The Neurologic Hypothesis From: Jonathan Bashor Date: 10/2/99 Time: 9:53:51 AM Remote Name: 126.96.36.199 Comments I hope neuro-imaging is going to provide data on which of the many hypotheses are probable. This research is still very young, and so far has been mostly used to compare stutterers vs. non-stutterers. In the future, it would be nice to compare people in one subtype vs. another. Maybe, there are some common features across the subtypes. Until those answers come, I "believe" in one of Dr. Gerald Maguire's findings. He found an irregularity in the limbic system of stutterers. One of the things the limbic system does is modulate our level of "internal" anxiety, and it is beyond our voluntary control. It is interesting, but probably disputed by other researchers. Anyway, I enjoyed your paper. Re: The Neurologic Hypothesis From: Frances Freeman Date: 10/4/99 Time: 12:53:50 PM Remote Name: 188.8.131.52 Comments Given the limitations inherent in the numbers of PWS in our behavioral/brain-imaging studies, we did two within group analyses. In Watson, B.C., Pool, K.D., Devous, M.D., Freeman, F.J., and Finitzo,T (1992) JSHR, we looked at brain blood flows as related to laryngeal reaction time (a measure of speech motor performance). In Watson, B.C., Freeman, F.J., Devous, M.D., Chapman, S.B., Finitzo,T. and Pool, K.D. (1994) JSHR, we looked at linguistic performance and regional cerebral blood flow patterns. In each case, we found evidence for sub-groups of stutterers based on patterns of behavioral and neurophysiologic patterns. These studies should be seminal, not final in their findings. However, there is one thing that I believe is very important in their design. In every case, we collected behavioral as well as neurophysiological imaging data. It is the relationship between behavior and brain function that is critical to our understanding of the disorder of stuttering. To collect only neurophysiological data -- no matter how sophistocated the technology -- is to miss the point (and the boat, I believe). I believe...that stuttering is a maladaptive motor learning disorder From: Thomas David Kehoe Date: 10/3/99 Time: 1:19:28 PM Remote Name: 184.108.40.206 Comments Francis Freeman wrote: > I know of no one in the field who will argue that stuttering is a homogeneous > disorder -- i.e. that it is a single entity with a single sufficient or > necessary cause, or even that all stutterers suffer from the same underlying > problem I'll argue that stuttering is a homogeneous disorder. What developmental stutterers have in common is: - Stuttering starts in childhood, usually between the ages of 2 and 4. - Stuttering is the only communication disorder in which the child develops normal, fluent speech, and then loses it. - Stutterers can talk fluently at some times and in certain situations, unlike other communication disorders (e.g., deafness). - Stuttering develops in stages. While there is debate about whether children can develop severe stuttering "overnight," there is no debate that many of the worst symptoms of adult stuttering, such as avoidances and substitutions, are not present at the start of stuttering in childhood. Looking at the homogeneous features of stuttering illuminates the cause or development of stuttering. I agree with Dr. Freeman that many stutterers also have other communication disorders. But this doesn't mean that their stuttering had an origin different from other stutterers. > From the time of Johnson, the concept of stuttering as an outgrowth or > exacerbation of normal developmental disfluency — of a developmental continuum > from normal fluency to stuttering — has been almost universally accepted and > used as a basis for research and treatment. From the time of Paula Tallal's research on language learning impairment, I've believed that stuttering develops on a track parallel to normal fluent speech development. Something small nudged the child onto a wrong track. After years of development the person is in an entirely different country. The stutterer develops all sorts of other symptoms along this track. Looking at the adult with LLI, stuttering, or other maladaptive developmental disorders, it appears that he or she has a huge problem, or a variety of problems. Different adults seem to have different disorders. But they all started at the same place, with a only a small difference from the normal population. > In keeping with a systems perspective, stuttering can be considered as one > symptom of a defect in a fluent speech generating system: a system that is > diffusely represented in the central nervous system and includes motoric > linguistic, and cognitive processing According to Ockham's Razor, the simplest explanation for a phenomenon is best. Complex theories are not better. Stuttering is a maladaptive motor learning disorder. A stutterer has fluent speech motor programs and stuttering speech motor programs. He has quiet speech motor programs and loud speech motor programs. He has fast and slow speech motor programs, questions and statements, authoratative and submissive speech programs. He may have more than one accent available. Environmental stimuli causes an individual to retrieve certain speech motor programs in certain situations. E.g., people