stuttering & nnf

Stuttering and
normal non-Fluency:
onSet and
development
Presenter: Ramya Maitreyee
II M.Sc (SLP)

Definition
Incidence and prevalence
Stuttering and Normal Non Fluency
 -Differential diagnosis
Onset of Stuttering
Development of Stuttering
 Patterns of Development
 The need for early identification and treatment of
stuttering

Van Riper (1982) defines “Stuttering” as a deviation
in the ongoing fluency of speech, an inability to
maintain the connected rhythm of speech” .
Wingate (1964):
Disruption in fluency of verbal expression .
Characterized by involuntary audible or silent
repetitions or prolongations in the utterances of short
speech elements namely sound syllables.
These disruptions usually occur frequently or are
marked in character .
Are not readily controllable.

Accompanied by accessory activities involving
speech apparatus, related or unrelated body structure
or stereotyped speech utterance.
Indications or reports of presence of emotional state
ranging from general condition of “excitement” of
“tension” to more specific emotions of negative
nature such as fear, irritation.

incidence and prevalence
Percentage of general population that stutter vary but
seem to center around 0.7 to 1.0% (Milsen, 1957).
Common among children less than 12 years age (1%)
than among adults (0.8%) (Andrews & Harris, 1964).
Males: Females = 3:1 to 10:1 (Hull &Timmons, 1969).
Stuttering is three times more common in families of
stutterers than in families of non-stutterers (Wepman,
1939; Johnson, 1961).

There may be a slightly higher prevalence among
lower socioeconomic groups than among higher ones
(Morgenstern, 1956).
Stuttering may be more prevalent among retarded in
particular among children with Down’s syndrome
(Gens, 1951; Edson, 1964)

Stuttering and normal non-
Fluency
Stuttering can be associated particularly in children with
variety of speech and language problems.
 Phonological problems (Louko, Edwards and Conture
1990; Nippold 1990).
Approximately 1/3rd
of children who stuttered have
DSL(Van Riper ,1971 & Bloodstein ,1981) .

BiggeSt cHallenge
Deciding not only if child is currently stuttering but
also to decide if child’s speech problems are likely to
continue if child receives speech and language
therapy.

There are 2 major problems with regard to definition or
classification of stuttering in children (Conture,1990)
• There is no known objective, listener independent
criteria for identifying instances of stuttering or classifying
children as stutterers vs normally fluent.
• There is no consensus among experienced clinician and
researchers regarding behavior of stuttering in children or
classification of children stutterers.

Differential diagnosis of children who stutter from
normally fluent :
Considerable overlap in number and nature of speech
dysfluencies exhibited by two talker groups (Johnson &
Associates 1959; Meyers, 1986 Yairi & Lewis, 1984;
Zebrowsky, 1991).
No known behavior, speech or otherwise that young
stutterers exhibit that young non stutterers never exhibit.
No published evidence that speech dysfluency of young
stutterers is categorically different from their fluent
peers (Conture, 1990).

If stuttering is severe or has been chronic problem for
some period of time, accurate diagnosis is seldom a
problem.
Most of such children can be easily distinguished from
non stuttering children.
Nevertheless, speech of many preschool age children
who are just beginning to stutter often sound very much
like that of other children of their age.

Their stuttering may be episodic and vary
substantially in frequency and severity from day to
day and situation to situation.
So, identifying stuttering among these children can
pose a significant diagnostic challenge for even
experienced, expert clinicians (Curlee, 1993).

Gorden and Luper (1992)
• Limited data base for the diagnostic procedures used to
identify beginning stuttering .
• There are multiple behaviors to simultaneously consider.
• It is not the mere presence, but the relative amount of
frequency and type of a child’s dysfluency that help us to
determine whether the child should be considered a
“stutterer”.

There is no purely objective means for determining
whether a child is stutterer any more than there is for
deciding which sound, syllable or word is stuttered.

Clinically any child who exhibits both 10% of overall
dysfluency and who produces 3 or more within word
dysfluencies per 100 words is highly likely to be at
risk for stuttering.
It is not hard to decide that a child’s is “stutterer” if
he or she produces 10 more instances of stuttering per
100 words spoken.
Clinician does not find difficulty in deciding that a
child is normally fluent if he or she exhibits
extremely fluent speech.

• It is however hard for clinician to decide about a
child whose behavior falls between those youngsters
representing a sizeable portion of all children who
stutter and who may be at low to moderate risk of
stuttering.
• Tests like SSI (Riley, 1980) or SPI (Riley, 1981) help
but are still less than adequate when describing these
‘in between’ children (Conture, 1990).

