Stuttering - Wikipedia

Stuttering, also known as stammering, is a speech disorder in which the flow of speech is disrupted by involuntary repetitions and prolongations of sounds, ... Stuttering FromWikipedia,thefreeencyclopedia Jumptonavigation Jumptosearch Speechdisorder "Stutter"redirectshere.Forotheruses,seeStutter(disambiguation). "Stammer"redirectshere.Forotheruses,seeStammer(disambiguation). "Stammerer"redirectshere.Forpeoplewiththeepithet"theStammerer",seeListofpeopleknownastheStammerer. "Stutterer"redirectshere.Forthefilm,seeStutterer(film). MedicalconditionStutteringOthernamesStammering,alaliasyllabaris,alalialiteralis,anarthrialiteralis,dysphemia.[1]SpecialtySpeech–languagepathologySymptomsInvoluntarysoundrepetitionanddisruptionorblockingofspeechComplicationsShame,bullying,socialanxiety,fearofpublicspeakingUsualonset2–5yearsDurationLongtermCausesUnknownDifferentialdiagnosisdysphonia[1]TreatmentSpeechtherapyMedicationDopamineantagonistsPrognosisUsuallyresolvesbylatechildhood;20%ofcaseslastintoadulthoodFrequencyAbout1% Stuttering,alsoknownasstammering,isaspeechdisorderinwhichtheflowofspeechisdisruptedbyinvoluntaryrepetitionsandprolongationsofsounds,syllables,words,orphrasesaswellasinvoluntarysilentpausesorblocksinwhichthepersonwhostuttersisunabletoproducesounds.[2][3]Thetermstutteringismostcommonlyassociatedwithinvoluntarysoundrepetition,butitalsoencompassestheabnormalhesitationorpausingbeforespeech,referredtobypeoplewhostutterasblocks,andtheprolongationofcertainsounds,usuallyvowelsorsemivowels.AccordingtoWatkinsetal.,stutteringisadisorderof"selection,initiation,andexecutionofmotorsequencesnecessaryforfluentspeechproduction".[4]Formanypeoplewhostutter,repetitionisthemainconcern.Theterm"stuttering"coversawiderangeofseverity,frombarelyperceptibleimpedimentsthatarelargelycosmetictoseveresymptomsthateffectivelypreventoralcommunication.Almost70millionpeopleworldwidestutter,[5]about1%oftheworld'spopulation.[4] Theimpactofstutteringonaperson'sfunctioningandemotionalstatecanbesevere.Thismayincludefearsofhavingtoenunciatespecificvowelsorconsonants,fearsofbeingcaughtstutteringinsocialsituations,self-imposedisolation,anxiety,stress,shame,lowself-esteem,beingapossibletargetofbullying(especiallyinchildren),havingtousewordsubstitutionandrearrangewordsinasentencetohidestuttering,orafeelingof"lossofcontrol"duringspeech.Stutteringissometimespopularlyseenasasymptomofanxiety,butthereisnodirectcorrelationinthatdirection.[6] Stutteringisgenerallynotaproblemwiththephysicalproductionofspeechsoundsorputtingthoughtsintowords.Acutenervousnessandstressarenotthoughttocausestuttering,buttheycantriggerstutteringinpeoplewhohavethespeechdisorder,andlivingwithastigmatizeddisabilitycanresultinanxietyandhighallostaticstressload(chronicnervousnessandstress)thatreducetheamountofacutestressnecessarytotriggerstutteringinanygivenpersonwhostutters,worseningthesituationinthemannerofapositivefeedbacksystem;thename'stutteredspeechsyndrome'hasbeenproposedforthiscondition.[7][8]Neitheracutenorchronicstress,however,itselfcreatesanypredispositiontostuttering. Thedisorderisalsovariable,whichmeansthatincertainsituations,suchastalkingonthetelephoneorinalargegroup,thestutteringmightbemoresevereorless,dependingonwhetherornotthepersonwhostuttersisself-consciousabouttheirstuttering.Peoplewhostutteroftenfindthattheirstutteringfluctuatesandthattheyhave"good"days,"bad"daysand"stutter-free"days.Thetimesinwhichtheirstutteringfluctuatescanberandom.[9]Althoughtheexactetiology,orcause,ofstutteringisunknown,bothgeneticsandneurophysiologyarethoughttocontribute.Therearemanytreatmentsandspeechtherapytechniquesavailablethatmayhelpdecreasespeechdisfluencyinsomepeoplewhostuttertothepointwhereanuntrainedearcannotidentifyaproblem;however,thereisessentiallynocureforthedisorderatpresent.Theseverityoftheperson'sstutteringwouldcorrespondtotheamountofspeechtherapyneededtodecreasedisfluency.Forseverestuttering,long-termtherapyandhardworkisrequiredtodecreasedisfluency.[10] Contents 1Characteristics 1.1Commonbehaviors 1.2Variability 1.3Feelingsandattitudes 1.4Fluencyanddisfluency 1.5Associatedconditions 2Causes 3Mechanism 3.1Physiology 3.2Abnormallateralization 3.3Otheranatomicaldifferences 3.4Dopamine 4Diagnosis 4.1Normaldisfluency 4.2Classification 4.2.1Developmental 4.2.1.1Neurogenicstuttering 4.2.2Acquiredstuttering 5Treatment 5.1Fluencyshapingtherapy 5.2Modificationtherapy 5.3Electronicfluencydevice 5.4Mobileapplications 5.5Medications 5.6Support 5.7Psychologicalapproach 5.8Diaphragmaticbreathing 6Prognosis 7Epidemiology 8History 9Bilingualstuttering 9.1Identification 9.2Research 10Inpopularculture 11Seealso 12Notes 13References 14Furtherreading 15Externallinks Characteristics[edit] Commonbehaviors[edit] Commonstutteringbehaviorsareobservablesignsofspeechdisfluencies,forexample:repeatingsounds,syllables,wordsorphrases,silentblocksandprolongationofsounds.Thesedifferfromthenormaldisfluenciesfoundinallspeakersinthatstutteringdisfluenciesmaylastlonger,occurmorefrequently,andareproducedwithmoreeffortandstrain.[11]Stutteringdisfluenciesalsovaryinquality:commondisfluenciestendtoberepeatedmovements,fixedpostures,orsuperfluousbehaviors.Eachofthesethreecategoriesiscomposedofsubgroupsofstuttersanddisfluencies.[12] Repeatedmovements[12] Syllablerepetition—asinglesyllablewordisrepeated(forexample:on—on—onachair)orapartofawordwhichisstillafullsyllablesuchas"un—un—underthe..."and"o—o—open". Incompletesyllablerepetition—anincompletesyllableisrepeated,suchasaconsonantwithoutavowel,forexample,"c—c—c—cold". Multi-syllablerepetition—morethanonesyllablesuchasawholeword,ormorethanonewordisrepeated,suchas"Iknow—Iknow—Iknowalotofinformation." Fixedpostures[12] Withaudibleairflow—prolongationofasoundoccurssuchas"mmmmmmmmmom". Withoutaudibleairflow—suchasablockofspeechoratensepausewherenothingissaiddespiteefforts. Superfluousbehaviors[12] Verbal—thisincludesaninterjectionsuchasanunnecessaryuhorumaswellasrevisions,suchasgoingbackandcorrectingone'sinitialstatementssuchas"I—Mygirlfriend...",wheretheIhasbeencorrectedtothewordmy. Nonverbal—thesearevisibleoraudiblespeechbehaviors,suchaslipsmacking,throatclearing,headthrusting,etc.,usuallyrepresentinganefforttobreakthroughorcircumventablockorstutteringloop. Variability[edit] Theseverityofastutterisoftennotconstantevenforpeoplewhoseverelystutter.Stuttererscommonlyreportdramaticallyincreasedfluencywhentalkinginunisonwithanotherspeaker,copyinganother'sspeech,whispering,singing,andactingorwhentalkingtopets,youngchildren,orthemselves.