whisper when they go into churches. Stutterers have stimilus-response patterns for retrieving fluent speech motor programs in certain situations, and retrieving stuttering speech motor programs in other situations. Effective stuttering therapies train the stutterer how to speak fluently -- enhancing the fluent speech motor programs -- and recondition his stimulus-response patterns to retrieve fluent speech motor programs in situations where he previously retrieved stuttering speech motor programs. Vocal cord spasm From: Peter Louw, Cape Town, South Africa Date: 10/7/99 Time: 9:26:54 AM Remote Name: 220.127.116.11 Comments Dear Madam I feel somewhat out of my depth here, as I am by training a lawyer and not a clinician - and this is obviously an academic discussion. However I was referred to your site after posting my question to the general panel of "The professor is in". My question is: Can it be possible that stuttering, i.e. the external behaviour which we see as prolongations etc, has a root cause being vocal cord spasms triggered by tension? I know that the majority of experts consider this unlikely, but this theory certainly makes sense to me, and I have been helped much by therapy based on it. I am aware that there is at least one argument against the vocal-cord spasm theory, such as the fact that a few people began to stutter even after their vocal cords had been removed. I don't have an answer to this, but I don't think that the theory should be discarded out of hand just because one or two individuals don't fit it - other factors may be at work here. I respect the rules of the conference and don't want to develop my own theme here, but I would greatly appreciate your opinion. The vocal-cord spasm theory is my pet interest. Many thanks and kind regards. Re: Vocal cord spasm From: FRANCES FREEMAN Date: 10/11/99 Time: 3:40:49 PM Remote Name: 18.104.22.168 Comments Dear Peter: In the 1970's my colleagues and I at Haskins Labs. did electromyographic (EMG) research on laryngeal muscle activity in moments of stuttering. The research clearly established that abnormal laryngeal muscle activity was part of the stuttering pattern for many people who stutter. There is a clear distinction between saying that the laryngeal muscles behave abnormally in stuttering and saying that laryngeal muscle spasms cause stuttering. However, over the subsequent years, more and more treatment programs in stuttering have included techniques which focus on modifying phonation as a means of increasing fluency. Some treatment programs have a primary focus on altering voice onset or vocal quality. My own approach with many stutterers focuses on laryngeal relaxation, altered vocal quality, and easy voice onsets. Your statement that some individuals begin to stutter after laryngectomy is based I believe on research Dr. David Rosenfeld and I did in the early 1980's. We advertised widely seeking to find individuals who stuttered and then had laryngectomies. We were interested in whether they continued to sutter after surgical removal of their vocal folds. We found a number of individuals who stuttered before laryngectomy, but ceased to stutter after the surgery. To our surprise, we found one individual who began to stutter after his larygectomy. I interviewed this individual and discovered his story to be accurate. However, he only stuttered when he placed his electrolarynx on one spot in his neck. We then studied the "fluency" of a number of people with laryngectomies. We found that individuals relearning speech with a "new voice" source were frequently disfluent, even though they would not be labeled stuttering. We concluded that integrating voice with articulation is a critical element of fluent speech. Anything that prevents smooth integration of voice with articulation will lead to disfluent speech and possibly stuttering. During the early 1980s, I was envolved in research with an adult onset voice disorder called spasmodic dysphonia, which involves spasms of the vocal folds. Many patients with SD demonstrate stuttering-like dysfluencies as an early symptom of their disorder. One of the first physicians to observe spasmodic dysphonia called it "laryngeal stuttering." There does not appear to be a relationship between SD and stuttering. Most recently, researchers into asthma and other respiratory disorders have described forms of asthma or respiratory reactive disorders in which the vocal fold function is markedly affected. Vocal fold spasms may be symptoms of some reactive respiratory disorders. Such a problem could be an underlying physiological disorder from which stuttering could develop. I find your question insightful. I wish I had a more definitive answer. I strongly believe that this is a area worthy of research. I am not sure how to set margins, or use the return to set up communications in this comments box. I hope this is readable. Sincerely yours Respiratory/Laryngeal Stuttering From: Heather Herrman Date: 10/8/99 Time: 10:46:57 AM Remote Name: 22.214.171.124 Comments I found your article interesting, in that not very many authors have broken down stuttering into so many sub-groups. It gives a whole new twist to the theories we are taught in school. I do have one question about