According to Wingate (1976) it is well documented
that children between 3-5 year experience periods of
dysfluency, which vary often depending upon
emotional and linguistic load present in community
interaction.
However only small percentage of these children
actually becomes stutterers.
3 views of seemingly different hypothesis regarding
2 types of dysfluencies (normal and stuttering) are
prevalent in literature.

1. Normal dysfluencies have a place on same continuum as
stuttering
• It is simply a more severe and frequent manifestation of
former.
Johnson (1942) expanded this concept and created
“Diagnosogenic theory of stuttering”.
He speculated that word and part word repetition were
common to all children and stuttering develops from parents
mislabeling of normal dysfluency as stuttering.

Johnson (1967) observed that listeners were unable
to appropriately identify samples of speech of
stutterers and non stutterers and concluded that there
is no clear evidence and sharp line of demarcation
between speech of stutterers and non stutterers.
2. Bloodstein(1918) proposed continuity hypothesis;
which supposes that normal non-fluency of early
childhood utterances change over time and evolve
into tense utterances and fragmentation of words that
are perceived by listeners as dysfluent or stuttering.

3. Other view holds that stuttering is different from NNF.
Certain speech traits are characteristics of stuttering
specifically syllable repetition and prolongation.
Yairi and Clifton (1972) and Silverman (1972b) observed
dysrhythmic phonation and tense pauses to occur least
frequently in normal dysfluent speakers.
Van Riper (1971) cited research employing
spectrographic and cineflurographic analysis to conclude
that dysfluencies of stuttering and non-stuttering differed
along several dimensions.

Arnold and Decicco (1982) compared supraglottal
and laryngeal muscular events during stuttering and
non stuttering disfluencies.
They concluded that 2 types of dysfluencies are
similar on supraglottal level but significantly
different on laryngeal level giving support that larynx
is core of stuttering moment.

Guidelines for differentiating Normal from
Abnormal disfluency
{From Van Riper, C.
The nature of stuttering (2nd
edition)}

BEHAVIOR STUTTERING NORMAL
DISFLUENCY
Syllable
repetitions
a. Frequency /word
b.Frequency for 100
words
c.Tempo
d.Regulartiy
e.Schwa vowel
f.Airflow
g.Vocal tension
More than two
More than two
Faster than normal
Irregular
Often present
Often interrupted
Often apparent
Less than two
Less than two
Normal tempo
Regular
Absent or rare
Rarely interrupted
Absent

Prolongations
h. Duration
i. Frequency
j. Regularity
k. Tension
l. When voiced
m. When unvoiced
n.Termination
Longer than 1 sec
More than 1 per 100 words
Uneven/interrupted
Important when present
May show rise in pitch
Interrupted airflow
Sudden
Less than one second
Less than 1 per 100 words
Smooth
Absent
No pitch rise
Airflow present
Gradual
Gaps (silent pauses)
o. Within word boundary
p. Prior to speech attempt
q. After the disfluency
May be present
Unusually long
May be present
Absent
Not marked
Absent

Phonation
r. Inflections
s. Phonatory arrest
t. Vocal fry
Restricted;
monotone
May be present
May be present
Normal
Absent
Usually absent
Articulatory
postures
u. Appropriateness
May be
inappropriate Appropriate

Reaction to stress
v. Type More broken words Normal
dysfluencies
Evidence of awareness
w. Phonemic consistency
x. Frustration
y. Postponements
z. Eye contact
May be present
May be present
May be present
May waver
Absent
Absent
Absent
normal

Yairi (1997) compared children who are beginning to
stuttering with their non stuttering counter parts:
2 1/2 to 3 times as many total instances of
dysfluencies.
5 to 6 times as many instances of Stuttering Like
Dysfluencies (SLDs).
Proportions of SLDs to total dysfluency that are
twice as large.
Six times as many dysfluency clusters.
Repetitions in which intervals between interactions
are shorter.
Twice as many head and neck movements
accompanying dysfluencies.

Zebrowski (1995) provided summary of selected
research in topography of early stuttering and how this
might differ these children from normally fluent peers.
Specific features includes:
a. Frequency of Speech Dysfluency:-
Refers to how often a child produces dysfluent
speech units within sample of predictable size or
duration.

• Johnson (1956) obtained speech samples of 89 young
stuttering children and compared them with age and
gender matched non-stuttering children.
They indicated that children who stuttered were more
than twice as dysfluent overall than their normally
fluent peers and produced more of almost every type of
speech dysfluency.

b. Type of proportion of dysfluency:-
 Type and frequency of dysfluency overlaps between
stuttering and normal dysfluent children.
 Children, who stutter relatively close to onset of
problem, produce more within word speech
dysfluency (Conture, 1999a, Zebrowsky and Conture
1989).