[13]Othersituations,suchaspublicspeakingandspeakingonthetelephone,areoftengreatlyfeared,andincreasedstutteringisreported.[14] Feelingsandattitudes[edit] Stutteringcouldhaveasignificantnegativecognitiveandaffectiveimpactonthepersonwhostutters.Ithasbeendescribedintermsoftheanalogytoaniceberg,withtheimmediatelyvisibleandaudiblesymptomsofstutteringabovethewaterlineandabroadersetofsymptomssuchasnegativeemotionshiddenbelowthesurface.[15]Feelingsofembarrassment,shame,frustration,fear,anger,andguiltarefrequentinpeoplewhostutter,[16]andmayactuallyincreasetensionandeffort,leadingtoincreasedstuttering.[17]Withtime,continuedexposuretodifficultspeakingexperiencesmaycrystallizeintoanegativeself-conceptandself-image.Manyperceivestutterersaslessintelligentduetotheirdisfluency;however,asagroup,individualswhostuttertendtobeofaboveaverageintelligence.[18]Peoplewhostuttermayprojecttheirattitudesontoothers,believingthattheothersthinkthemnervousorstupid.Suchnegativefeelingsandattitudesmayneedtobeamajorfocusofatreatmentprogram.[17] Manypeoplewhostutterreportahighemotionalcost,includingjobsorpromotionsnotreceived,aswellasrelationshipsbrokenornotpursued.[19] Fluencyanddisfluency[edit] Linguistictaskscaninvokespeechdisfluency.Peoplewhostuttermayexperiencevaryingdisfluency.[20]Tasksthattriggerdisfluencyusuallyrequireacontrolled-languageprocessing,whichinvolveslinguisticplanning.Instuttering,itisseenthatmanyindividualsdonotdemonstratedisfluencieswhenitcomestotasksthatallowforautomaticprocessingwithoutsubstantialplanning.Forexample,singing"HappyBirthday"orotherrelativelycommon,repeatedlinguisticdiscourses,couldbefluidinpeoplewhostutter.Taskslikethisreducesemantic,syntactic,andprosodicplanning,whereasspontaneous,"controlled"speechorreadingaloudrequiresthoughtstotransformintolinguisticmaterialandthereaftersyntaxandprosody.Someresearchershypothesizethatcontrolled-languageactivatedcircuitryconsistentlydoesnotfunctionproperlyinpeoplewhostutter,whereaspeoplewhodonotstutteronlysometimesdisplaydisfluentspeechandabnormalcircuitry.[20] Associatedconditions[edit] Stutteringco-occurswithotherlearningdisorders.Theseassociateddisabilitiesinclude: Attentiondeficithyperactivitydisorder(ADHD):Adisordercharacterizedbyproblemssustainingattention,hyperactivity,oractingimpulsively.[21]TheprevalenceofADHDinschool-agedchildrenwhostutterisaround4-50%.[22][23][24][25] Dyslexia:Adisorderinvolvingdifficultieswithreadingandspelling.[26]Theprevalencerateofchildhoodstutteringindyslexiaisaround30-40%,whileinadultstheprevalenceofdyslexiainadultswhostutterisaround30-50%.[27][28][29] Causes[edit] Nosingle,exclusivecauseofdevelopmentalstutteringisknown.Avarietyofhypothesesandtheoriessuggestsmultiplefactorscontributingtostuttering.[30]Amongtheseisthestrongevidencethatstutteringhasageneticbasis.[31]Childrenwhohavefirst-degreerelativeswhostutterarethreetimesaslikelytodevelopastutter.[32]However,twinandadoptionstudiessuggestthatgeneticfactorsinteractwithenvironmentalfactorsforstutteringtooccur,[33]andmanystutterershavenofamilyhistoryofthedisorder.[34] Thereisevidencethatstutteringismorecommoninchildrenwhoalsohaveconcurrentspeech,language,learningormotordifficulties.[35]RobertWest,apioneerofgeneticstudiesinstuttering,hassuggestedthatthepresenceofstutteringisconnectedtothefactthatarticulatedspeechisthelastmajoracquisitioninhumanevolution.[36] Anotherviewisthatastutterorstammerisacomplextic.Thisviewisheldforthefollowingreasons.Italwaysarisesfromrepetitionofsoundsorwords.Youngchildrenlikerepetitionandthemoretensetheyarefeeling,themoretheylikethisoutletfortheirtension–anunderstandableandquitenormalreaction.Theyarecapableofrepeatingalltypesofbehaviour.Themoretensionthatisfelt,thelessonelikeschange.Themorechange,thegreatercanbetherepetition.So,whenathree-year-oldfindshehasanewbabybrotherorsisterhemaystartrepeatingsounds.Therepetitionscanbecomeconditionedandautomaticandensuingstrugglesagainsttherepetitionsresultinprolongationsandblocksinhisspeech.Moreboysstammerthangirls,intheratioof3–4boys :1girl.Thisisbecausethemalehypothalamic-pituitary-adrenal(HPA)axisismoreactive.Asmalesproducemorecortisolthanfemalesunderthesameprovocation,theycanbetenseoranxiousandbecomerepetitive.[37] Ina2010article,threegeneswerefoundbyDennisDraynaandteamtocorrelatewithstuttering:GNPTAB,GNPTG,andNAGPA.Researchersestimatedthatalterationsinthesethreegeneswerepresentin9%ofthosewhohaveafamilyhistoryofstuttering.[38][39] Forsomepeoplewhostutter,congenitalfactorsmayplayarole.Thesemayincludephysicaltraumaatoraroundbirth,learningdisabilities,aswellascerebralpalsy.Inothers,therecouldbeaddedimpactduetostressfulsituationssuchasthebirthofasibling,moving,orasuddengrowthinlinguisticability.[31][33] Thereisclearempiricalevidenceforstructuralandfunctionaldifferencesinthebrainsofstutterers.Researchiscomplicatedsomewhatbythepossibilitythatsuchdifferencescouldbetheconsequencesofstutteringratherthanacause,butrecentresearchonolderchildrenconfirmsstructuraldifferencestherebygivingstrengthtotheargumentthatatleastsomeofthedifferencesarenotaconsequenceofstuttering.[40][41] Auditoryprocessingdeficitshavealsobeenproposedasacauseofstuttering.Stutteringislessprevalentindeafandhard-of-hearingindividuals,[42]andstutteringmaybereducedwhenauditoryfeedbackisaltered,suchasbymasking,delayedauditoryfeedback(DAF),orfrequencyalteredfeedback.[30][43]Thereissomeevidencethatthefunctionalorganizationoftheauditorycortexmaybedifferentinpeoplewhostutter.[30] Thereisevidenceofdifferencesinlinguisticprocessingbetweenpeoplewhostutterandpeoplewhodonot.[44]Brainscansofadultstutterershavefoundgreateractivationoftherighthemisphere,whichisassociatedwithemotions,thanofthelefthemisphere,whichisassociatedwithspeech.Inaddition,reducedactivationintheleftauditorycortexhasbeenobserved.