areas. We return to these issues later, but for the present some background information on stuttering is required, and at the outset, this requires us to be aware of two different types of stuttering, the developmental and acquired versions, and a further fluency disorder, cluttering.

1.1.1Developmental stuttering

This is by far the most common type of stuttering, and the one that forms the basis of discussion for all but three chapters of this book. This version, also sometimes called idiopathic stuttering, refers to stuttering that arises in childhood, usually in the preschool years, and for multifactorial reasons. Throughout this book, the term ‘stuttering’ is used to refer exclusively to the developmental condition, unless explicitly stated otherwise.

1.1.2Acquired stuttering

Acquired stuttering is a cover-term for two types of onset: neurogenic stuttering, which occurs following neurological trauma of varying aetiologies (for example, stroke, head injury, tumour, drug use and misuse); and psychogenic stuttering, which may be related to a distressing event (for example, bereavement, divorce). Van Riper (1982) has also argued that there is a third type, occult stuttering. This refers to the appearance of stuttering in adulthood with no apparent neurological or psychological onset, which he argues is actually the re-emergence of a developmental stutter that may have been undiagnosed in early life, and has subsequently been in some state of remission. We return to the issue of acquired stuttering in Chapter 17.

1.1.3Cluttering

Cluttering is a disorder of fluency whose definition is currently under review (see Chapters 8 and 18). There is ongoing debate regarding the range of features that should be included under a core definition, particularly with regard to high level language difficulties, but the ‘lowest common denominator’ (LCD) definition (St. Louis & Schulte, 2011) outlines a conservative position that is widely adhered to by researchers and clinicians, alike. This definition holds that, for cluttering to be diagnosed, there will be overly rapid and/or jerky speech that must appear in conjunction with at least one of three further features: excessive co-articulation, abnormal pausing or excessive nonstuttering-like disfluencies. These features do not need to be in evidence all the time for cluttering to be confirmed. Cluttering commonly occurs alongside a range of other speech/language disorders, most notably stuttering, which can further complicate differential diagnosis. We discuss cluttering from an aetiological perspective in Chapter 8, including the full LCD definition and identification and diagnosis. Therapeutic aspects of the disorder are considered in Chapter 18.

1.2Normal disfluency and stuttering

Levels of fluency vary from person to person, but no one is completely fluent. Even the most eloquent and articulate speaker will, from time to time, make speech errors. The nature of these will vary, but common ones include hesitation and phrase revisions; there may also be single word repetitions, or perhaps the insertion of an interjection such as ‘um’ or ‘er’. Listeners tend not to pay too much attention to most breaks of fluency that occur in speech, and even if there are a substantial number of certain types of disfluency in a person’s speech, they may still not be perceived as indicating a ‘speech problem’ if those disfluencies are of a particular type.

To understand the nature of stuttering disfluencies, we first need to consider the range of disfluencies that may occur in speech. Campbell and Hill (1987) have identified a number of major disfluency types: (1) hesitation (of one second or longer); (2) interjection (such as ‘um’ and ‘er’); (3) phrase/sentence revision (where a speaker goes back to rephrase the sentence or phrase); (4) unfinished word; (5) phrase/sentence repetition; (6) word repetition; (7) part-word repetition (which can be either sound, syllable or multisyllable repetitions; (8) prolongations (the unnatural stretching of a sound); (9) block (a session of sound, which can either be momentary or lasting, arising from an occlusion in the vocal tract that is at an inappropriate location, at an appropriate location but mistimed, or both) – blocks are usually accompanied by increased localized tension; and (10) other (such as inappropriate breathing patterns).