• Four most frequently produced dysfluencies for boys
who stuttered were
Sound and syllable repetition
 Whole word repetition
 Interjection
 Prolonged sounds.
• For non-stuttered boys
Interjections
 Revisions
 Whole word and sound syllable repetition
(Johnson and Associates, 1959).

c. Duration of Instances of stuttering:-
A widely used protocol for identifying early
stuttering includes some measures of estimation of
stuttering duration.
They directly or indirectly specify that instances of
stuttering of one sec, or longer help to distinguish
stuttering from normal dysfluency (Cooper and
Cooper 1985; Pindzola 1987; Van Riper 1982).

d. Number of repeated units within sound, syllable
and word repetition:-
Adams (1980) and Pindzola (1987) contend that
sound, syllable or part word repetition consisting of
more than 2 repeated units reflects beginning
stuttering.

e. Associated non-speech behavior:-
The presence, type, variety and magnitude of speech
and non speech behavior associated with stuttering
has been used in identifying and rating its severity
(Riley 1980).
Conture and Kelly (1991) measured non speech
behavior of 3-7 year old children who stutter and
found more head turns, eye blinks and upper lip
rising during their stuttered words than non stuttering
children.

• Several protocols (Gorden & Luper, 1992) have been
published that are designed to help SLPs to distinguish
who are typically fluent from those children who
stutter (Adams, 1977; Pindzola & White, 1986).
However fewer instruments (Cooper & Curlee, 1985)
helped clinician to distinguish among children who
stutter.

• One widely used protocol designed to differentiate
children at risk for continuing to stutter from those
likely to discontinue stuttering is Stuttering
Prediction Instrument (SPI).
• It examines aspects of children’s assessing children
who stutter or who are expected to stutter (Yaruss &
Conture, 1993).
• Conture (1991) stated that complex and dimensional
nature of early stuttering makes its diagnosis a
consideration of probabilities not absolute.

• Geetha Y V (1996) devised Dysfluency Assessment
Procedure for Children (DAPC) to assess dysfluent
children in age range of 2.3-6 years. It consisted of
Questionnaire: - It consisted of 40 questions which
was prepared on basis of SSI, SPI, and Stuttering
chronicity prediction Instrument and literature on
factors associated with stuttering onset and
development.
Test Battery: - Consisted of tests of articulation and
language. Diagnostic Kannada Picture Articulation
Test and Kannada Language Test was used.

SSI was used to assess severity of stuttering.
Assessment of speech and non speech
characteristics: - Speech samples were elicited using
recitation, narration, conversation.
Comprehensive
crucial for identifying differentiation of dysfluencies.
A detailed questionnaire was prepared incorporating
which consisted of
• Historical, Attitudinal and behavioral factors
• Motor, speech, language development
• Scholastic history

• Items which were more important were given more
weightage in scoring yielding a score of 50.
• It was found that Historical and Attitudinal factors
overlap in scores between NNF and very mild
stuttering.
• NNF had scores less than 5 and Stuttering children
had 5-15.

• Attitudinal factors were important in determining
stuttering dysfluencies as more negative attitude of
self.
• Behavioral factors clearly differentiated Stuttering
and NNF and scores were directly related to severity
of problem.
• NNF had 0 score and it ranged from 0-20 for
stuttering.

Onset and develOpment Of
stuttering.
• Stuttering at or near onset not only differs from that
of the ‘typical’ adult who stutters but also that of the
‘typical’ school age child who has it.
• The disorder following onset tends to develop over a
period of years in a fairly predictable way along a
continuum or track.
• According to Van Riper (1982) he believes that there
is more than one track along which it can develop.

Onset Of stuttering
Can begin at any age.
Onset -2-5 years (Darley, 1955, Johnson &
Associates, 1959; Yairi 1983).
The mean ages of onset that have been reported range
from 28 months (Yairi, 1983) to 46 months (Darley,
1955).
The age of onset age at which an
informant reports that he or she first concluded that a
child’s repetitions and/or other hesitations were
abnormal.

Information about stuttering at onset
Reports by informants who are not SLPs.
Information is incomplete
Based on what can readily be observed by a layperson
through vision and hearing.
There are undoubtedly physiological and psychological
events associated with it that either cannot be observed
without instrumentation or even if observed would be
unlikely to regard as related to the onset of the disorder.

nature Of Onset
Difficult to answer
Most of the data relevant to it (Johnson & Associates,
1959) are from reports by parents and other
laypersons, reported months (or years) after the
disorder is thought to have begun.

