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To overcome stuttering, it helps to understand it. What is a stutter? What causes stuttering? How can stuttering best be addressed?
Stuttering has been documented throughout recorded history. Many ultra-high achievers have experienced stammering and succeeded despite their problems. For instance, Moses is thought by historical analysts to have had speech problems.
No one speaks any language with perfect fluency. We all make verbal mistakes that fit the formal descriptor: disfluency. For most people, such verbal stumbles are rare and follow no particular pattern. Around 1% of the world population lives with a stammer or stutter; a disorder affecting their fluency of speech. They experience stuttering episodes to the point of impeding their communication.
The World Health Organization’s, (WHO) International Classification of Mental and Behavioural Disorders define the primary symptoms of stuttering, formally known as dysphemia, as the: ‘speech impediment characterised by frequent repetition or prolongation of sounds, syllables or words; or by the rise of frequent doubts or pauses which interrupt speech’s rhythmic flow.’
The WHO also notes: ‘The individual knows precisely what he or she wishes to say, but at the same time may have difficulty saying it.’
Expressed in everyday language: stutterers typically repeat or prolong sounds or can be unable to utter a sound without substantial effort.
Stuttering can be classified in any number of ways. Two that seem useful are developmental dysfluency, almost always in early childhood, and pathologic dysfluency triggered by, for example,head injury, stroke or progressive neurological disorders.
Whatever the presumed origin of a stutter, it can be further classified by its symptoms, primary and secondary. Primary symptoms are the repetitions and prolongations. Secondary symptoms are avoidance and frustration. Secondary symptoms may be an expected response to the adverse social feedback that stutters receive.
Some of the primary and secondary symptoms, such as the body language, head movement, eye blinking and unusual eye movement, grimacing, quivering lips, and hand gestures, may be adaptations; attempts to deal with the challenge.
In the majority of cases stuttering is a childhood phenomenon. Indeed, from ages 18–24 months stuttering seems to be a normal and expected part of language development. Stuttering, as a problem, affecting up to 10% of children, emerges or continues in children between two and six years old, as they are developing the more sophisticated speech patterns, which are necessary for effective communication.
For most, their stuttering, sometimes also known as childhood-onset fluency disorder, has ceased before they begin formal education. For a few it persists a touch longer. In around 70% of cases it spontaneously disappears before puberty, and for 80% stuttering has gone by adulthood.
More males than females stutter, and when the stammer develops in childhood, males are more likely to continue stuttering into adulthood. Where it persists, there seems also to be a risk of social anxiety and mental health problems emerging.
What causes stuttering?
Early theories, from around a century ago, to date, have proposed that:
- Stuttering was caused by ‘auditory amnesia’. That is self-evidently false if the person can eventually pronounce the problem syllable.
- Stutterers have an inability to access ‘auditory images’. The self-contradictory nature of that theory is, I hope, obvious to all: auditory vs images. People who stammer almost always report knowing what they want to say, demonstrating that they have formed an ‘image’ of their desired communication.
- Temporary paralysis of laryngeal nerve fibres. Again, the flaws in such reasoning are fairly clear: a person repeating the same syllable evidently is not suffering from laryngeal paralysis; if they were, they would be unable to make any noise.
- Anatomical problems with control of the tongue. Misguided medical interventions included cutting parts of the tongue! Needless to say, that did not work, and in many cases caused great harm.
- Stutterers are fixated at the libido stage of oral development. Since this is utterly untestable, it cannot be taken seriously as a scientific explanation.
- Stuttering emerges as a result of negative responses from caregivers to children’s attempts at speech production. That theory is more plausible, and there is some evidence to support it.
When trying to understand any phenomenon, thinking starts off being very primitive and simplistic, and usually plain wrong, and grows as we conduct more detailed analysis, and reflection.
There is some evidence for several of all the possible causes: genetic, sensory, motor, structural, processing, psychological theories, and trauma theories.
Is stammering genetically caused? Or is the appearance of ‘running in families’ more a function of imitation and enculturation, children copying their role models? To date, there is no conclusive evidence of purely genetic causality.
Only in rare cases where there has been head trauma followed by the emergence of long-term disfluency can we be confident of ‘knowing the cause’. Even then, in the vast majority of brain injuries that trigger stuttering we are still unable to state specifically which part of the brain injury is responsible for the stammer.
At best we can say, ‘injury to the presumed speech or verbal motor control areas of the brain.’ Alas, that is about as useful as diagnosing a broken-down car as having the inability to move, with a presumed engine problem. It does no more than eloquently express the blindingly obvious.
