Is There Anything New in Stuttering or Are You Still Doing the Same Old Things?
About the presenter: Walter Manning is a professor and Associate Dean in the School of Audiology and Speech-Language Pathology at The University of Memphis. He received his bachelors degree from Lycoming College in Pennsylvania in 1964, his masters degree from Penn State University in 1967, and his doctorate from Michigan State University in 1972. He served on the faculty of the University of Nebraska from 1972 to 1977. At the University of Memphis he teaches courses in fluency disorders and research methods. He has published more than 60 articles in a variety of professional journals and has presented on many occasions to regional, national, and international meetings. He is a member of the Steering Committee of ASHA's Special Interest Division 4 [Fluency & Fluency Disorders], serves as a reviewer for several journals and is currently an Associate Editor for the Journal of Fluency Disorders. In 1996 he completed a text titled "Clinical decision making in the diagnosis and treatment of fluency disorders" published by Delmar Publishers of Albany, NY. He has served several positions in the Tennessee Association of Audiologists and Speech-Language Pathologists including Vice President for Planning and President. He has is a fellow of ASHA and has received the honors of Tennessee Association.
Is there anything new in stuttering or are you still doing the same old things?
by Walter H. Manning
The University of Memphis
Sometimes it will happen at a party, or a reception, or sitting next to someone on a plane. I'll mention that I enjoy writing, teaching, reading, researching, and doing clinical work with people who stutter. And then the person I'm talking with will begin to say things such as "Oh really, you work with people who stutter. How interesting. Have you found out yet what causes it? Is it . . . ah. . . psychological? Is there anything new in the treatment of stuttering?" Because of that last question, and depending on who is doing the asking, I sometimes feel myself becoming a little defensive. You see, I'd prefer to convince my listener that the area of fluency disorders is both dynamic and creative and that we constantly come up with ideas that are innovative and effective.
It happened again the other day. This time the question was a little more pointed. A former speech-language pathologist to whom I was being introduced, mentioned that she had recently read a newspaper article about stuttering treatment. She gathered from the article that clinicians were still doing the same things they were doing when she began working in the field some 30 years earlier. Circumstances at that moment didn't permit me to take the time to convince her otherwise. So I told her to go out and purchase a good recent book on the topic, preferably the one by Manning. . . or maybe even one by Conture, Guitar, or Starkweather.
It was about this time that I had begun thinking about a topic for the ISAD paper that I had promised to Judy Kuster. It occurred to me that this might be as good a time as any to come up with a considered answer to the frequently asked question - Is there anything really new in stuttering? Of course I had some thoughts about the treatment strategies and techniques that have been developed during the past 20-30 years and I was aware of the theoretical concepts about stuttering etiology and development that had been presented in the more recent literature. It occurred to me that my colleagues in the specialty of fluency disorders are also asked the same questions and that I might be able to get some help from them. So, I spent the next morning emailing many of the people I know who are active in the research and treatment of stuttering and my friends in self-help organizations. They too had had these same experiences and based on their responses, they were as intrigued as I was by the possibility of gathering their thoughts on the question of whether there was really anything new in stuttering.
I should mention that I didn't have any rigid criteria for what constituted new theoretical concepts or applied techniques. I simply asked these people to list what they felt were at least two or three new and innovative ideas that had occurred in the field in the past 25-30 years. Some colleagues responded with just a few thoughts and some with lengthy lists. There were two people who suggested that there had been few truly new ideas presented in the recent decades and that many of the concepts discussed today were really new editions of ideas that were first discussed some 50 to 70 years ago. It was argued, for example, that not much has changed since Johnson's streamlined effortless speech and Van Riper's pullouts and preparatory sets. Most of those responding, however, felt that there were a number of new and beneficial ideas introduced during the last few decades. I found it interesting that there was agreement in many of their comments.
In the following paragraphs I have attempted to summarize my own thoughts, as well as those of my colleagues. As I looked over the responses it occurred to me that it would be both natural and logical for many of the theoretical and clinical ideas popular in the field today to have evolved from previous efforts - good ideas tend to come around again. Thus, some ideas that seem to be new are not thoroughly new but rather indicate a swing of the pendulum back to previous concepts of etiology and development. As we have increased our knowledge of how speech is created, coordinated, monitored, and adjusted, we are able to take steps in understanding why approximately 1% of all speakers throughout the world are unable to produce it fluently. The availability of new technology has allowed researchers to revisit and elaborate on the original ideas. Research on the genetic and biological variables of stuttering are probably the best example of these ideas.