Inaccurate reports
The persons making them either were not aware of
child’s earliest moments of stuttering or considered
them to be normal hesitations.
This would tend to make the onset of disorder appear to
have been more sudden than it really was.

• Though the data bearing on this question have to be
interpreted with caution for the reasons indicated earlier,
they do seem to indicate that the onset could be:
Sudden or gradual (Yairi, 1983)
But usually is gradual (Van Riper, 1982).
• The percentage of cases reported by other investigators
in which the onset was gradual are 86 (Ajuriaguerra,
1958), 92 (Morley, 1957) 76 (Preus, 1981), 69 (Berlin,
1954) and 90 (Van Riper, 1982)

Onset Of stuttering in adults
Regarded as disorder of childhood
Onset almost always occurs before the age of 18, usually
before the age of 5.
However there are number of reports of persons who began
to stutter after the age of 18.
Some of these may be cases in which the person stuttered
for at least a short time during childhood, stopped and began
again as an adult, it seems unlikely that they all are. So
probably stuttering can have its onset during adulthood.

• Some of the findings of onset of stuttering
(Starkweather)
▫ Most stuttering begins between the onset of speech and
puberty median age of onset is 4 years (Andrews and
Harris, 1964).
▫ The dysfluencies of preschool children who stutter are
primarily whole word repetitions and interjections
(Westby, 1979).

▫ In children, onset is typically gradual. Often there is
nothing unusual in circumstances at the time of onset
i.e. no shocks, fright, illness or injury (Van Riper
1971).
▫ There is no systematic pattern of environmental events
at the time of stuttering onset but many parents report
that there was a source of emotional tension in the
household at or around the time of onset such as illness
of a family member, absence of parents etc.

COnditiOns COntributing tO
Onset

Less influential factors: These factors do not have a
strong influence on precipitating the problem of
stuttering
I. Physical development: -
Same general physical make up as children who
speak normally.
No evidence that children who stutter are distinctive
in terms of general developmental milestones
(Andrews and Harris, 1984)

II. Illness: -
Silverman (1906) points out, if illness affects CNS, a
cause and effect relationship between illness and onset
of stuttering may be possible.
CWS do not appear to have more illness than those who
do not (Andrews and Harris, 1964; Johnson and
Associates, 1959)

III. Imitation: -
 This consideration of stuttering onset may be
influenced by culture of the speaker,
E.g, Otsuki (1958) reported that in Japan, imitation was
viewed as a major casual factor in 70% of his cases.
 Van Riper (1982) indicated that there were several
instances where imitation appeared to be involved in
onset of stuttering

IV. Shock or fright: -
Parents may report the onset of stuttering following a
traumatic emotional event (Van Riper, 1982).
Parents may report onset of stuttering associated with
an event without knowing that their child had been
stuttering for some time in school and other locations.
Moreover Silverman indicates that almost in all cases
the ‘traumatic’ events are not really very traumatic.

V. Emotional and communicative conflicts: -
Some parents suspect that a variety of interpersonal
and family stresses can bring about stuttering.
There is no indication that children who stutter have
a greater number of emotional conflicts than their
normally speaking counterparts (Adams, 1993; Van
Riper, 1982).
 Again as with illness, shock or fright emotional or
communicative stress undoubtedly enhances the
possibly of breakdowns in the motor sequencing of
speech (Van Riper, 1982)

VI. Socio economic status: -
 Few data available indicates that stuttering is present
in all socio economic groups.
Van Riper (1982) reviewed several studies that
report varying amount of stuttering across both
cultures and races.
Gillespie and Cooper (1973) and Dyker and Pindzola
(1995) reported data showing a higher occurrence of
stuttering in African populations.
Bloodstein (1987) suggest that occurrence of
stuttering may be related to the imposition of high
standards for achievement of status and prestige.

More influential factors:-
These factors have greater influence on likelihood of
stuttering.
The following conditions may be best thought of as
predisposing factors that can place a child at greater
risk for both precipitating and maintaining stuttering
(Silverman, 1992)

I. Gender: –
Kent (1983) discussed the fact that higher occurrence
of stuttering in males is one of the few consistencies
about the disorder.
However, stuttering begins with approximately equal
frequency with young boys and girls.
Females are much more likely to recover from
stuttering during pre school years than males.

The reason why males consistently show a higher
persistence of stuttering may relate to boys being less
adept at language and speech activities or less able to
adapt to communicative stress.
Based on result of several studies, Yairi and
Ambrose (1999) suggest that gender and genetics
interact in such a way that young females who stutter
are much less likely to persist in stuttering than
young males.

