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From: Ken St. Louis
Date: 14 Oct 2010
Time: 08:34:16 -0500
Remote Name: 157.182.15.31
Nancy, This is from the American Speech-Language-Hearing Association. (1999). Terminology pertaining to fluency and fluency disorders: Guidelines. Asha, Supplement No. 19, 41-2, 29-36. I chaired the task force with Mick Hanley & Steve Hood. Some have said that we need to revisit some of these definitions. Ken 3.2. Fluency Disorder. A fluency disorder is a “speech disorder” characterized by deviations in continuity, smoothness, rhythm, and/or effort with which phonologic, lexical, morphologic, and/or syntactic language units are spoken. In recent years, the profession of speech-language pathology has adopted the term fluency disorders to denote a category of “speech disorders” (as opposed to “language disorders”), that includes such related disorders as stuttering and cluttering as well as the more specific categories of neurogenic stuttering and psychogenic stuttering. Indeed, the SID responsible for these Guidelines deals with “fluency and fluency disorders.” Specific disorders of rate (i.e., too fast, too slow, or too irregular) are generally considered to be fluency disorders as well, even though other disorders, e.g., word retrieval or insufficient vocabulary, might be present and even responsible for rate problems. 3.3. Disfluency. Disfluency refers to breaks in the continuity of producing phonologic, lexical, morphologic, and/or syntactic language units in oral speech. The generic term, disfluency, refers to breaks that are normal, abnormal, or ambiguous (i.e., sometimes regarded as normal and sometimes abnormal). The most commonly regarded normal disfluencies are: hesitations or long pauses for language formulation (e.g., “This is our [pause] miscellaneous group.”), word fillers (e.g., “The color is like red.”) (also known as “filled pauses”), nonword fillers (sometimes called interjections) (e.g., “The color is uh red.”), and phrase repetitions (e.g., “This is a—this is a problem.”). The most common ambiguous disfluencies are whole word repetitions (e.g., “I-I-I want to go.” or “This is a better-better solution.”). The most commonly regarded abnormal disfluencies (i.e., stutterings) are: part-word (or sound/syllable) repetitions (e.g., “Look at the buh-buh-ba-baby.”), prolongations (e.g., “Ssssssssometimes we stay home.”), blockages (silent fixations/prolongations of articulatory postures) or noticeable and unusually long (tense/silent) pauses at unusual locations to postpone or avoid (e.g., “Give me a glass (3-sec pause ) of water.”), and any of the above categories when accompanied with decidedly greater than average duration, effort, tension, or struggle. Although the term disfluency does not necessarily imply abnormality, it is often used synonymously with stuttering and, as noted in section 3.4, interchangeably with dysfluency. Clinicians often use disfluency to refer to stuttering for a number of reasons, including: (1) they assume it is perceived by clients to be, connotatively, a less negative term than stuttering, (2) they believe it sounds more scientific or objective than stuttering, or (3) they regard it to be synonymous with stuttering. There is little empirical or logical support for any of these assumptions. Clinical researchers occasionally prefer the term disfluency to stuttering because they find it easier to make reliable judgments of all disfluencies than only those further judged to be stutterings. “Normal developmental disfluencies” refer to higher than adult levels of normal disfluencies that occur in preschool children as they learn language normally. Approximately half of nonstuttering children go through an identifiable period of “increased normal developmental disfluency” during this time (Johnson & Associates, 1959). Starkweather (1987) introduced the term, “discontinuity,” because it differentially refers to breaks in the continuity or flow of speech and not to other problems of fluency, such as a rate that is too slow. Given Starkweather’s analysis, the Task Force concurs that the term “discontinuity” makes a useful distinction and, therefore, might result in more incisive use of terminology. Nevertheless, it chose to accord preference to the term disfluency (in spite of its misuses) because it is overwhelmingly the more popular term referring to breaks in continuity. “Nonfluency” is sometimes used synonymously with disfluency. 3.4. Dysfluency. (Same as stuttering [see 3.5].) According to Wingate (1984), the “dys” and “dis” prefixes are quite different. The “dys” prefix implies abnormality, such that a word beginning with “dys” denotes an abnormal condition. By contrast, the “dis” prefix denotes separation, negation, or signals a contrast with the morpheme which follows it. Wingate cites three of four dictionary references to support his view. It must be pointed out, however, that all dictionaries, such as the Oxford Unabridged Dictionary, do not show this distinction. Some hold that the “dys” prefix in the field of speech-language pathology implies an underlying, organic impairment whereas the “dis” prefix implies deviant behavior. Accepting the somewhat controversial assumption that the prefixes are different, dysfluency (or “abnormal fluency”) is essentially synonymous with stuttering. However, most recent texts still prefer the term stuttering. As noted, dysfluency is frequently used interchangeably with disfluency (see 3.3), although professional consensus suggests that the two terms are not necessarily synonymous. 