the respiratory/laryngeal hypothesis. Does typical asthma/allergy medications (ie. inhalers, pills, etc.) have any affect on the person's stuttering episodes? Thank you for your time. Heather Herrman Graduate student at MSU, Mankato Re: Respiratory/Laryngeal Stuttering From: Frances Freeman Date: 10/11/99 Time: 3:48:58 PM Remote Name: 126.96.36.199 Comments Dear Heather: YES -- YES -- They do. At least some do. My observations are based on patients I have known who have been placed on various medications for asthma or allergy during or after stuttering treatment. As one patient described it, the medication did not make her fluent, but it made it significantly easier for her to use the behavioral controls she had learned in treatment. I will also share a story about a little boy Sandy Friel-Patti and I saw. This child had a spinal disorder, and traveled to England where he was place in a special brace. The brace helped his back, but restricted his breathing pattern. He developed marked stuttering symptoms, including struggle. When the brace was removed and his normal breathing was unrestricted, he became a fluent speaker again. This suggests that the alteration or restriction of respiration can affect fluency and even induce stuttering. Again, this is an important area of research. However, it will be successful ONLY if we seek the sub-group for whom this problem applies. Clearly it does not apply to everyone who stutterers. Dr. Freeman From: Jerry Johnson Date: 10/8/99 Time: 5:31:38 PM Remote Name: 188.8.131.52 Comments I hope you dont mind, but I came across a cartoon in THE NEW YORKER, 9.6.99, p 76, that I think you can appreciate. The language might not be appropriate to this event, but here goes: Three guys are at the bar, very scruffy looking characters. The one guy says to the other "Are you just pissing and moaning, or can you verify what you're saying with data?" Re: Dr. Freeman From: P & M Date: 10/11/99 Time: 3:53:14 PM Remote Name: 184.108.40.206 Comments Dear Jerry: I thought I made it clear at the onset and in the title. To use the NEW YORKER'S words, I'm "pissing and moaning." If I had data to prove these hypotheses, I would be submitting my findings to Science or at least JSHR. However, Jerry, I'm a old lady and getting older by the minute. I was hoping to light a fire under some younger Turks. I don't care if they seek to prove my hypotheses right or wrong. I just want them tested. Fran Common Underlying Problem From: Barbara Dahm Date: 10/9/99 Time: 5:45:31 AM Remote Name: 220.127.116.11 Comments I think the statement “stuttering can be considered as one symptom of a defect in a fluent speech generating system: a system that is diffusely represented in the central nervous system and includes motoric linguistic, and cognitive processing.” (Watson & Freeman, 1994) is probably the best and most accurate definition of stuttering that exists. In fact, I quote it in Generating Fluent Speech, a therapy program that incorporates this concept of stuttering. I also find it interesting that you have broken down etiology to various possibilities. As I treat people who stutter I am at a loss to understand which component causes the system to malfunction. However, I have observed time and again that variability in one component affects the functioning of the others, so much so that whatever the original cause may have been, all the components function ineffectively at least some of the time. Therefore, although the etiology of stuttering may not be the same for all people who stutter, I do believe that there is a common underlying problem among everyone who stutters. This common denominator is that the motor, linguistic and cognitive aspects of speech production do not allow for the generation of normally sounding, fluent speech. Furthermore, I believe that the therapy goal for all people who stutter is to make sure that all of the components function correctly. If the focus is on only one of the components, the system will continue to be in danger of a breakdown. Re: Common Underlying Problem From: I agree!! I agree!! Amen, Amen. Date: 10/11/99 Time: 4:25:38 PM Remote Name: 18.104.22.168 Comments Dear Barbara: I couldn't agree more with respect to behavioral treatment, especially with adults. However, I am not persuaded that behavioral management alone is the only or total therapy appropriate for all PWS. Relapse remains a problem with the best behavioral treatment programs. "Bad days" throw off even clients with very good recoveries. I am persuaded that understanding underlying etiologic factors could open the way for medical therapies which would support behavioral therapies. Pharmocologic therapies have been demonstrated to help some individuals who stutter, but with the same medications, other stutterers became worse while others showed no change. Only by understanding sub-groups can we focus therapies appropriately. The genetic counseling area is another for which further research is essential. I have had clients who were not planning to have children because they were afraid their children would inherit their stuttering. This is a sad sacrifice, especially if their stuttering is not genetically transmitted. Certainly not all stuttering has a genetic linkage. If we knew