II. Age: -
Children who are approximately 2 to 7 years of age
are much more likely to begin stuttering than older
children, adolescents or adults.
There is a much greater clearance of stuttering onset
before age 5 than after age 7 years.
Andrews (1984) suggests that the risk of developing
stuttering drops by 50% after age 4, 75% after age 6
and is virtually nil by age 12.

 Onset of stuttering during middle or later adult years
is extremely a rate is likely to occur only in cases of
neurological or psychological origin.
Yairi and Ambrose (1992b) found that boys begin
stuttering an average of 5 months later than girls.

III. Genetic factors-
Bloodstein (1995) review indicates that percentage
of persons who have relatives on maternal or paternal
side who stuttered ranges from 30 to 69%.
Studies concerning stuttering have focused on
occurrence of stuttering in families, particularly in
instances where there is density of stuttering in 1st
and
2nd
degree relatives.
Research during past few decades has indicated a
genetic component in selected groups of people who
stutter (Cox, Seider and Kidd, 1984)

IV. Twinning: -
The relationship of twinning to stuttering is of
course, closely connected to genetic factors.
Approximately 1/3rd
of all twin pairs are monozygotic
pairs and are genetically identical.
The remaining twin pairs are dizygotic and share
about half of their polymorphic genes.
A child is more likely to stutterer if he is a member
of a twin pair in which the other twin also stutters
(Howie, 1981).
This is especially true if twins are monozygotic. It is
less likely that both members of fraternal twin pair
will stutter5 (Howie, 1981)

V. Brain injury –
Van Riper (1982) summarizes findings that report
considerably greater than 1% occurrence of stuttering
with brain injury, especially for speakers with CP and
epilepsy.
However it can sometimes be difficult to distinguish
motor speech and language problems (part word
finding) from fluency breaks.
In addition, speakers who are developmentally
delayed often have a higher than usual occurrence of
stuttering especially those with Down’s syndrome.

Van Riper (1982) summarized results of 7
independent studies indicating prevalence figures
ranging from low of 7% (Schaeffer and Shearer
1968) to a high of 60% for clients with Down’s
Syndrome (Preus 1973).
Averaging all 7 studies and 2 reported categories of
general retardates and monogloids results in
prevalence figure of 24%.
In addition developmental delays and neuro-
pathological influences can mask identification of
fluency disorders.
Studies indicate that both verbal and non verbal
intelligence is slightly lower in speakers who stutter
in contrast to control subjects.

VI. Speech and language development:-
As series of studies of Andrews and Harris (1964) ;
Berrty (1938); Guitar (1998); Kloine and
Starkweather (1979); Wall (1980); Peters and Guitar
(1991) concluded that children who stutter typically
achieve lower scores than their peers on measures of
receptive vocabulary, age of speech and language
onset, MLU and expressive and receptive syntax.
Recent investigations suggest that relationship of
stuttering and expressive language and phonological
abilities is far from simple.

Watkins, Yairi and Ambrose (1999) studied 62 pre
school children who recovered from stuttering and 22
who still persisted, on language skills and found that both
groups of children displayed expressive language scores
well above normative values. These results counter the
frequently expressed opinion that young children who
stutter demonstrate delays in expressive language.
Paden, Yairi and Ambrose (1999) studied phonological
abilities of these same children and concluded that
preschool children who stutter and are slow to develop
phonologically are usually in the group whose stuttering
will be persistent.

VII. Motor coordination: -
There is some evidence that adults who stutter have
greater difficulty in fine motor coordination (Riley &
Riley, 1984; Starkweather, 1987, Van Riper, 1982).
 A significant part of act of speaking is a motor skill
and any delay or deficit in this aspect could certainly
adversely affect development of normal fluency.
There is some indication of a lack of appropriate
interaction between laryngeal and supralaryngeal
behaviors during fluent speech in young children who
stutter (Conture, 1985).

Development of
stuttering
There have been several attempts to describe how
symptomatology of stuttering in preschool children
evolves into that evinced by most adults.
The most traditional view of stuttering development
is one of gradual increase in awareness and struggle,
and thus severity.

Bluemel’s primary anD
seconDary stages
One of the first attempts to describe the development
of disorder was by Dr.Charles Bluemel (1932, 1957).
 He referred to stuttering evinced during first stage as
“primary” stuttering and that evinced during the
second as “secondary” stuttering.
 He described primary stuttering as consisting of
relatively effortless repetitions and prolonged
articulatory postures. This type would be exhibited
by most children at or near onset.

Secondary stuttering
Marked by conscious struggle to articulate while
mental process of speech is momentarily halted.
The stammerers breathing is disturbed like wise his
vocalization and articulation.
He uses starters to get the speech going.
He becomes conditioned against difficult words and
situations and he develops speech aversion and
avoidance.
He resorts to synonyms and circumlocutions to avoid
his stammering.

