State of the Art in Stuttering Science, Theory and Treatment

Speech-language pathologists and other scientists associated with the field have been debating the nature and definition of stuttering for decades (Bloodstein, 1995; Conture, 2001; Guitar, 2006; Starkweather, 1987; VanRiper, 1982; Wingate, 1964). It is reasonable to suggest that such a task is inherently difficult, as the core pathology remains elusive and the behavioral manifestations variable (Bloodstein, 1995; Conture, 2001; Guitar, 2006; Starkweather, 1987; VanRiper, 1982). Subsequently, an oversimplified examination of the stuttering literature (from the 20th and 21st century) reveals that nearly all the differing views on stuttering could be distilled into three prevailing paradigms. (To keep things simple, I have labeled the three competing views on stuttering paradigms, when they are all at best pre-paradigmatic.) The first would have to be a psychological perspective on stuttering, which at its core suggests that stuttered speech results from some type of anxiety tension experienced by the speaker (Bloodstein, 1995; Johnson, 1950; Sheehan, 1970; Van Riper, 1982). Those within this paradigm would focus on the reduction of speech-related anxiety and speech-avoidance as well as the acceptance of stuttering and self as core tenets for stuttering modification treatment (Bloodstein, 1995; Johnson, 1950; Sheehan, 1970; Van Riper,1982). ). Another paradigmatic view on stuttering would be to suggest that stuttering results from (behavioral) incoordination within the speech motor mechanisms (Shine, 1980; Starkweather, 1982, 1987; Webster, 1977b). Those within this paradigm would likely focus their fluency shaping treatment on retraining speech coordination, in hopes that the newly acquired speech patterns would be incompatible with stuttered speech and would also become habitual (Shine, 1980; Starkweather, 1982, 1987; Webster, 1977b). Finally, an emerging third paradigmatic view of stuttering would likely suggest that stuttered speech is the result of errors in speech-related neurological anatomy or processing (Alm, 2005; Wu et al., 1995, 1997). Those within this paradigm may judiciously select treatment strategies from both stuttering modification and fluency shaping, while incorporating other treatments (such as pharmaceuticals and prosthetic speech feedback devices) that they believe alter or bypass the deviant speech-related neurophysiological malfunction (Kalinowski & Saltuklaroglu, 2006; Snyder, 2004).

When faced with the reality of competing paradigmatic views of stuttering, Yairi & Ambrose (2005) opine, "It is our position that, whatever else the clinical disorder of stuttering entails, there seems to be relatively little disagreement that the term stuttering refers to the domain of motor speech production and its disruption by speech disfluencies. Physical, physiological, cognitive, and emotional components, regardless of how frequent or intense they might be, would not be labeled as 'stuttering' if they did not accompany a speaker's disfluent speech" (p. 19). Yairi & Ambrose extend their position by stating that stuttering "is first and foremost a disorder of speech" (p. 84).

If only reality could be so simple...

One day, a student (GW) walked into my office to inquire about stuttering. He was hard of hearing (HH) and used amplification. While he was an effective oral communicator, he also was proficient in American Sign Language and the simultaneous use of speech and sign (SimCom). GW stuttered in both speech and SimCom and was looking for guidance on a thesis he was writing on stuttering in sign language. GW came to ask me what was known about stuttered sign and what it might look like in other signers.

Ok, I'm going to be honest--while I was familiar with the accounts of stuttered sign language (Silverman & Silverman, 1971; Montgomery & Fitch, 1988), it was hard for me to consider this phenomenon as particularly valid, as it did not make much sense to me at the time. And this sort of scientific tunnel-vision is a documented phenomenon, as Thomas Kuhn suggests that when data falls beyond the accepted paradigm or theoretical framework, it is largely disregarded or ignored (Kuhn, 1996).

But it's hard to disregard a phenomenon being demonstrated by a student sitting in your office.