[30][33] Thecapacitiesanddemandsmodelhasbeenproposedtoaccountfortheheterogeneityofthedisorder.Inthisapproach,speechperformancevariesdependingonthecapacitythattheindividualhasforproducingfluentspeech,andthedemandsplaceduponthepersonbythespeakingsituation.Capacityforfluentspeechmaybeaffectedbyapredispositiontothedisorder,auditoryprocessingormotorspeechdeficits,andcognitiveoraffectiveissues.Demandsmaybeincreasedbyinternalfactorssuchaslackofconfidenceorselfesteemorinadequatelanguageskillsorexternalfactorssuchaspeerpressure,timepressure,stressfulspeakingsituations,insistenceonperfectspeech,andthelike.Instuttering,theseverityofthedisorderisseenaslikelytoincreasewhendemandsplacedontheperson'sspeechandlanguagesystemexceedtheircapacitytodealwiththesepressures.[45]However,theprecisenatureofthecapacityorincapacityhasnotbeendelineated. Mechanism[edit] Physiology[edit] Thoughneuroimagingstudieshavenotyetfoundspecificneuralcorrelates,thereismuchevidencethatthebrainsofadultswhostutterdifferfromthebrainsofadultswhodonotstutter.Severalneuroimagingstudieshaveemergedtoidentifyareasassociatedwithstuttering.Ingeneral,duringstuttering,cerebralactivitieschangedramaticallyincomparisontosilentrestorfluentspeechbetweenpeoplewhostutterandpeoplewhodonot.Thereisevidencethatpeoplewhostutteractivatemotorprogramsbeforethearticulatoryorlinguisticprocessingisinitiated.Brainimagingstudieshaveprimarilybeenfocusedonadults.However,theneurologicalabnormalitiesfoundinadultsdoesnotdeterminewhetherchildhoodstutteringcausedtheseabnormalitiesorwhethertheabnormalitiescausestuttering.[40] Studiesutilizingpositronemissiontomography(PET)havefoundduringtasksthatinvokedisfluentspeech,peoplewhostuttershowhypoactivityincorticalareasassociatedwithlanguageprocessing,suchasBroca'sarea,buthyperactivityinareasassociatedwithmotorfunction.[20]Onesuchstudythatevaluatedthestutterperiodfoundthattherewasoveractivationinthecerebrumandcerebellum,andrelativedeactivationofthelefthemisphereauditoryareasandfrontaltemporalregions.[46] Functionalmagneticresonanceimaging(fMRI)hasfoundabnormalactivationintherightfrontaloperculum(RFO),whichisanareaassociatedwithtime-estimationtasks,occasionallyincorporatedincomplexspeech.[20] Researchershaveexploredtemporalcorticalactivationsbyutilizingmagnetoencephalography(MEG).Insingle-word-recognitiontasks,peoplewhodidnotstuttershowedcorticalactivationfirstinoccipitalareas,theninleftinferior-frontalregionssuchasBroca'sarea,andfinally,inmotorandpremotorcortices.Thestutterersalsofirsthadcorticalactivationintheoccipitalareasbuttheleftinferior-frontalregionswereactivatedonlyafterthemotorandpremotorcorticeswereactivated.[20][46] Duringspeechproduction,peoplewhostuttershowoveractivityintheanteriorinsula,cerebellumandbilateralmidbrain.Theyshowunderactivityintheventralpremotor,RolandicopercularandsensorimotorcortexbilaterallyandHeschl'sgyrusinthelefthemisphere.[40]Additionally,speechproductionyieldsunderactivityincorticalmotorandpremotorareas.[40] Abnormallateralization[edit] Muchevidencefromneuroimagingtechniqueshassupportedthetheorythattherighthemisphereofpeoplewhostutterinterfereswithleft-hemispherespeechproduction. Adultswhostutterhaveanatomicaldifferencesingyriwithintheperisylvianfrontotemporalareas.Alargeamountofwhitematterisfoundintherighthemisphereofthebrain,includingtheregionofthesuperiortemporalgyrus.Thiswasdiscoveredusingvoxel-basedmorphometry(VBM).Ontheotherhand,lesseramountsofwhitematterarefoundintheleftinferiorarcuatefasciculusconnectingthetemporalandfrontalareasinstutteringadults.[47] Resultshaveshownthatthereislesscoordinationbetweenthespeechmotorandplanningregionsinthebrain'slefthemisphereofmenandwomenwhostutter,whencomparedtoanon-stutteringcontrolgroup.[48]Anatomicalconnectivityofthespeechmotorandplanningregionsislessvigorousinadultswhostutter,especiallywomen.Menwhostutterseemtohavemoreright-sidedmotorconnectivity.Ontheotherhand,stutteringwomenhavelessconnectivitywiththerightmotorregions.[48] Innon-stuttering,normalspeech,PETscansshowthatbothhemispheresareactivebutthatthelefthemispheremaybemoreactive.Bycontrast,peoplewhostutteryieldmoreactivityontherighthemisphere,suggestingthatitmightbeinterferingwithleft-hemispherespeechproduction.Anothercomparisonofscansanteriorforebrainregionsaredisproportionatelyactiveinstutteringsubjects,whilepost-rolandicregionsarerelativelyinactive.[49] Bilateralincreasesandunusualright-leftasymmetryhasbeenfoundintheplanumtemporalewhencomparingpeoplewhostutterandpeoplewhodonot.[46]ThesestudieshavealsofoundthatthereareanatomicaldifferencesintheRolandicoperculumandarcuatefasciculus.[4] DenisDraynasuggeststhatbrainimagingstudiesofpeoplewhostutterdonottellifthedifferencesinthebrainanatomycausedstutteringoriftheyaretheeffectofstuttering;InthemousemodelforstutteringcreatedbyDraynaandteam,theynoticedsignificantsimilaritiesbetweenthevocalizationsinmice(carryingGNPTABmutation)andhumanstuttering.[50]Researchersinvestigatedthebraintissuefromthemicemutantsandreportedasignificantdecreaseinthenumberanddensityofastrocytesintheircorpuscallosum.[51] Astrocyteisastar-shapedcellinthebrainthatsupportsthenervecellsbysupplyingoxygenandnutrients,andtakingawaythewaste. Thecorpuscallosumenablesthecommunicationbetweentheleftandrighthemispheresofthebrain.[52]Follow-upexperimentswiththeGNPTABmutationintroducedtobraincelltypesshowedthatthevocalizationdefectsinmicewerespecifictothelossofastrocytes.[53]Micedidnotshowstuttering-likevocalizationdefectswhenthemutationisengineeredtootherbraincelltypes.[54] Otheranatomicaldifferences[edit] Thecorpuscallosumtransfersinformationbetweentheleftandrightcerebralhemispheres.Thecorpuscallosum,rostrum,andtheanteriormid-bodysectionsarelargerinadultswhostutterascomparedtonormallyfluentadults.Thisdifferencemaybeduetounusualfunctionsofbrainorganizationinstutteringadultsandmaybearesultofhowthestutteringadultsperformedlanguage-relevanttasks.Furthermore,previousresearchhasfoundthatadultswhostuttershowcerebralhemispheresthatcontainuncommonbrainproportionsandallocationsofgrayandwhitemattertissue.[55] Dopamine[edit] Mainarticle:Dopaminehypothesisofstuttering Recentstudieshavefoundthatadultswhostutterhaveelevatedlevelsoftheneurotransmitterdopamine,andhavethusfounddopamineantagoniststhatreducestuttering(seeanti-stutteringmedicationbelow).[46]Overactivityofthemidbrainhasbeenfoundatthelevelofthesubstantianigraextendedtotherednucleusandsubthalamicnucleus,whichallcontributetotheproductionofdopamine.[40]However,increaseddopaminedoesnotimplyincreasedexcitatoryfunctionsincedopamine'seffectcanbebothexcitatoryorinhibitorydependinguponwhichdopaminereceptors(labelledD1–D5)havebeenstimulated. Diagnosis[edit] Somecharacteristicsofstutteredspeecharenotaseasyforlistenerstodetect.Asaresult,diagnosingstutteringrequirestheskillsofacertifiedspeech–languagepathologist(SLP).Diagnosisofstutteringemploysinformationbothfromdirectobservationoftheindividualandinformationabouttheindividual'sbackground,throughacasehistory.