Bluemel’s theory
Characteristics
.simple disturbance in speech
.effortless
core behaviors
Secondary behaviors
avoidance
struggle

But Bluemel’s scheme has been criticized for several
reasons.
Behaviors which he indicates as being symptomatic
of primary stuttering can be observed in speech of
normal speaking preschool age children.
It does not adequately describe symptomatology of
disorder in school age children, particularly in those
of elementary school age.

Stuttering does not always begin with relatively
relaxed hesitations of which person is unaware. It
has been reported that children evinced behavior
characteristics of secondary stuttering immediately
following onset of disorder.
It does not describe in sufficient detail the transition
between beginning stuttering and fully developed
form of disorder.

BlooDstein’s four
phases
Bloodstein (1960) has proposed 4 stage scheme that
includes aspects of symptomatology of disorder in
school age children as well as in preschool age ones
and adults.
He appropriately points that there is considerable
variation in the age at which a person evinces
symptomatology associated with each phase.

phase 1 (pre schooler)
oEpisodic.
oStuttering is still in its rudimentary form.
oAppears for periods of weeks or months between
long internals of normal speech.
oThere is apparently high percentage of
spontaneous recovery.

oChild stutters most when excited or upset when
seeming to have great deal to say or under condition
of communicative pressure.
oDominant symptom is repetition. Much of the
repetitions consist of repetition of initial syllables as
it does in older stutterers, there is usually a
conspicuous tendency to repeat whole words.

oThere is a marked tendency for stuttering to occur at
the beginning of the sentences, clause or phrase.
oIn contrast to more advanced stuttering, interruptions
occur not only on content words, but also on function
words of speech pronouns, conjunctions articles and
prepositions.
oMost of the time children in first phase of stuttering
show little evidence of concern about interruption in
their speech.

phase ii (elementary
school)
oChronic.
oThere are few, if any, intervals of normal speech.
oChild has a self concept of stuttering.
oStuttering occurs chiefly on major parts of
speech nouns, verbs, adjectives and adverbs.
oFewer tendencies to stutter only on initial words
of sentences and phrases and whole word
repetitions are no longer quite as common.

oDespite a self concept as a stutterer, child usually
evinces little or no concern about the speech
difficulty.
oThere is absence of features of advanced stuttering as
anticipation of stuttering, substitution, avoidance of
speaking circumlocution, word sound and situation
fears.
oStuttering increases chiefly under conditions of
excitement and when the child is speaking rapidly.

phase iii (late chilDhooD
anD early aDolescence)
oStuttering comes and goes largely in response to
specific situations.
oPerson often reports difficulty in situations like
classroom recitation, speaking to strangers, using
telephone.
oCertain words or sounds are regarded as more
difficult than others.

oIn varying degrees, word substitutions and
circumlocutions are seen.
oIt tends to be done only occasionally and more often
as reaction to frustration.
oNo avoidance of speech situations and no evidence of
fear.

phase iv (aDulthooD)
oVivid, fearful, anticipations of stuttering
oFeared words, sound and situations
oVery frequent word substitutions and circumlocution.
oAvoidance of speech situation, evidence of fear and
embarrassment.

van riper’s tracks of
stuttering
Van Riper (1982) agreed with Bloodstein that the
process through which symptomatology of disorder
in preschool children evolves into adult form.
 However he concluded that continuum along which
it developed was not same for all persons.
He indicated that there at least 4 tracks along which
it can develop.

Track I---Typical Development of
Stuttering
• Previously fluent Gradual onset
• Cyclic long remissions
• good articulation normal rate
• syllabic repetitions no tensions
• loci: first words, function words
• no awareness no frustration

track ii---- cluttering
• Often late, at time of first sentences
• never very fluent, gradual onset
• no remissions
• poor articulation fast spurts
• gaps, revisions, syllable and word repetitions
• no tensions, no tremors
• loci: first words, long words scattered throughout
sentence
• variable pattern
• no awareness, no frustration

track iii--- “shocks anD
frights”
• Any age previously fluent
• sudden onset, often after trauma
• Steady few short remissions
• normal articulation
• slow careful rate
• much tension
• tremors
• beginning of utterance, after pauses
• highly aware much frustration

Track 1, suggest more than 50% of cases follow,
quite similar continuum defined by Bloodstein’s 4
phases.
As such, it has the same limitation as scheme
proposed by Bloodstein symptoms that define
beginning of this track also are exhibited by some
normal speaking preschool age children.