which sub-groups or which individual PWS are at risk for genetic transmission of stuttering, we could offer psychological relief to the majority of PWS whose problem is not transmitted genetically. Finally, with young children beginning to stutter, knowledge of etiologic factors (differential diagnosis of their problem) may be of great importance in planning efficient and effective treatment. In preventive management, etiology may be of critical import. Thank you again for your insightful comments. Fran Re: Common Underlying Problem From: Barbara Dahm Date: 10/15/99 Time: 4:42:07 PM Remote Name: 22.214.171.124 Comments I believe that behavioral management alone is not highly beneficial to most people who stutter. If we look at stuttering as a breakdown in a dynamic, multi-dimensional speech production system, it would follow that therapy must be comprehensive and simultaneously touch on all aspects of the system. We can't change behavior unless we change the concepts that lie behind the behavior. Also positive attitudes must be developed in order to enable change to occur. Subgroups are important for all the reasons you state, but by the time older children and adults come for therapy, whatever the original cause may have been, the whole system has been affected.I believe it also has to be treated as a whole system. Dr. Freeman From: Jerry Johnson Date: 10/13/99 Time: 11:23:36 AM Remote Name: 126.96.36.199 Comments Thanks for your sense of humor and your history of research. You contribute nothing but good stuff to the undying search for the truth about stuttering. We need more people like you, so don't get too old too soon. Some years ago I authored a definition of stuttering you might be interested in, I called it: The Dynamics of Stuttering are as follows: Stuttering, with its neurological, physiological, chemical, and genetic underpinnings, along with its negatively enhanced developmental, environmental, sociological, psychological, and behavioral components, and which manifests itself in negatively reinforced episodic stuttered speech and disordered language, becomes a powerful, self-reinforced behavior which ultimately becomes totally integrated into a person's life. I think this covers the waterfront and indicates to me the profound problem we hard-core adult stutterers have in maintaining our therapies long term. It takes much effort thats for sure. And isn't this the reason to "catch" stuttering at its onset to treat both caregivers and child. I have written a number of papers, along with my wife, Maxine, dealing with child and parental issues. Thanks again for your contributions to understanding stuttering. Out on a limb From: Joseph Diaz-Dallas NSP Date: 10/18/99 Time: 8:26:52 PM Remote Name: 188.8.131.52 Comments Francis, Great story you wrote. We miss you here in Dallas. I'll share your thoughts with the chapter. My email:email@example.com Importance of Looking at Children and a few other comments From: Anthony J. Caruso Date: 10/19/99 Time: 9:44:23 AM Remote Name: 184.108.40.206 Comments I have enjoyed reading your paper, Fran! It is thought provoking provides some interesting perspectives. One comment I would make is that in light of your remarks --the importance of studying young children who stutter can not be over stated. Although a challenging population to do physiological studies on, nonetheless, we must develop appropriate procedures and noninvasive, minimally intrusive technology for use with children near the onset of stuttering. It would be difficult if not impossible to address some of your ideas without such reasearch. One another point, re: models, we just published a model or stuttering from a motor speech perspective (Caruso & Strand, 1999). It is like most models, in need of testing, and built of balsa wood rather than concrete, but I think it addresses some of your comments in this ISAD paper. Again, thank you for your contribution--as always,you have provide me with new and interesting perspectives. Vocal Cord Spasm From: Terisita Carter Date: 10/21/99 Time: 5:14:45 PM Remote Name: 220.127.116.11 Comments Dear Mr. Louw I would like to comment on your interest to the vocal cord spasm theory being the cause of stuttering. I am currently doing graduate studies to become a SLP but likewise, I maybe somewhat out of depth as well. However, I would like to share with you what I have learned while doing research in stuttering. Stuttering is one of the most extensively studied, yet poorly understood communicative disorders. Many theories have been proposed to the possible cause of stuttering, unfortunately, the etiology is unknown. I do believe that stuttering is a developmental disorder that usually manifests during early childhood; but, there are a few exceptions to this theory. However factors such as vocal cord spasms, as well as other behaviors, are merely associated behaviors that occur as the result of stuttering. Re: Vocal Cord Spasm From: Peter Louw, South Africa Date: 10/22/99 Time: 5:40:44 AM Remote Name: 18.104.22.168 Comments Dear Ms Carter Many thanks for your message. Yes, while I accept that many experts consider the vocal-cord theory unlikely, I believe that there is some difference of opinion among therapists themselves. I know, for