[56]Informationfrombothsourcesshouldconsiderthingssuchasage,thevarioustimesithasoccurred,andotherimpediments.[57]TheSLPmaycollectacasehistoryontheindividualthroughadetailedintervieworconversationwiththeparents(ifclientisachild).Theymayalsoobserveparent-childinteractionsandobservethespeechpatternsofthechild'sparents.[58]TheoverallgoalofassessmentfortheSLPwillbe(1)todeterminewhetheraspeechdisfluencyexists,and(2)assessifitsseveritywarrantsconcernforfurthertreatment. Duringdirectobservationoftheclient,theSLPwillobservevariousaspectsoftheindividual'sspeechbehaviors.Inparticular,thetherapistmighttestforfactorsincludingthetypesofdisfluenciespresent(usingatestsuchastheDisfluencyTypeIndex(DTI)),theirfrequencyandduration(numberofiterations,percentageofsyllablesstuttered(%SS)),andspeakingrate(syllablesperminute(SPM),wordsperminute(WPM)).Theymayalsotestfornaturalnessandfluencyinspeaking(naturalnessratingscale(NAT),testofchildhoodstuttering(TOCS))andphysicalconcomitantsduringspeech(Riley’sStutteringSeverityInstrumentFourthEdition(SSI-4)).[58]Theymightalsoemployatesttoevaluatetheseverityofthestutteringandpredictionsforitscourse.Onesuchtestincludesthestutteringpredictioninstrumentforyoungchildren(SPI),whichanalyzesthechild'scasehistory,part-wordrepetitionsandprolongations,andstutteringfrequencyinordertodeterminetheseverityofthedisfluencyanditsprognosisforchronicityforthefuture.[59] Stutteringisamultifaceted,complexdisorderthatcanimpactanindividual'slifeinavarietyofways.Childrenandadultsaremonitoredandevaluatedforevidenceofpossiblesocial,psychologicaloremotionalsignsofstressrelatedtotheirdisorder.Somecommonassessmentsofthistypemeasurefactorsincluding:anxiety(Endlermultidimensionalanxietyscales(EMAS)),attitudes(personalreportofcommunicationapprehension(PRCA)),perceptionsofself(self-ratingofreactionstospeechsituations(SSRSS)),qualityoflife(overallassessmentofthespeaker'sexperienceofstuttering(OASES)),behaviors(olderadultself-report(OASR)),andmentalhealth(compositeinternationaldiagnosticinterview(CIDI)).[60] TheSLPwillthenattempttocombinetheinformationgarneredfromtheclient'scasestudyalongwiththeinformationacquiredfromtheassessmentsinordertomakeafinaldecisionregardingtheexistenceofafluencydisorderanddeterminethebestcourseoftreatmentfortheclient. StutteringcanalsobediagnosedpertheDSM-5diagnosticcodes[61]byclinicalpsychologistswithadequateexpertise.ThemostrecentversionoftheDSM-5describesthisspeechdisorderas"Childhood-OnsetFluencyDisorder(Stuttering)"fordevelopmentalstuttering,and"Adult-onsetFluencyDisorder".However,thespecificrationaleforthischangefromtheDSM-IVisill-documentedintheAPA'spublishedliterature,andisfeltbysometopromoteconfusionbetweentheverydifferentterms"fluency"and"disfluency". Normaldisfluency[edit] Mainarticle:Developmentaldysfluency Preschoolagedchildrenoftenhavedifficultieswithspeechconcerningmotorplanningandexecution;thisoftenmanifestsasdisfluenciesrelatedtospeechdevelopment(referredtoasnormaldysfluencyor"otherdisfluencies").[62]Thistypeofdisfluencyisanormalpartofspeechdevelopmentandtemporarilypresentinpreschoolagedchildrenwhoarelearningtospeak.[62]Thesenormaldisfluenciescanpresentasinterjections("Um"),multisyllaberepetitions("IwantIwanttodothat")orrevised/abandonedutterances("Iwant/heywhat'sthat?").[62]Normaldisfluencyshouldberuledoutbeforediagnosingstuttering.[63] Classification[edit] Developmentalstuttering(alsoknownaschildhoodonsetfluencydisorder)isstutteringthatoriginateswhenachildislearningtospeakandmaypersistasthechildmaturesintoadulthood.Stutteringthatpersistsaftertheageofsevenisclassifiedaspersistentstuttering.[62] Othermuchlesscommoncausesofstutteringincludeneurogenicstuttering(stutteringthatoccurssecondarytobraindamage,suchasafterastroke)andpsychogenicstuttering(stutteringrelatedtoapsychologicalcondition).[62] Otherdisorderswithsymptomsresemblingstutteringincludeautism,cluttering,Parkinson'sdisease,essentialtremor,palilalia,spasmodicdysphonia,selectivemutism,andsocialanxiety. Developmental[edit] Stutteringistypicallyadevelopmentaldisorderbeginninginearlychildhoodandcontinuingintoadulthoodinatleast20%ofaffectedchildren.[30][64]Themeanonsetofstutteringis30months.[65]Althoughthereisvariability,earlystutteringbehavioursusuallyconsistofwordorsyllablerepetitions,whilesecondarybehaviourssuchastension,avoidanceorescapebehavioursareabsent.[66]Mostyoungchildrenareunawareoftheinterruptionsintheirspeech.[66]Withyoungstutterers,disfluencymaybeepisodic,andperiodsofstutteringarefollowedbyperiodsofrelativelydecreaseddisfluency.[67] Thoughtherateofearlyrecoveryisveryhigh,[30]withtimeayoungpersonwhostuttersmaytransitionfromeasy,relaxedrepetitiontomoretenseandeffortfulstuttering,includingblocksandprolongations.[66]Someproposethatparentalreactionsmayaffectthedevelopmentofachronicstutter.Recommendationsto"slowdown","takeabreath","sayitagain",etc.,mayincreasethechild'sanxietyandfear,leadingtomoredifficultieswithspeakingand,inthe"cycleofstuttering,"toyetmorefear,anxietyandexpectationofstuttering.[68]Withtimesecondarystuttering,includingescapebehaviourssuchaseyeblinkingandlipmovements,maybeused,aswellasfearandavoidanceofsounds,words,people,orspeakingsituations.Eventually,manybecomefullyawareoftheirdisorderandbegintoidentifythemselvesasstutterers.Withthismaycomedeeperfrustration,embarrassmentandshame.[69]Other,rarerpatternsofstutteringdevelopmenthavebeendescribed,includingsuddenonsetwiththechildbeingunabletospeak,despiteattemptstodoso.[70]Thechildusuallyisunabletoutterthefirstsoundofasentence,andshowshighlevelsofawarenessandfrustration.Anothervarietyalsobeginssuddenlywithfrequentwordandphraserepetition,anddoesnotincludethedevelopmentofsecondarystutteringbehaviours.[70] Neurogenicstuttering[edit] Stutteringisalsobelievedtobecausedbyneurophysiology.Neurogenicstutteringisatypeoffluencydisorderinwhichapersonhasdifficultyinproducingspeechinanormal,smoothfashion.Individualswithfluencydisordersmayhavespeechthatsoundsfragmentedorhalting,withfrequentinterruptionsanddifficultyproducingwordswithouteffortorstruggle.Neurogenicstutteringtypicallyappearsfollowingsomesortofinjuryordiseasetothecentralnervoussystem.Injuriestothebrainandspinalcord,includingcortex,subcortex,cerebellar,andeventheneuralpathwayregions.