Where brain injury is not the cause, if brain structure is the source of the problem, it sounds plausible to speculate that wherever in the brain speech is formed, and wherever the coordination of the physical movements takes place, those structures are involved, in some way.
However, we just don’t know how speech is formed in the brain. Yes, we can theorise, logically, what must happen for speech to be created, but we simply don’t know. Yes, we can say that something is not functioning the way it normally does, and that some element or structure in the brain is/are the cause of the problem. Alas, that is no more than a statement of the obvious; no more than re-describing the problem using more complex language.
When trying to learn about causes from stuttering adults, who suffer no known brain damage, who have no known structural differences in their brains, many report that they know exactly what they want to say, what words they want to use, and how to structure the sentence appropriately, but simply ‘can’t get the word out’. That indicates, in such cases, that whatever is causing stuttering, it is NOT at the meaning formation, or language formation stages of speech production, (that is fortunate, because we do not know how language is formed in the brain).
There appears to be a link between social anxiety levels and stuttering. In cases where anxiety worsens a person’s stutter, it is reasonable infer that something about the processes that cause or follows the anxiety are somehow interfering in speech production – we just don’t know how, or what is the mechanism of interference.
It is known that when people become more self-conscious of their speech that induces anxiety. ‘Distraction theory’ holds that when consciousness is more focussed on what others think and how they may react to what is being said, than on speech production, that insufficient mental capacity remains available for speech production. While intuitively that makes sense; it does not explain why one person stutters when experiencing social anxiety and another feels the anxiety in the pit of the stomach, but can still form their words unimpeded.
When brain scans have been conducted, there appears to be more activity in the right hemisphere of those people who experience disfluencies, than those who do not. Alas, while that may be telling us something useful, we still don’t know whether the greater right brain activity is causal or consequential, or neither, or both. For instance, faced with speech production problems, the adaptive brain could reasonably be expected to find a way to work around the stammering problem, and that work-around might involve more right-brain activity.
The fact that most (around 80%) children ‘grow out of’ stuttering indicates that for most people stuttering is a delayed developmental disorder, which, in the majority of cases ‘self-corrects’.
If stuttering is, in the main, a developmental challenge, perhaps the question for the 20% who do not ‘grow out of’ stuttering, could be: what embeds their stuttering? Does the social anxiety caused by stuttering, make it more likely, and does it then, through repetition, become a ‘hard-wired’ habit, an embedded part of a person’s identity? Is stuttering a learned behaviour under certain circumstances? Currently, although that theory sounds plausible, we just don’t know.
What do we know, about how to overcome stuttering, when it is not head injury induced?
Speech therapy, delayed audio feedback and online and app-based training, are the main ways to try to address a stuttering problem. Rehearsing making the sounds that a person finds challenging is central to speech therapy approaches. As is relaxation.
When people are more relaxed, and feel emotionally safe; when they are confident, they tend to stammer less. When people are less self-conscious, they stutter less. For reasons unknown, when people sing what they want to say, they are less likely to stammer. That effect seems to remain when a person has sung what they wish to say, before saying it. Perhaps there is some kind of rehearsal effect going on. Or perhaps the brain recruits other systems (music production) in such a way that bypasses whatever is causing stuttering.
In extreme cases, Haloperidol, an ‘anti-psychotic’ drug, which is known to help with acute psycho- motor agitation, is sometimes useful with stammerers. The theory being that the stammering is, at least in part, a psycho-motor problem. However, quite how it works, and why it works with some stammers and not others, is not known.
One of the best films ever made on how to overcome stuttering was ‘The Kings Speech’, in which the autodidact, Lionel Logue helped King George VI to manage his stutter. Indeed, for any one studying stuttering or seeking to overcome a stammer, the film is hugely helpful, and inspiring. Congratulations to all involved; you have helped many people.
Here are four simple steps that have helped others. The 4 Rs.
- Relax – after deciding what to say, the person deliberately choose to adopt a relaxed state.
- Recall – they recall how to make the sounds they wish to make.
- Recruit – they decide to sing what they want to say in their heads.
- Rehearse – they rehearse what they want to say mentally, before saying it out loud.
A call to those who do not stammer. If you speak with someone who stammers, please be understanding. Your kindness and patience will help the person relax, create a safe place for them to overcome their challenge, and help your interaction flow more smoothly.
Professor Nigel MacLennan runs the performance coaching practice PsyPerform.