instance, that a group of Italian speech pathologists have recently had much success with a group of clients who were treated on this basis. My own experience with Passive Airflow therapy, based on the vocal-cord spasm theory, was very positive, even though it is not a miracle cure. May I refer you to the book which I wrote on the subject, being "Coping with Stuttering", 1996, Delta Books, Jonathan Ball Publishers, Johannesburg, South Africa. As a 49-year old person who stutters and who has been involved with stuttering self-help groups for many years, I have trained many people to use the Passive Airflow technique. This fluent-speech technique, together with a comprehensive support programme including attending self-help groups and extensive stress management, is in my opinion the best way to help adults who stutter. Though I have read some of the criticism against the vocal-cord theory, I have not found them convincing. Why do people consider it so unlikely that a stress-related vocal cord spasm can result in stuttering? It makes a lot of sense to me. Let's take the example of a young boy of three years old. He has just started to talk in sentences. One day a dog bites him. It is a terribly stressful experience, and he is in high stress. He wants to speak to his mother and say: "Mommy, the dog bit me!" But unfortunately he is one of that small part of the population whose vocal cord muscles are extremely sensitive to stress (in all its forms). So his vocal cords constrict, which means that it becomes very difficult to speak. In spite of this he does attempt to speak, and tries to say the "m" sound of "Mommy". He is able to close his lips, but not much more due to the constriction in his throat. So he repeats the m sound. This is a real struggle, but at last he manages to say the whole word. The next day, another stressful thing happens to him. He is scolded by his mother for being naughty. So he is in stress, and wants to respond to his mother's anger. He again wants to say "Mommy", and the same thing happens: he struggles with the m-sound, and at last is able to say it. So his struggles are being rewarded. This results in conditioning. He is able to speak, but only after a struggle which gradually becomes conditioned behaviour. So a pattern develops: stress resulting in vocal cord spasm, resulting in struggled speech, resulting in saying the word or sound. As this is the last day of the conference, I doubt whether you will have an opportunity to respond. You may not even see this posting. If you do, and if you wish to continue the conversation, feel free to contact me via my e-mail address, being firstname.lastname@example.org Kind regards, and once again thanking you for your posting. Peter Louw The Limb didn't break, and wasn't sawed off From: Steve Hood Date: 10/21/99 Time: 9:48:05 PM Remote Name: 22.214.171.124 Comments Fran --- WONDERFUL ARTICLE !!!! You've captured many salient features. Your paper should be required reading for doctoral students who wish to specialize in fluency, fluency disorders and stuttering. I have long thought of stuttering as being a syndrome, multidimensional and that there is much to stuttering that is more a syndrome than a unitary entity. Why should doc students read your paper??? Because you have given them enough experimental questions and research hypotheses to fuel their research career to well past the point of tenure, promotion to the rank of full professor, and to the point of retirement as a "distinguished university professor" enjoying the benefits of a small pension, retirement and Medicare. You comments about getting old... Me too, I guess. But young researchers at the start of their careers should give strong thought to what you wrote, and look for "research nuggets for further research" that you have suggested. Wonderful Paper.... Thanks for sharing your ideas. I am glad the limb didn't break. Steve Hood Beyond the limits From: Lilia Harutyunyan Date: 10/22/99 Time: 8:59:07 AM Remote Name: 126.96.36.199 Comments I found the paper very informative and interesting. In this connection I would like to present my attitude towards the problem. I am Lilia Harutyunyan - a Professor of Armenian Republican Centre of Stuttering Treatment. I have worked with stutterers for many years. As a result a program of stable normalization of stutterers' speech was worked out. The basic element of this program is the understanding of stuttering as a steady pathological state which tends to self-support and self-restoration. This is the main reason of suttering relapses. With such understanding of stuttering one is able to conclude that stutteters' speech may be considered to be steadily normalized only after the formation of a new steady normal state which is capable to provide self-support and self-restoration like the stable pathological state was. This program allows to form new steady normal state during one year, even for the most heavy degrees of stuttering. Extensive research over many years has revealed that after the new SNS is formed. The possibility of stuttering relapses is practically eliminated. For many persons these words may be showed as an empty declaration. It is clear that every one may uphold his own opinion, but always the