[4] Acquiredstuttering[edit] Inrarecases,stutteringmaybeacquiredinadulthoodastheresultofaneurologicaleventsuchasaheadinjury,tumour,stroke,ordruguse.Thestutteringhasdifferentcharacteristicsfromitsdevelopmentalequivalent:ittendstobelimitedtopart-wordorsoundrepetitions,andisassociatedwitharelativelackofanxietyandsecondarystutteringbehaviors.Techniquessuchasalteredauditoryfeedback(seebelow),whichmaypromotedecreasingdisfluencyinthosewiththedevelopmentalcondition,arenoteffectivewiththeacquiredtype.[30][64][71] Psychogenicstutteringmayalsoariseafteratraumaticexperiencesuchasagrief,thebreakupofarelationshiporasthepsychologicalreactiontophysicaltrauma.Itssymptomstendtobehomogeneous:thestutteringisofsuddenonsetandassociatedwithasignificantevent,itisconstantanduninfluencedbydifferentspeakingsituations,andthereislittleawarenessorconcernshownbythespeaker.[72] Treatment[edit] Mainarticle:Stutteringtherapy Beforebeginningtreatment,anassessmentisneeded,asdiagnosingstutteringrequirestheskillsofacertifiedspeech–languagepathologist(SLP).[73] Whilethereisnocompletecureforstuttering,severaltreatmentoptionsexistthathelpindividualstobettercontroltheirspeech.Manyoftheavailabletreatmentsfocusonlearningstrategiestominimizestutteringthroughspeedreduction,breathingregulation,andgradualprogressionfromsingle-syllableresponsestolongerwords,andeventuallymorecomplexsentences.Furthermore,somestutteringtherapieshelptoaddresstheanxietythatisoftencausedbystuttering,andconsequentlyworsensstutteringsymptoms.[74]Thismethodoftreatmentisreferredtoasacomprehensiveapproach,inwhichthemainemphasisoftreatmentisdirectedtowardimprovingthespeaker'sattitudestowardcommunicationandminimizingthenegativeimpactstutteringcanhaveonthespeaker'slife.[75]TreatmentfromaqualifiedS-LPcanbenefitstutterersofanyage.[76] Speechlanguagepathologiststeachpeoplewhostuttertocontrolandmonitortherateatwhichtheyspeak.Inaddition,peoplemaylearntostartsayingwordsinaslightlyslowerandlessphysicallytensemanner.Theymayalsolearntocontrolormonitortheirbreathing.Whenlearningtocontrolspeechrate,peopleoftenbeginbypractisingsmooth,fluentspeechatratesthataremuchslowerthantypicalspeech,usingshortphrasesandsentences.Overtime,peoplelearntoproducesmoothspeechatfasterrates,inlongersentences,andinmorechallengingsituationsuntilspeechsoundsbothfluentandnatural.Whentreatingstutteringinchildren,someresearchersrecommendthatanevaluationbeconductedeverythreemonthsinordertodeterminewhetherornottheselectedtreatmentoptionisworkingeffectively."Follow-up"or"maintenance"sessionsareoftennecessaryaftercompletionofformalinterventiontopreventrelapse.[77] Fluencyshapingtherapy[edit] Fluencyshapingtherapy,alsoknownas"speakmorefluently","prolongedspeech",or"connectedspeech",trainspeoplewhostuttertospeaklessdisfluentlybycontrollingtheirbreathing,phonation,andarticulation(lips,jaw,andtongue).Itisbasedonoperantconditioningtechniques.[78] Peoplewhostutteraretrainedtoreducetheirspeakingratebystretchingvowelsandconsonants,andusingotherdisfluency-reducingtechniquessuchascontinuousairflowandsoftspeechcontacts.Theresultisveryslow,monotonic,butfluentspeech,usedonlyinthespeechclinic.Afterthepersonwhostuttersmasterstheseskills,thespeakingrateandintonationareincreasedgradually.Thismorenormal-sounding,fluentspeechisthentransferredtodailylifeoutsidethespeechclinic,thoughlackofspeechnaturalnessattheendoftreatmentremainsafrequentcriticism.Fluencyshapingapproachesareoftentaughtinintensivegrouptherapyprograms,whichmaytaketwotothreeweekstocomplete. Modificationtherapy[edit] Thegoalofstutteringmodificationtherapyisnottoeliminatestutteringbuttomodifyitsothatstutteringiseasierandlesseffortful.[79]Therationaleisthatsincefearandanxietycausesincreasedstuttering,usingeasierstutteringandwithlessfearandavoidance,stutteringwilldecrease.ThemostwidelyknownapproachwaspublishedbyCharlesVanRiperin1973andisalsoknownasblockmodificationtherapy.[80]However,dependingonthepatient,speechtherapymaybeineffective.[81] Electronicfluencydevice[edit] Mainarticle:Electronicfluencydevice Alteredauditoryfeedback,sothatpeoplewhostutterheartheirvoicedifferently,hasbeenusedforover50yearsinthetreatmentofstuttering.[82]Alteredauditoryfeedbackeffectcanbeproducedbyspeakinginchoruswithanotherperson,byblockingoutthepersonwhostutters'voicewhiletalking(masking),bydelayingslightlythevoiceofthepersonwhostutters(delayedauditoryfeedback)orbyalteringthefrequencyofthefeedback(frequencyalteredfeedback).Studiesofthesetechniqueshavehadmixedresults,withsomepeoplewhostuttershowingsubstantialreductionsinstuttering,whileothersimprovedonlyslightlyornotatall.[82]Ina2006reviewoftheefficacyofstutteringtreatments,noneofthestudiesonalteredauditoryfeedbackmetthecriteriaforexperimentalquality,suchasthepresenceofcontrolgroups.[83] Mobileapplications[edit] Stutteringtreatmentusingmobileapplication TherearespecializedmobileapplicationsandPCprogramsforstuttertreatment.Thegoalpursuedbytheapplicationsofthiskindisspeechcyclerestoration–Isay–>Ihear–>Ibuildaphrase–>Isayandsoon,usingvariousmethodsofstuttercorrection.[84] Theuserinteractswiththeapplicationthroughalteredauditoryfeedback:theysaysomethingintotheheadset'smicrophoneandlistentotheirownvoiceintheheadphonesprocessedbyacertainmethod.[84] Thefollowingstuttercorrectionmethodsaretypicallyusedinapplications: MAF(maskingauditoryfeedback).Itisbasicallymaskingbywhitenoiseorsinusnoisesoftheuser'sownspeech.Scientistsbelievethatpeoplewhostuttercanspeakmoresmoothlywhentheydonotheartheirownspeech.Thismethodisconsideredold-fashionedandineffective.[85][86][87] DAF(delayedauditoryfeedback).Thismethodinvolvessendingtheuser'svoicefromamicrophonetoheadphoneswithadelayoffractionsofasecond.Thegoalofthismethodistoteachpeoplewhostuttertoprolongvowelsandreducetheirspeechrate.Afterspeechcorrectionwithlongdelays,theapplicationisadjustedatshorterdelayswhichincreasethespeechrateuntilitbecomesnormal.[88][89] FAF(frequency-shiftedauditoryfeedback).Thismethodinvolvesshiftingtheuser'svoicetonefrequencythattheyarelisteningtocomparedtotheirownvoice.Theshiftrangecanbedifferent:fromseveralsemitonestohalfanoctave.[90][91][92] Usingmetronomesandtempocorrectors.Rhythmicmetronomestrikesareusedinthismethod.Theeffectivenessofthemethodisrelatedtothefactthatrhythmhaspositiveeffectonsomeonewhostutters,especiallywhenpronouncingslowly.