Consequently, the sudden and dramatic cessation of my denial to the existence of stuttered sign was quickly followed by a review of the literature:

Additionally, during my initial research into the stuttered sign phenomenon, I also began informally inquiring within the deaf community if others had observed stuttering-like disfluencies in native signers. And while these accounts are all secondhand, at least two ASL interpreters did directly observe stuttering-like behaviors in native signers. One colleague that had attended graduate school at Gallaudet University described a college peer, Daniel (a pseudonym), who would inexplicably initiate signing by tapping his hand on his chest. Subsequently, his name-sign evolved into the "d" handshape tapped on the chest. Another account was noted by a Gallaudet University student who was an ASL interpreter and speech-language pathology graduate student. She reported signing with a number of native signers that demonstrated a variety of stuttering-like disfluencies. However, this interpreter was unsure if the deviant signing was best described as stuttered or cluttered sign, as stuttered sign has not been clearly identified or operationally defined, thus making an apparent diagnosis difficult.

So in conclusion, data suggests that the stuttered sign phenomenon exists. Survey results also suggest that while this phenomenon seems more prevalent in SimCom, it also exists in manual signed communication as well. Finally, while the incidence and prevalence of stuttered sign in the deaf or HH population does seem to be significantly less than in the hearing population, it appears to be present nonetheless.

So where do we go from here?

In a sense, this data forces us to entertain a limited number of options relative to how we perceive the stuttering phenomenon. We can continue to believe that stuttering is a speech disorder and subsequently ignore or disregard data to the contrary. It could also be opined that stuttered sign really is not stuttering at all, but another disorder stemming from a uniquely different core pathology. One could also suggest that stuttered sign is really just an extension (or subtype) of symptomology from the stuttered speech phenomenon and subsequently ignore or discredit accounts suggesting that stuttered sign occurs in some people that have only used signed communication as their primary communication modality. Finally--we could also begin to question the sanctity of stuttering as a speech disorder unto itself and accept the reality that stuttered sign may exist.

If we choose to entertain the notion that stuttering extends beyond the label of "speech disorder" and may exist in other modalities such as sign, then our traditional explanations of stuttering as a speech disorder fail to account for the phenomenon. Subsequently, it could be suggested that "stuttering" is a symptom or consequence, rather than the pathology unto itself. Much like dysphagia, which is symptomatic of limitations or malfunctions in the normal swallow process, the act of "stuttering" may be symptomatic of limitations or malfunctions in expressive communication, rather than speech alone.

For those that wish to consider this alternative view of stuttering as symptomatic of limitations or malfunctions in expressive communication, please allow me to provide some food for thought:

Simply stated, the rules and production for speech and sign are not the same. Signing is fundamentally different than spoken communication in that a completely different set of linguistic units are used. One could suggest that fundamental units of speech are sounds and syllables (Geffer, 1996); however, sign is a visual language that is not bound by the syllable, but rather by distinctive features such as: handshape, location, movement, palm orientation, and non-manual signs (Valli & Lucas, 1992; Stokoe, 1965). Subsequently, it should be no surprise that the characteristics of stuttered speech may not clearly translate into the characteristics of stuttered sign. Instead, the characteristics of the stuttering phenomenon will reflect the modality being expressed. If this latter point is reality, then stuttering secondary to expressive communication is likely to be largely unrecognized and subsequently under-diagnosed in non-oral modalities.

So after a bit of collaborative research, reflection, and discussion with GW, he submitted a list of eight potential characteristics of stuttered sign (Whitebread, 2004). These potential characteristics include:

1. Inconsistent interruptions in sign and finger-spelling.
2. Stuttered symptoms most often occur at the initiation of a gesture.
3. Hesitation of sign movement.
4. Repetition of sign movement while keeping the original handshape.
5. Exaggerated Signs / "Prolonged" Signs.
6. Unusual body movements completely unrelated to linguistic communication.
7. Poor fluidity of the sign.
8. Inappropriate muscular tension (in the arms and hands) associated with signing.