Another question raised is whether the disorder that
develops along tracks II, III and IV is same as that
which develops along track 1.
Though all are labeled as “stuttering’, it might not be
the same disorder.
 The symptomatology evidenced by children on tack
II seems to be that of cluttering (Silesman, 1992).

Conture (1991)
a. Alpha Behaviors:-
 They are brief, subtle inefficiencies in speech
production characterized by short within word
pauses, laryngeal catches and articulatory arrests at
the beginning of an utterance or at the transition
between sounds and syllables.
 These subtle breaks appear to occur as a result
of interplay between child’s capacity for producing
fluency and environmental stimuli or demands.

b. Beta behaviors:-
They are oscillatory movements of speech
mechanism which are characterized by brief to
lengthy repetitive productions.
These are compensatory or copying reactions to the
original alpha factors and take the form of syllable
repetitions, laryngeal adduction and nostril flaring.

c. Gamma behaviors: -
They are speech movements that are relatively tense,
fixed or both and are viewed as coping reactions to
the beta activities.
These behaviors take the form of fixed laryngeal
adductory postures, labial contacts and lingual
posturing.
They result in inaudible sound prolongations or
cessation of airflow or voicing.
This stage is a significant step in development of
stuttering, marking a reduced likelihood that
spontaneous recovery will take place.

d. Delta Behaviors: -
They are both nonverbal and verbal reactions to beta,
gamma and possibly alpha behaviors and are seen as
reactive speech and non speech behaviors.
These coping reactions are in the form of such
responses as pharyngeal muscle constrictions, vocal
fold lengthening and shortening, blinking of eye lids
and eyeball movements.

Although this pattern of development assists in
understanding how stuttering may sometimes evolve,
there is a growing body of data that suggests that such
development is not always the case.
The longitudinal data accumulated by Yairi and his
associated concerning onset and development (Yairi &
Ambrose 1992a, 1992b, 1999) suggest that stuttering in
young children can reach an advanced form soon after
onset.
The most interesting finding is the observation that a
substantial number of children show a dramatic decline in
both frequency and severity of stuttering within first six
months after onset (Yairi & Ambrose 1992; Yairi,
Ambrose & Nirmann, 1993).

Peters and Starkweather (1989) in their study on
“Development of stuttering throughout Life”
provided a comprehensive view of development of
normal and abnormal fluency from perspective of
three aspects of human development.
Speech motor behavior, linguistic behavior, social,
emotional and cognitive behavior.
They have divided life span into 5 phase as
preschool, early school years, puberty and
adolescence, late adolescence and early adulthood.

According to them, stuttering develops most
dramatically in early years of life and continues to
change in less dramatic ways throughout life.
They concluded that human beings grow in
predictable ways throughout life.
Most importantly, certain aspects of stuttering change
be seen as particularization of human development.

Development of
stuttering During miDDle
age anD beyonD
 There is an implicit assumption that once stuttering
has reached its most severe form, usually during
adolescence or early adulthood it ceases to develop in
predictable manner.
 Research pertaining to this assumption began during
1980s.

 There is some evidence that personality and attitudes
tend to change in predictable ways during adult life
cycle (Sheehy, 1976).
 Since personality attributes and attitudes influence
stuttering severity it would not be particularly
surprising if stuttering did change during middle age
and beyond.

Peters and Starkweather (1989) reported the following
changes tend to occur after age of 30 years:-
During this period, a gradual decline in the severity
of stuttering is seen.
 New behaviors are no longer acquired.
Tendency for a reduction of abnormality has largely
stopped.
Increased self confidence maturity seems to reduce
the frequency with which all stuttering behavior
occur.
Occasionally there is complete remission.

Some findings for development of stuttering:
There is tendency for the amount and frequency of
dysfluency in normal speakers to decrease with age
during the second year of life (Yairi, 1981) and
presumably throughout the preschool period.
During school years, there is a continued but slight
decrease in the frequency of dysfluency in normal
children.
Stuttering changes over time. The pace of this change
is highly variable and course of development is also
variable but some common characteristics are
identifiable as trends of development in young
stutterers (Bloodstein, 1960)

There is tendency for dysfluencies of stuttering
children to fragment briefer units of speech
(Bloodstein, 1960) and for the rate of repetition to
increase (Van Riper, 1984)
There is a tendency for the amount of tension and
forcing to increase (Bloodstein, 1960)
Early stuttering is likely to be episodic over time.
With development, this changes to fluctuations in
severity over time (Bloodstein, 1960)

Early stuttering is as likely to occur in one
circumstances as in any other but with continued
development it tends to become associated with
specific speaking situations (Bloodstein, 1960)
There is a tendency for children who stutter to
recover spontaneously (Ingham, 1985)
Females are more likely to recover than males
(Andrews, et al. 1983)
Stutterers are late in passing speech milestones.
(Andrews et al., 1983)

Reductions of parental speech rate are significantly
correlated with the extent of improvement in
children’s stuttering during treatment (Starkweather
& Gottwald, 1984).
Children may also have traumatic onset, the mute
period being reported in some of the cases (Van
Riper, 1971).
Adult onset may also follow physiological trauma
(Peacher & Harris, 1946).