[93] Usingvisualfeedback.Thismethoddeterminestheuser'sspeechparameters(forinstance,speechtempo)andtheirrepresentationonscreenasvisualinformation.Theprincipalgoalofthemethodisallowingtheusertoeffectivelymanagetheirvoicethroughachievingthedefinedtargetedparameters.Itissupposedthattheuserseesvisualrepresentationofbothcurrentandtargetedparameters(suchasspeechtempo)onthescreenwhilepronouncing.[94][95] Medications[edit] AlthoughnomedicationisFDAapprovedforstuttering,severalstudieshaveshowncertainmedicationstohavebeneficialeffectsonreducingtheseverityofstutteringsymptoms.Althoughdifferentclassesofmedicationshavebeeninvestigated,thosewithdopamineblockingactivityhavebeenshowninnumeroustrialstohavepositiveeffectsonstuttering.ThesemedicationsareFDAapprovedintheUnitedStatesandholdsimilarapprovalinmostcountriesforotherconditionsandtheirsafetyprofilesarewellestablishedinthesedisorders. Thebeststudiedmedicationinstutteringisolanzapinewhoseeffectivenesshasbeenestablishedinreplicatedtrials.OlanzapineactsasadopamineantagonisttoD2receptorsinthemesolimbicpathway,andworkssimilarlyonserotonin5HT2Areceptorsinthefrontalcortex.[96]Atdosesbetween2.5–5 mg,olanzapinehasbeenshowntobemoreeffectivethanplaceboatreducingstutteringsymptoms,andmayserveasafirst-linepharmacologicaltreatmentforstutteringbasedonthepreponderanceofitsefficacydata.[97][98]However,othermedicationsaregenerallybettertoleratedwithlessweightgainandlessriskofmetaboliceffectsthanolanzapine. Risperidoneandhaloperidolhavealsoshowneffectivenessinthetreatmentofstuttering.However,haloperidolinparticularoftenresultinpoorlong-termcomplianceduetoconcerningsideeffectssuchasmovementdisordersandprolactinelevation,whichcanalsooccurwithrisperidone.[97][99]Otherdopamineactivemedicationsreportedtopositivelytreatstutteringincludearipiprazole,asenapine,lurasidone,whichtendtobebettertoleratedthanolanzapinewithlessweightgain.Allthesemedicationsaswellasolanzapinecancarrythepotentialriskofalong-termmovementdisorderknownastardivedyskinesia. Theinvestigationalcompound,ecopipamisuniquefromotherdopamineantagonistsinthatitactsonD1receptorsinsteadofD2,owinglittle,ifanyrisk,ofmovementdisorders.Anopenlabelstudyofecopipaminadultsdemonstratedsignificantlyimprovedstutteringsymptomswithnoreportsofparkinsonian-likemovementdisordersortardivedyskinesiawhichcanbeseenwithD2antagonists.[100]Inaddition,ecopipamhadnoreportedweightgain,butinsteadhasbeenreportedtoleadtoweightloss.[100]Inapreliminarystudy,itwaswelltoleratedinsubjects,effectivelyreducedstutteringseverity,andwasevenassociatedinashort-termstudywithimprovedqualityoflifeinpersonswhostutter.[100]Furtherresearchisstillwarranted,butthisnovelmechanismisshowingpromiseinthepharmacologictreatmentofstuttering. Oneshouldalwaysconsultwithamedicaldoctorbeforeconsideringmedicationtreatmentofstutteringtoreviewpotentialrisksandbenefits. Support[edit] WithexistingbehavioralandprosthetictreatmentsprovidinglimitedreliefandpharmacologictreatmentsinneedofFDAapprovalforwidespreaduse,supportgroupsandtheself-helpmovementcontinuetogainpopularityandsupportfromprofessionalsandfrompeoplewhostutter.Self-helpgroupsprovidepeoplewhostutterasharedforumwithinwhichtheycanaccessresourcesandsupportfromothersfacingthesamechallengesofstuttering.[74]Oneofthebasictenetsbehindtheself-helpmovementisthatsinceacuredoesnotexist,qualityoflifecanbeimprovedbynotthinkingaboutthestammerforprolongedperiods.Psychoanalysishasclaimedsuccessinthetreatmentofstuttering.[101]Hypnotherapyhasalsobeenexploredasamanagementalternative.[102][103][104]Supportgroupsfurtherfocusonthefactthatstutteringisnotaphysicalimpedimentbutapsychologicalone.[105] Psychologicalapproach[edit] Cognitivebehaviortherapyhasbeenusedtotreatstuttering.[106]Alsosociologicalapproacheshasbeenexploredregardinghowsocialgroupsmaintainstutteringthroughsocialnorms.[107] Diaphragmaticbreathing[edit] Severaltreatmentinitiatives,forexampletheMcGuireprogramme[108]andtheStarfishProject,advocatediaphragmaticbreathing(orcostalbreathing)asameansbywhichstutteringcanbecontrolled. Prognosis[edit] Amongpreschoolerswithstuttering,theprognosisforrecoveryisgood.Basedonresearch,about65%to87.5%ofpreschoolerswhostutterrecoverspontaneouslyby7yearsofageorwithinthefirst2yearsofstuttering,[62][65][109]andabout74%recoverbytheirearlyteens.[110]Inparticular,girlsseemtorecoverwell.[110][111]Forothers,earlyinterventioniseffectiveinhelpingthechildovercomedisfluency.[112] Oncestutteringhasbecomeestablished,andthechildhasdevelopedsecondarybehaviors,theprognosisismoreguarded,[112]andonly18%ofchildrenwhostutterafterfiveyearsrecoverspontaneously.[113]Stutteringthatpersistsaftertheageofsevenisclassifiedaspersistentstuttering,andisassociatedwithamuchlowerchanceofrecovery.[62]However,withtreatmentyoungchildrenmaybeleftwithlittleevidenceofstuttering.[112] Foradultswhostutter,thereisnoknowncure,[110]thoughtheymaymakepartialrecoveryorevencompleterecoverywithintervention.Peoplewhostutteroftenlearntostutterlessseverely,thoughothersmaymakenoprogresswiththerapy.[112] Emotionalsequelaeassociatedwithstutteringprimarilyrelatestostate-dependentanxietyrelatedtothespeechdisorderitself.However,thisistypicallyisolatedtosocialcontextsthatrequirespeaking,isnotatraitanxiety,andthisanxietydoesnotpersistifstutteringremitsspontaneously.Researchattemptingtocorrelatestutteringwithgeneralizedorstateanxiety,personalityprofiles,traumahistory,ordecreasedIQhavefailedtofindadequateempiricalsupportforanyoftheseclaims. Epidemiology[edit] Thelifetimeprevalence,ortheproportionofindividualsexpectedtostutteratonetimeintheirlives,isabout5%,[114]andoverallmalesareaffectedtwotofivetimesmoreoftenthanfemales.[64][115][116]However,thereisnotmuchinformationknownabouttheunderlyingcauseforsuchaskewedsexratio.[48]Moststutteringbeginsinearlychildhood,andstudiessuggestthat2.5%ofchildrenundertheageof5stutter.[117][118]Asseeninchildrenwhohavejustbegunstuttering,thereisanequivalentnumberofboysandgirlswhostutter.Still,thesexratioappearstowidenaschildrengrow:amongpreschoolers,boyswhostutteroutnumbergirlswhostutterbyaboutatwotooneratio,orless.[116][118]Thisratiowidenstothreetooneduringfirstgrade,andfivetooneduringfifthgrade,[119]asgirlshavehigherrecoveryrates.[110]Duetohigh(approximately65–75%)ratesofearlyrecovery,[115][120]theoverallprevalenceofstutteringisgenerallyconsideredtobeapproximately1%.