3.5. Stuttering. Given the diversity of professional opinion on the what constitutes stuttering, the Task Force recommends that clinicians and researchers recognize and indicate which of the following four uses, or combinations thereof, of the term stuttering they refer to in their references to this fluency disorder. Two uses refer primarily to the behavior of stuttering, and two refer primarily to individuals who manifest the behavior. The first two are essentially perceptual definitions (i.e., defined by a listener), the first from a specific symptom orientation and the second from a nonspecific orientation. The third defines stuttering in terms of private experience of the person who stutters, and the fourth focuses on the suspected cause or nature of stuttering. In all cases, stuttering refers to a communication disorder related to speech fluency which generally begins during childhood (but, occasionally, as late as early adulthood). Some individuals refer to this typical stuttering as “developmental stuttering.” Others refer to stuttering as a “syndrome,” focusing thereby on a set of symptoms that may coexist in any stuttering individual. Neurogenic stuttering and psychogenic stuttering comprise special cases that are not subtypes of typical or “developmental”stuttering, despite the widespread use of these terms (see 3.12 and 3.13). 3.5.1. Stuttering refers to speech events that contain monosyllabic whole-word repetitions, part-word repetitions, audible sound prolongations, or silent fixations or blockages. These may or may not be accompanied by accessory (secondary) behaviors (i.e., behaviors used to escape and/or avoid these speech events). This definition implies that certain categories of symptoms or disfluencies (see below) can generally be classified as abnormal and that others can be considered normal. With this definition, the fact that specific examples within any of the above disfluency categories may be variously perceived as normal or abnormal is generally disregarded. Also, the category of monosyllabic whole word repetitions is not always considered stuttering, depending on such variables as age of the client, locus within the utterance, duration, and other factors. This definition implies that stuttering occurs on specific language units, e.g., words or syllables. This definition is intuitively appealing to clinicians for it renders stuttering a quantifiable phenomenon, suggests specific targets of therapy (i.e., the disfluency categories with the most stuttering), and allows for careful clinical descriptions of accessory (secondary) behaviors (see 3.6). It also has appeal for research, especially in determining beforehand which subjects will and will not be included in stuttering groups. 3.5.2. Stuttering consists of speech events that are reliably perceived to be stuttering by observers. This definition relies on operationalism, i.e., defining a difficult concept by the operations used to measure it. Specifically, the definition implies that a listener or conversation partner does not require a specific orientation to identify instances of stuttering. One does so because he or she knows the language in question and can therefore identify abnormalities in its production. The operations involved are those that are quanitifiable and that specify reliability assessments. The definer must demonstrate a reasonable degree of agreement with other “judges” on the measures taken, as well as with himself or herself in repeated assessments, in identifying specific instances of stuttering. This definition grants credibility to the obvious situation that one does not need to be trained to recognize stuttering, as is the case when laymen diagnose a stuttering problem. No doubt, speech events regarded as stuttering in the previous definition are responsible for most judgments of stuttering. Nevertheless, with this symptom-nonspecific definition, a “moment of stuttering” may, in some circumstances, be attributed to disfluency categories which, in other circumstances, would be regarded as normal, and vice versa. As in the previous definition, stuttering is quantifiable and allows for careful descriptions of accessory (secondary) behaviors. This operational definition has appeal for clinicians who choose to use an approach in therapy requiring “on line” counts or immediate consequences or feedback to be provided immediately after each “moment of stuttering.” It is also particularly appealing to researchers who require reliable measures of stuttering. 3.5.3. Stuttering refers to the private, personal experience of an involuntary loss of control by the person who stutters. As such, it often affects the communicative effectiveness of the speaker. This definition focuses on the experience of the person who stutters rather than judgments of clinicians, observers, or theoreticians. The most vocal advocate of this view is Perkins (1990), who wrote that “stuttering is the involuntary disruption of a continuing attempt to produce a spoken utterance” in which “involuntary” is understood to reflect the speaker’s feeling of “loss of control.” This orientation allows the clinician to appreciate the difference between “real” and “faked” stuttering and have a more inclusive definition for the client who claims to be a “stutterer” but overtly “stutters” only on rare occasions. This definition has particular appeal to persons, especially adults, with a history of stuttering themselves for it describes what they experience as stuttering. It has been regarded by many to have questionable use alone in clinical and research efforts because objective, replicable judgments of stuttering are difficult or impossible to obtain. 