It has been suggested that stuttering, in and of itself, is not a disorder (Conture, 1991; Garber & Siegel, 1982; Kalinowski, Dayalu, Stuart, Rastatter & Rami, 2000; Snyder, 2004). On the contrary, recent research is leading some to believe that stuttered speech is a symptomatic compensatory response to errors in speech related processing on the central (i.e., neural) level (Kalinowski et al., 2000; Snyder, 2004). If we are to believe that stuttered sign is reality, then it could be suggested that stuttering (in all its expressive modalities) may be a symptomatic compensatory response to processing errors at the central level. These processing errors may represent limitations or malfunctions in the formulation, processing, or execution of expressive output or communication. Stated differently, stuttering behaviors may represent a natural bodily response attempting to self-correct or bypass neural processing errors in expressive output or communication occurring at a central level.

So what exactly is expressive communication?

At the risk of sounding too esoteric, it seems a bit naïve to suggest that expressive communication is limited to that of speech and sign, while excluding other potential forms such as handwritten or musical expression (While the latter could be debated, a serving of Baker's bourbon and a John Coltrane track played on a hi-fi system begs to differ). In short, if we are to accept the notion that the stuttered response exists secondary to expressive communication, then it should be predicted that the stuttering phenomenon will occur in other expressive modalities.

And nature does not disappoint. The earliest account (that I have found) of such a phenomenon is in 1909, where the existence of "piano stuttering", "violin stuttering" and "penmanship stuttering" was documented (Scripture, 1909). Roman (1959) published an article suggesting a correlation between stuttered speech and stuttered handwriting, complete with graphological examples of the phenomenon. His research concluded that the stuttered handwriting phenomenon manifested itself as a: difficulty in initiating the motor act of writing, difficulty carrying out the writing action smoothly and precisely, and the difficulty maintaining unity within the written sequence. Likewise, Saltuklaroglu, Robbins, Kalinowski, Guntupalli & Nanjundeswaran (2005) report Normalized Jerk data from writing samples of stuttering and non-stuttering participant groups, which provides quantifiable data supporting the existence of stuttering in grapheme productions . If this conclusion reflects reality, then I predict that this stuttering phenomenon should also be demonstrated in typing as well.

Further, Silverman & Bohlman (1988) published an account of "flute stuttering", in which the performer reported difficulty in initiation relative to playing the flute. Similarly, Meltzer (1992) reported an occurrence of "horn stuttering", in which the performer reported "hesitant stumbling attacks robbing my performance of grace and ease." Moreover, I would like to report an account of "trumpet stuttering", where the performer reports, "As one who stuttered, and still does every now and then, I can tell you that it feels EXACTLY the same. In fact, it WAS stuttering." The performer went on to demonstrate a "trumpet stuttering" secondary behavior, avoidance, with his admission of, "I would always play slow and pretty pieces. And while people absolutely didn't know it--there was a reason why I played that particular musical style: my tongue couldn't handle the double or triple tonguing. I simply couldn't do it" (Snyder, 2006).

A new paradigm for the stuttering phenomenon?

If the data presented in this manuscript does reflect reality, then we are forced to question the belief that stuttering is a speech disorder. On the contrary, the stuttering phenomenon appears to occur in a variety of expressive (communication) modalities. Further, if this suggestion is reality, then stuttering ceases to be a single (speech-related) pathology unto itself. Instead, it is suggested that the observable manifestations of stuttering behaviors are symptomatic responses relative to their corresponding expressive modality. These symptomatic behaviors may be in response to errors in the formulation, processing, and/or execution of expressive output, such as language; it is suggested that these symptomatic behaviors are natural compensatory responses at self correction from errors in processing or initiation at the central level.

In short, if the data and analysis presented in this manuscript do reflect reality, then the traditional views and definitions of stuttering as a speech disorder fail to account for the stuttering phenomenon. Consequently, researchers and clinical scientists may consider abandoning much of the prevailing paradigmatic (i.e., pre-paradigmatic) thought on stuttering, as it can no longer provide a truly scientific and falsifiable theoretical framework capable of accounting for the stuttering phenomenon. If stuttering behaviors are indeed symptomatic responses relative to errors in expressive output, including expressive communication, then a new paradigm will need to emerge to account for this new perceived reality.

A special note of thanks to Peter Reitzes for his editorial comments and suggestions on this manuscript, and to Judith Maginnis Kuster for her invitation to share this perspective in the International Stuttering Awareness Day Online Conference, 2006.

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