[64][121] Cross-culturalstudiesofstutteringprevalencewereveryactiveinearlyandmid-20thcentury,particularlyundertheinfluenceoftheworksofWendellJohnson,whoclaimedthattheonsetofstutteringwasconnectedtotheculturalexpectationsandthepressureputonyoungchildrenbyanxiousparents.Johnsonclaimedtherewerecultureswherestuttering,andeventheword"stutterer",wereabsent(forexample,amongsometribesofAmericanIndians).Laterstudiesfoundthatthisclaimwasnotsupportedbythefacts,sotheinfluenceofculturalfactorsinstutteringresearchdeclined.Itisgenerallyacceptedbycontemporaryscholarsthatstutteringispresentineverycultureandineveryrace,althoughtheattitudetowardstheactualprevalencediffers.Somebelievestutteringoccursinallculturesandraces[31]atsimilarrates,[64]about1%ofgeneralpopulation(andisabout5%amongyoungchildren)allaroundtheworld.AUS-basedstudyindicatedthattherewerenoracialorethnicdifferencesintheincidenceofstutteringinpreschoolchildren.[117][118]Atthesametime,therearecross-culturalstudiesindicatingthatthedifferencebetweenculturesmayexist.Forexample,summarizingprevalencestudies,E.CooperandC.Cooperconclude:"Onthebasisofthedatacurrentlyavailable,itappearstheprevalenceoffluencydisordersvariesamongtheculturesoftheworld,withsomeindicationsthattheprevalenceoffluencydisorderslabeledasstutteringishigheramongblackpopulationsthanwhiteorAsianpopulations"(Cooper&Cooper,1993:197).Inhis"StutteringanditsTreatment:Elevenlectures"MarkOnslowremarkedthat"onerecentstudywithmanyparticipants(N=119,367)[122]convincinglyreportedmorestutteringamongAfricanAmericansthanotherAmericans.Whythiscouldbethecaseischallengingtoexplain..."[123] Differentregionsoftheworldareresearchedveryunevenly.ThelargestnumberofstudieshasbeenconductedinEuropeancountriesandinNorthAmerica,wheretheexpertsagreeonthemeanestimatetobeabout1%ofthegeneralpopulation(Bloodtein,1995.AHandbookonStuttering).Africanpopulations,particularlyfromWestAfrica,mighthavethehigheststutteringprevalenceintheworld—reachinginsomepopulations5%,6%andevenover9%.[124]Manyregionsoftheworldarenotresearchedsufficiently,andforsomemajorregionstherearenoprevalencestudiesatall(forexample,inChina).SomeclaimthereasonforthismightbealowerincidenceinthegeneralpopulationinChina.[125] History[edit] LewisCarroll,thewell-knownauthorofAlice'sAdventuresinWonderland,hadastammer,asdidhissiblings. Becauseoftheunusual-soundingspeechthatisproducedandthebehaviorsandattitudesthataccompanyastutter,ithaslongbeenasubjectofscientificinterestandspeculationaswellasdiscriminationandridicule.PeoplewhostuttercanbetracedbackcenturiestothelikesofDemosthenes,whotriedtocontrolhisdisfluencybyspeakingwithpebblesinhismouth.[126]TheTalmudinterpretsBiblepassagestoindicateMoseswasalsoapersonwhostuttered,andthatplacingaburningcoalinhismouthhadcausedhimtobe"slowandhesitantofspeech"(Exodus4,v.10).[126] Galen'shumoraltheorieswereinfluentialinEuropeintheMiddleAgesforcenturiesafterward.Inthistheory,stutteringwasattributedtoimbalancesofthefourbodilyhumors—yellowbile,blood,blackbile,andphlegm.HieronymusMercurialis,writinginthesixteenthcentury,proposedmethodstoredresstheimbalanceincludingchangesindiet,reducedlibido(inmenonly),andpurging.Believingthatfearaggravatedstuttering,hesuggestedtechniquestoovercomethis.Humoralmanipulationcontinuedtobeadominanttreatmentforstutteringuntiltheeighteenthcentury.[127]Partlyduetoaperceivedlackofintelligencebecauseofhisstutter,themanwhobecametheRomanemperorClaudiuswasinitiallyshunnedfromthepubliceyeandexcludedfrompublicoffice.[126] InandaroundeighteenthandnineteenthcenturyEurope,surgicalinterventionsforstutteringwererecommended,includingcuttingthetonguewithscissors,removingatriangularwedgefromtheposteriortongue,andcuttingnerves,orneckandlipmuscles.Othersrecommendedshorteningtheuvulaorremovingthetonsils.Allwereabandonedduetothehighdangerofbleedingtodeathandtheirfailuretostopstuttering.Lessdrastically,JeanMarcGaspardItardplacedasmallforkedgoldenplateunderthetongueinordertosupport"weak"muscles.[126] NotkerBalbulus,fromamedievalmanuscript. ItalianpathologistGiovanniMorgagniattributedstutteringtodeviationsinthehyoidbone,aconclusionhecametoviaautopsy.[127]BlessedNotkerofSt.Gall(c.840–912),calledBalbulus("TheStutterer")anddescribedbyhisbiographerasbeing"delicateofbodybutnotofmind,stutteringoftonguebutnotofintellect,pushingboldlyforwardinthingsDivine,"wasinvokedagainststammering. AfamousBritonwhostammeredwasKingGeorgeVI.GeorgeVIwentthroughyearsofspeechtherapy,mostsuccessfullyunderAustralianspeechtherapistLionelLogue,forhisstammer.ThisisdealtwithintheAcademyAward-winningfilmTheKing'sSpeech(2010)inwhichColinFirthplaysGeorgeVI.ThefilmisbasedonanoriginalscreenplaybyDavidSeidler,whoalsostuttereduntilage16. AnothernotablecasewasthatofBritishPrimeMinisterWinstonChurchill.Churchillclaimed,perhapsnotdirectlydiscussinghimself,that"[s]ometimesaslightandnotunpleasingstammerorimpedimenthasbeenofsomeassistanceinsecuringtheattentionoftheaudience..."[128]However,thosewhoknewChurchillandcommentedonhisstutterbelievedthatitwasorhadbeenasignificantproblemforhim.[129]HissecretaryPhyllisMoircommentedthat"WinstonChurchillwasbornandgrewupwithastutter"inher1941bookIwasWinstonChurchill'sPrivateSecretary.Shealsonotedaboutoneincident,"'It’ss-s-simplys-s-splendid,'hestuttered—ashealwaysdidwhenexcited."LouisJ.Alber,whohelpedtoarrangealecturetouroftheUnitedStates,wroteinVolume55ofTheAmericanMercury(1942)that"Churchillstruggledtoexpresshisfeelingsbuthisstuttercaughthiminthethroatandhisfaceturnedpurple"andthat"bornwithastutterandalisp,bothcausedinlargemeasurebyadefectinhispalate,Churchillwasatfirstseriouslyhamperedinhispublicspeaking.Itischaracteristicoftheman’sperseverancethat,despitehisstaggeringhandicap,hemadehimselfoneofthegreatestoratorsofourtime." Forcenturies"cures"suchasconsistentlydrinkingwaterfromasnailshellfortherestofone'slife,"hittingastuttererinthefacewhentheweatheriscloudy",strengtheningthetongueasamuscle,andvariousherbalremedieswereused.[130]Similarly,inthepastpeoplehavesubscribedtotheoriesaboutthecausesofstutteringwhichtodayareconsideredodd.Proposedcausesofstutteringhaveincludedticklinganinfanttoomuch,eatingimproperlyduringbreastfeeding,allowinganinfanttolookinthemirror,cuttingachild'shairbeforethechildspokehisorherfirstwords,havingtoosmallatongue,orthe"workofthedevil".