general judge is His Majesty Experiment. I do not want to say that this is a simple job. It has its complications, but it may be done. The authenticity of my words may be revealed by inviting you to Armenian Republican Centre of stuttering treatment where you will be able to contact directly with my patients. I am ready to demonstrate my program practically on the patients with the most heavy degrees of stuttering too. My general goal is to reveal that perfectly fluent speech is a reality for all stutterers. Below I want to cite the letters of two of my patients. Yours, Prof. L.Haruryunyan P.S. Dear Francis, Can you, please, give me your ordinary and e-mail address for future contacts. My e-mail is: email@example.com Attachment 1 Republic of Armenia Town Yerevan, Komitas ave. 48a bldg, app. 48 (tel. 254755) Ordian Teresa My name is Teresa. I was born in Yerevan on 28.11.1982. From childhood I've second grade of hearing. I wear hearing aid, but I hate it. I've attended to an usual kindergarten, and finished the school with high progress. I begun to stammer as I was 5, at the beginning I was stammering on separate words, which started with vowels. Gradually it incresed and during small excitements I stammered also between the words. Since I was 5, I studied with a special surdologopadicist, then I've visited to different specialists, but nothing came out of it. As I was 13-14 I stammered so much, that at school before the lessons I already felt, that I couldn't speak, I couldn't answer even the lesson I learnt perfectly. About 1,5 years all the lessons I answered written besides English as I was sure that I can answer English lessons. But in the summer of 1997 my Granny on my mother's side suddenly heard on TV program about the recovery of stammering by a method developed by respectful Mrs. Harutyunyan. I have subscribe for the recovery and in October the recovery begun. I and my parents were sure that everything will be all right. I didn't attend the school for 15 days and took part in the recovery studies held by Mrs. Harutyunyan. There, in the method included to ask different questions in the street to the people with an unusual temp (extremely slowly) and tell them about my problems. At the beginning I was very much ashamed to do it, but after a while I understood that it's the only way to overcome the internal awe. That everyday studies required a lot of effort, but I was very happy as I discovered that my speech was already regulated. When I attended school, I already asked my teachers to ask me lessons everyday. A revolution occured in my life. It seems that I've made a new feature. About a year I spoke with the help of the hand. Then I gradually left the hand and now I speak like all others. Sometimes, when I'm very much excited, or when I hasten to say something, I feel that I stumble on a word, but immediately I use the hand. From the next word my speech is already regulated, but that time I feel that I could say the same slowly and calmly and no problem I'd have. It's not very much expressed all the time. Now I'm a first year student of the State Institute of Fine Arts. From the childhood I'd had already elected my profession, I want to become painter-modeller. I speak normally, I'm self-confident. I'm very much grateful and thankful to Mrs. Harutyunyan. I'm happy, that there're people like Mrs. Harutyunyan in the world, who help people to be free of the suffering situations, and make them and their relatives happy. Attachment 2 Stepan Babayan. While I still stammered I didn't want to meet with the people. I was afraid from the telephone. Always I became nervous from each trifles. When we heard about Lilia Harutyunyan, we her and most important that at first meetings I trusted that I shall recover. I was silent ten days. Then I began to speak with a hand and very slowly. I had done different exercises: voice, weakening and so on. At the beginning it was difficult to ask questions in the street on very slow rate. But after some days I freely asked anyone. And so at me the feeling of reliance was formulated. Almost a year I spoke on slow rate. Now I speak quietly in normal rate. I thank destiny, that gave me a chance to meet such clever and kind woman. Armenia, Yerevan, Adana 30 (tel. 561 459). I want to use this info today! From: L. Gustafson Date: 10/22/99 Time: 4:39:06 PM Remote Name: 188.8.131.52 Comments Awesome article! Although the incidence of dysfluency cases have been low for me in the school-setting your hypotheses for subgroups intuitively makes sense to me. It gives me some further questions to ask/areas to assess while working with students, especially those who may be more of the linguistic subtypes (clutterers?) vs. speech-motor types (stutterers?) Besides addressing the particular client's linguistic difficulty area(ie word-finding,complex grammar) how else would your treatment strategies differ among types? Are there any techniques you would use with all sub-groups? How do you differentiate aud. processing problems with word-finding difficulties if the breakdowns are similar? I realize all these questions may require an additional article that puts you even further out on the limb, so if you would like me to tune into Stuttering Conf. 3 just let me know.