Note that Campbell and Hill (ibid) make no distinction here between stuttering disfluencies and normal disfluencies. Leaving aside the necessarily vague ‘other’ category, this is because all of these behaviours (except blocking) could simultaneously be defined as stuttering and also be characteristic of normal disfluency. So what indicates the difference between normal and abnormal fluency if there is such an overlap? First, the severity of each moment of disfluency will be a factor. A person producing a single repetition of a single syllable word is unlikely to be considered as stuttering; on the other hand, a person repeating the same word eight times will likely be perceived as having a speech problem, even if such an event occurs only twice in a five-minute speech sample. Second, the frequency of disfluency will also be a factor: the greater the number of disfluent moments over a given period of time, the greater the likelihood of perception of stuttering by the listener. Third, disfluencies that contain extra effort (or carry extra tension) are far more likely to be perceived as stuttering (Starkweather, 1987). Blocking, for example, is the only disfluency listed on Campbell and Hill’s list that intrinsically carries excessive tension and, similarly, it is the only type that (assuming the block is long enough to be noticed) is not characteristic of normal disfluency. Excessive tension goes hand-in-hand with stuttering, not with normal speech, and the greater its presence, the greater the likelihood of an association with stuttering. Fourth, sub-lexical disfluencies – those which comprise only part of a word, such as blocking, prolonging, phoneme and part-word repetitions – are regarded as characteristic of stuttering rather than normal disfluency; whilst the repetition of larger units, particularly phrase repetition and phrase revision, is more likely to be associated with normal disfluency. Wyrick (1949) discovered that the majority of repetitions in stuttered speech (63 per cent) were typified by part-word repetitions, a finding later corroborated by Soderberg (1967). Conversely, McClay and Osgood (1959) recorded that 71 per cent of the disfluencies found in nonstuttered speech were made up of word repetitions, with phrase repetitions accounting for 17 per cent and part-word repetitions for 12 per cent. These findings have been corroborated in a number of other studies (Boehmler, 1958; Johnson, 1959). However, opinions currently differ as to whether single syllable word repetitions should be seen as stuttering (Anderson & Wagovich, 2010; DSM-5, 2013; Yairi & Ambrose, 2013; Yairi et al., 2002) or normal non fluency (Howell, 2013; Riley & Riley, 1994). We return to this debate in Chapter 5.

It is generally accepted that prolongations and blocks tend to be associated with stuttering and not normal disfluency (Gregory & Hill, 1984), and it is highly unusual to find prolongations in nonstuttered speech (Williams & Kent, 1958; Young, 1961). If they do occur, prolongations are likely to be associated with a hesitancy as the speaker considers forming a phrase, such as ‘W…e…ll, I’m not too sure…’ or ‘Y…e…s, but on the other hand…’. Unlike stuttering, these prolongations are under the speaker’s control. Silent blocks are almost never encountered in normally disfluent speech. The presence of even one fleeting block in among 500 fluent words may still lead a clinician to suspect a stutter. The presence of one longer block is likely confirmation of the diagnosis.

1.3Primary and secondary stuttering

Thus far, we have suggested that stuttering can be identified by a range of core behaviours; blocks, prolongations, part-word repetitions and arguably single-syllable word repetitions. These fluency breakdowns may also be referred to as primary stuttering, a term that relates directly to such observable breakdowns in speech fluency. Secondary stuttering is characterized by learned behaviours that become attached to the primary activity, and include such concomitant features as sudden loss of eye contact, rapid eye blinking, hand tapping, head nodding, jaw jerk, tongue thrust and nostril flaring. These behaviours may be used as a means of avoiding primary stuttering, for example by the use of starter phrases (‘Okay, well…’) or interjections (‘um… um…’) to help run up to difficult words¹ or may be used to help initiate speech. We return to this area in more detail when we talk about the assessment of stuttering in Part II.

We have just seen that the physical act of eye avoidance in association with a moment of stuttering may be regarded as secondary stuttering, but other devices, most commonly a range of avoidance strategies, are often used by those with an established stutter. These may include word or phoneme avoidance as well as the avoidance of people and situations that are perceived as difficult for the speaker. However, there is a subgroup for whom avoidance becomes the most significant part of the stutter. This sometimes continual use of avoidance to conceal stuttering is known as interiorized stuttering (Douglas & Quarrington, ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• List of figures
• List of tables
• Preface to the second edition
• Acknowledgements
• Part I The Aetiology of Stuttering and Cluttering
• PART II The Treatment of Stuttering and Cluttering
• References
• Author index
• Subject index