[130] Somepeoplewhostutter,whoarepartofthedisabilityrightsmovement,havebeguntoembracetheirstutteringvoicesasanimportantpartoftheiridentity.[131][132]InJuly2015theUKMinistryofDefence(MOD)announcedthelaunchoftheDefenceStammeringNetworktosupportandchampiontheinterestsofBritishmilitarypersonnelandMODcivilservantswhostammerandtoraiseawarenessofthecondition.[133] Bilingualstuttering[edit] Identification[edit] Bilingualismistheabilitytospeaktwolanguages.Manybilingualpeoplehavebeenexposedtomorethanonelanguagesincebirthandthroughoutchildhood.Sincelanguageandculturearerelativelyfluidfactorsinaperson'sunderstandingandproductionoflanguage,bilingualismmaybeafeaturethatimpactsspeechfluency.Thereareseveralwaysduringwhichstutteringmaybenoticedinbilingualchildrenincludingthefollowing. Thechildismixingvocabulary(codemixing)frombothlanguagesinonesentence.Thisisanormalprocessthathelpsthechildincreasetheirskillsintheweakerlanguage,butmaytriggeratemporaryincreaseindisfluency.[134] Thechildishavingdifficultyfindingthecorrectwordtoexpressideasresultinginanincreaseinnormalspeechdisfluency.[134] Thechildishavingdifficultyusinggrammaticallycomplexsentencesinoneorbothlanguagesascomparedtootherchildrenofthesameage.Also,thechildmaymakegrammaticalmistakes.Developingproficiencyinbothlanguagesmaybegradual,sodevelopmentmaybeunevenbetweenthetwolanguages.[134] Addingasecondorthirdlanguagebetweentheagesofthreeandfiveyearsofagemaycausestutteringtoincrease(becomemoresevere).However,thismaybethecaseonlywhen:(1)thechild'sfirstlanguageisnotstrongorthechildisexperiencingdifficultiesintheirfirstlanguage,(2)Onelanguageisusedmorethantheotheror,(3)thechildresistsspeakingtheadditionallanguage. Stutteringmaypresentdifferentlydependingonthelanguagestheindividualuses.Forexample,morphologicalandotherlinguisticdifferencesbetweenlanguagesmaymakepresentationofdisfluencyappeartobemoreorlessofaproblemdependingontheindividualcase.[135] Research[edit] Muchresearchisbeingconductedtolookattheprevalenceofstutteringinbilingualpopulationsandthedifferencesbetweenlanguages.Forinstance,onestudyconcludedthatbilingualchildrenwhospokeEnglishandanotherlanguagehadanincreasedriskofstutteringandalowerchanceofrecoveryfromstutteringthanmonolingualspeakersandspeakerswhospokesolelyalanguageotherthanEnglish.[136]Anotherstudy,thoughmethodologicallyweak,showedrelativelyindistinguishablepercentagesofmonolingualandbilingualpeoplewhostutter.[137]Duetosomuchconflictingdata,therelationshipbetweenbilingualismandstutteringhasbeencalledenigmatic,[138]whichcandemonstratetheintricaciesofthetopicandencouragesmoreresearchtobeconductedinordertoswaythebeliefofimpacttherelationshipbetweenbilingualismandstutteringhas. Inpopularculture[edit] Seealso:Stutteringinpopularculture JazzandEurodancemusicianScatmanJohnwrotethesong"Scatman(SkiBaBopBaDopBop)"tohelpchildrenwhostutterovercomeadversity.BornJohnPaulLarkin,ScatmanspokewithastutterhimselfandwontheAmericanSpeech-Language-HearingAssociation'sAnnieGlennAwardforoutstandingservicetothestutteringcommunity.[139] Arkwright,themainprotagonistintheBBCsitcomOpenAllHours,hadaseverestutterthatwasusedforcomiceffect.[140] Seealso[edit] AllIndiaInstituteofSpeechandHearing Dyscravia EuropeanLeagueofStutteringAssociations InternationalStutteringAwarenessDay IsraelStutteringAssociation Listsoflanguagedisorders Listofstutterers MichaelPalinCentreforStammeringChildren MonsterStudy NationalStutteringAssociation,UnitedStates Speech–languagepathology Speechprocessing StutteringFoundationofAmerica TheIndianStammeringAssociation Notes[edit] 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References[edit] Guitar,Barry(2005).Stuttering:AnIntegratedApproachtoItsNatureandTreatment.SanDiego:LippincottWilliams&Wilkins.ISBN 978-0-7817-3920-7. Ward,David(2006).StutteringandCluttering:Frameworksforunderstandingtreatment.HoveandNewYorkCity:PsychologyPress.ISBN 978-1-84169-334-7. Furtherreading[edit] Alm,PerA(2004)."Stutteringandthebasalgangliacircuits:acriticalreviewofpossiblerelations"(PDF).JournalofCommunicationDisorders.37(4):325–69.doi:10.1016/j.jcomdis.2004.03.001.PMID 15159193.[permanentdeadlink] Alm,PerA.(2005).OntheCausalMechanismsofStuttering.Doctoraldissertation,Dept.ofClinicalNeuroscience,LundUniversity,Sweden. ComptonDG(1993).Stammering :itsnature,history,causesandcures.Hodder&Stoughton.ISBN 978-0-340-56274-1. Conture,EdwardG(1990).Stuttering.PrenticeHall.ISBN 978-0-13-853631-2. Fraser,Jane(2005).IfYourChildStutters:AGuideforParents.StutteringFoundationofAmerica.ISBN 978-0-933388-44-4. Mondlin,M.,HowMyStutteringEnded[CaseStudy,JudithM.Kuster,MinnesotaStateUniversity,Mankato]http://www.mnsu.edu/comdis/kuster/casestudy/path/mondlin.html Raz,MirlaG.(2014).PreschoolStuttering:WhatParentsCanDo.GerstenWeitzPublishers.ISBN 9780963542625. Rockey,D.,SpeechDisorderinNineteenthCenturyBritain:TheHistoryofStuttering,CroomHelm,(London),1980.ISBN 0-85664-809-4 Goldmark,Daniel."StutteringinAmericanPopularSong,1890–1930."InLerner,Neil(2006).SoundingOff:TheorizingDisabilityinMusic.NewYork,London:Routledge.pp. 91–105.ISBN 978-0-415-97906-1. Howell,Peter(2011).RecoveryfromStuttering.NewYork:PsychologyPress.ISBN 978-1136941054. Externallinks[edit] Listentothisarticle(3 parts,52minutes) Theseaudiofileswerecreatedfromarevisionofthisarticledated16 January 2006 (2006-01-16),anddonotreflectsubsequentedits.(Audiohelp ·Morespokenarticles) Lookupstammering orstutteringinWiktionary,thefreedictionary. NationalHealthInstitute AmericanSpeech-Language-HearingassociationArchived2009-10-16atthePortugueseWebArchive TheStutteringFoundation AustralianStutteringWarriorsInc StutteringatCurlie ClassificationDICD-10:F98.5ICD-9-CM:307.0OMIM:184450609261MeSH:D013342ExternalresourcesMedlinePlus:001427 vteStuttering/stammeringTherapyOrganizations AmericanInstituteforStuttering BritishStammeringAssociation EuropeanLeagueofStutteringAssociations IndianStammeringAssociation InternationalStutteringAssociation IsraelStutteringAssociation McGuireProgramme MichaelPalinCentreforStammeringChildren NationalStutteringAssociation StutteringCenterofWesternPennsylvania StutteringFoundationofAmerica Other DelayedAuditoryFeedback Electronicfluencydevice InternationalStutteringAwarenessDay NationalStutteringAwarenessWeek TheMonsterStudy Popularculture AFishCalledWanda Attentionbandits! 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