Few cases of stuttering following brain injury have
been reported. Diffuse brain injury has also been
reported as a precursor to stuttering behaviors (Helm,
Butler & Benson, 1978)
Stuttering has occasionally been reported as a sequel
to aphasia (Helm, Butler & Benson, 1978)

patterns of Development
First, the discontinuous behavior, pauses, repetitions
prolongations and broken words that take up time but do
not convey information, become truncated.
The first noticed abnormal child’s fluency is excessive
amount of whole words to parts of words. Eg: The child
says “But, but, but, but I don’t want”. The repeated
element may be shortened further ‘b-b-b-b-but’.
Hence, one characteristic of typical course of development
is progressive truncation of repeated elements (Bloodstein,
1960).

• The next change in the most typical course of
development is use of one or more behaviors that
indicate there is tension in larynx.
• Three behaviors are common:
 Prolonged vowels with pitch rise
 Broken words
 Increased loudness.

Prolonged vowels with pitch rise is siren like e.g. the
child says “May I have some?” and vowel in ‘may’ is
prolonged like Maaaay and pitch of voice rises
slowly and steadily and it continues as long as vowel
is prolonged.
Increased tension in larynx leads to increased vocal
loudness.
The voice becomes increasingly loud as vowel is
prolonged.

Finally, the more elaborate secondary features
develop, those designed to avoid stuttering :
Changing words
 Postponing the attempt on the word.
 Diverting attention from dysfluency.
 Avoiding talk altogether.
In beginning these tricks are effective but
gradually these behaviors lose their effectiveness
and change in form.

Avoidance is also important in development of
disorder: -
Many who repeat whole word excessively manage to
grow into normal speakers.
Those who do not are the ones who react to
repetitiveness in their speech with struggle, forcing
tension and avoidance.
 Not only do they react in avoidant way, they
incorporate this reaction into their habitual talking
pattern.

tHe neeD for early iDentifiCation
anD treatment
Stuttering is a disorder of childhood, onset of which
is more than 90% of the individuals is before the age
of 6 years.
Clinicians are often apprehensive in counseling the
parents regarding the need for intervention for young
children with stuttering in terms of duration of
treatment required, outcome expected, the techniques
which facilitate recovery etc. This is more so with
those who adhere to the Johnson’s Diagnosogenic
Theory.

This is a serious problem when the current emphasis
is more on early identification and intervention.
Stuttering has serious impact on the individual’s
personal (self-esteem), psychological, social,
educational, vocational and interpersonal relations.
There are some risk factors suggested in the literature
for predicting recovery or to make decisions
regarding intervention such as the presence of family
history, chronicity and severity of the problem,
associated phonological and language delays or
defects, consistency of the problem, child’s and/or
parental concern etc.

However, early identification and treating children
close to onset of stuttering is increasingly emphasized
by many authors for the following reasons:
It is easy, less time consuming and more long lasting
(i.e., approximately 1-3 months or 20 hours for
children (Starkweather & Gottwald, 1986) to one to
several months/years or 140 hours for adults (Van
Riper, 1973; Webster, 1974) and is reported to be
dependent on the chronicity of the problem

Reported rates of success is higher (>90%) compared
to that for adults (50-75%) (Franken, 1988;
Starkweather, Gottwald & Halfond, 1990; Webster,
1974).
Relapsed rates for treated adults are reported to be
around 50% (Franken, 1988); whereas for children it
is close to zero (Starkweather, Gottwald & Halfond,
1990).

Adults who are treated are reported to have carefully
monitored speech (Boberg & Kully, 1994) and
diminished quality of speech (Franken, 1988) or may
have residual stuttering behaviors (Prins, 1984) while
the treated children are reported to be no different
from their non-stuttering peers (Starkweather,
Gottwald & Halfond, 1990).

Although it is reported that many children with
stuttering spontaneously recover, nearly 20% would
continue to stutter if not treated and it is not a small
number when 1% of the total adult population who
continue to stutter if not treated is considered.
The impact of stuttering problem on the young minds
to live with it could be quite handicapping
emotionally, socially, educationally and vocationally
as reported by many persons with stuttering.

stuttering &amp; nnf

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