3.5.4. Stuttering refers to disordered speech that occurs as the result of: (1) certain physiological, neurological, or psychological deviations; (2) certain linguistic, affective, behavioral, or cognitive processes; or (3) some combination thereof. This is not a definition per se. Instead, it refers to numerous definitions such as: “Stuttering is an anticipatory, apprehensive, hypertonic avoidance reaction” (Johnson, Brown, Curtis, Edney, & Keaster, 1967); “Stuttering occurs when the forward flow of speech is interrupted by a motorically disrupted sound, syllable, or word or by the speaker’s reactions thereto” (Van Riper, 1982); or “. . .stuttering constitutes a covert repair reaction to some flaw in the speech plan” (Kolk & Postma, 1997). These definitions focus on theory construction and address the questions, “What causes stuttering?” and/or “What is the nature of stuttering?” Such definitions, to the extent that they balance available knowledge with available research technology, can lead to testable hypotheses about the nature of stuttering. Cause-based definitions are appealing to many stuttering clients, especially those seeking “answers” or insights into their disorder. In some cases, such definitions suggest new or specific approaches to therapy. By contrast, they are generally not suitable for measuring stuttering behaviors in clinical or research settings. 3.5.5. Other comments As with the case of the “general” definition provided, a number of definitions of stuttering include elements of more than one of the above variants. For example, the World Health Organization (1977) defined stuttering as “disorders of rhythm of speech in which the individual knows precisely what he wishes to say, but at the time is unable to say it because of involuntary, repetitive prolongation or cessation of a sound.” The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised (1994) (DSM-IV) indicates that “the essential feature of Stuttering is a disturbance in the normal fluency and time patterning of speech that is inappropriate for the individual’s age.” Stuttering is characterized by “frequent repetitions or prolongations of sounds or syllables,” but also can include “interjections … broken words (e.g., pauses within a word), … audible or silent blocking (filled or unfilled pauses in speech), …circumlocutions (e.g., word substitutions to avoid problematic words), … and monosyllable whole word repetitions (e.g., ‘I-I-I-I see him’).” In addition the DSM-IV requires that “the disturbance in fluency interferes with academic or occupational achievement or with social communication” and all these difficulties exceed those usually associated with a “speech-motor or sensory deficit,” if present. Many individuals who stutter acquire maladaptive patterns of thinking and feeling, sufficiently common to be identified as frequent covert aspects of stuttering. For example, a child who stutters may adopt the belief that speaking is inherently difficult (Bloodstein, 1995). Those who stutter for a number of years often acquire the negative self-concept of a “stutterer,” leading them to adopt other beliefs and attitudes consistent with this self-concept (Cooper, 1990, Peters & Guitar, 1991). Also, many stuttering children and adults report fear or anxiety about speaking, or the prospect of speaking; frustration from the excessive time and effort imposed by stuttered speech; embarrassment, shame or guilt following stuttering episodes; and even hostility toward other conversation partners (Van Riper, 1982). Stuttering is often used in lay usage to refer to disfluencies (see 3.3), both normal and abnormal. Also, many nonstutterers report that they have experienced stuttering of a sort they would regard as abnormal a few times in their lives. In 1993, as the result of the influence of a number of consumer and self-help groups, the American Speech-Language-Hearing Association (ASHA) adopted a policy in which person-first language is to be used in lieu of direct labels (Executive Board Meeting Minutes, 1993). According to the policy, stutterer is regarded as potentially insensitive to the individual who manifests the problem of stuttering. Therefore, authors are required to use the term, person who stutters, instead of the term, stutterer. Recent articles have tended to use abbreviations, e.g., PWS for person who stutters or CWS for child who stutters to avoid the awkwardness inherent in using the longer versions. No systematic research was carried out to support the ASHA “person-first” policy. Since its inception, limited research has shown that person-first labeling may or may not be perceived less negatively by speech-language-hearing impaired individuals, parents of such clients, speech-language pathology students, and the public. In the case of the terms, stutterer, stammerer, or clutterer, the results do not clearly indicate that these direct labels consistently communicate greater sensitivity than the person-first versions (Robinson & Robinson, 1996; St. Louis, In press). More research is needed, but the available findings cast doubt on both the need and wisdom underlying the recent changes in terminology. Person-first labeling warrants serious consideration when referring to specific individuals, especially in clinical situations, for it implies that there is much more to a person than the fact that he or she stutters. On the other hand, given the fact that many nonstutterers report that they have occasionally “stuttered,” the person who stutters nomenclature may create ambiguity in descriptions of subjects in research reports wherein the traditional distinction between stutterer and nonstutterer is important. Until additional research is completed, clinicians or researchers will—and possibly should—use their own discretion in the use of those terms. Stammering is synonymous with stuttering and is the common term for the disorder in Great Britain. In North America, the term stammering is rarely used by speech-language pathologists.