As a result of reading through the responses of my colleagues and preparing this paper, it's my belief that there are many new and exciting ideas taking place in the understanding and treatment of stuttering. I believe that the specialty area is continuing to respond, on both theoretical and clinical levels, to the challenge of helping those who stutter as well as the parents and spouses who are affected by this problem. Because of space limitations, I have provided short summary statements indicating what seem to be the best examples of the newer ideas in the treatment of stuttering. It may be that these comments will generate discussion and eventually result in a more complete paper on this topic.
Theories and Models:
The Capacities and Demands model has been especially useful as a clinical strategy for stuttering diagnosis and intervention. Although this model may be less capable than others for explaining the onset of stuttering, future investigations of children's' motoric, linguistic, cognitive, and emotional capacities and demands (particularly during the early critical stages of language learning) should continue to result in new ideas for prevention and treatment. This model also nicely accommodates what is known about the relationships between a child's ability to achieve fluent speech and the abilities required for normal language and speech (e.g. how motor function may be effected by linguistic demands). The model has led to strategies for enhancing a child's capacities for producing fluent speech as well as decreasing the communicative demands.
In recent years, researchers investigating the nature of stuttering have utilized medical technology in their studies. The ability to provide images of the brain via positron emission tomography (PET) scans and magnetic resonance imaging (MRI) has significantly extended the evidence that the brain function of stutterers is different from normal-speaking subjects. Although we don't yet know what this research will eventually tell us about etiology, improved technology and analysis methods will continue to yield exciting results. Studies of dopamine levels in individuals who stutter and the related possibilities for using medication to control stuttering provide another interesting direction of recent research. Findings such as these tend to provide additional evidence to counter the notion that people stutter because they are neurotic, have a personality disorder, or, as some would have had us believe, have an unusual relationship with one or more of their sphincters.
The evidence from a number of neuromotor studies has increased our understanding about the ability of people who stutter to control the speed and timing of their speech production system. In more recent years there has been less emphasis on the more peripheral functioning of the nervous system and more effort directed toward understanding the central processing ability of stutterers.
Investigations of the genetic basis of stuttering, begun in the 1970s by Kidd and his associates and continued by Yairi and colleagues provide evidence for a major genetic component in stuttering onset. A current genetic investigation, being conducted by the National Institutes of Health, holds great promise in leading to increased understanding concerning the etiology, development, and possibly treatment of stuttering.
Diagnosis and Therapy:
Many respondents commented on how the work of Yairi and his colleagues has dramatically changed the way we view the onset and development of stuttering in young children. The series of studies by this group has helped to improve the diagnostic decisions relating to abnormality and chronicity in young children. We now know, for example, that certain forms and rate of fluency breaks are unique to young children who stutter and that young children can sometimes present with sudden and complex onset. The same can be said of Conture and his associates in their studies of clustering, nonverbal behavior, and linguistic variables in early stuttering. We know much more about the occurrence of spontaneous recovery from stuttering in young children and the factors that are related to this phenomenon. Simply stated, we have far more accurate information than we did 30 years ago about the nature of early stuttering onset and development in children. This knowledge, in turn, is leading to more complete diagnostic evaluations.
Another consistent response was that clinicians treating young children for stuttering are more likely to use direct manipulation of the child's speech behavior than they were even a few years ago. Although indirect methods of altering the child's environment continue to be a component of treatment, clinicians have shown impressive results with directly facilitating the speech and motor skills necessary for achieving fluent speech. In addition, there is accumulating data which indicate that early and direct intervention is highly effective with preschool children.
There was general agreement that stuttering is less likely to be thought of purely as an environmentally determined event and an operant that can be shaped by its consequences. However, contingency management treatment techniques have been refined and applied with success to young children and adults.
Nearly all respondents felt that clinicians today are more likely to treat clients in a more comprehensive manner than in the past. Clinicians appreciate the many levels of intervention rather than concentrating only on the frequency of stuttering and the mechanics of speech modification. Most agreed that there is greater value placed on the cognitive and affective aspects of treatment and that counseling is at the core of most successful treatment. This view also coincides with the model adopted by the World Health Organization that describes a problem in terms of impairment (neurophysiological events), disability (the visible and audible manifestations of the behavior), and handicap (the reactions of the individual to the problem).
One negative change of recent years was the decision by the American Speech-Language-Hearing Association (ASHA) not to require graduate students to obtain practicum hours in the area of fluency disorders. On the other hand, ASHA has supported the development of special interest divisions including Division 4, Fluency and Fluency Disorders. The fact that this Division was the first one to achieve creation of a commission to regulate specialty recognition may have far reaching effects. The work of the Commission on Fluency and Fluency Disorders should result in increasing the competence of clinicians working with persons who stutter.
There seems to be an increasing realization of the value of involving the family in the process of treatment for stuttering, particularly in the case of children and adolescents. Several of those responding also pointed out that clinicians are more likely to provide counseling for clients and their families and to deal in a more straightforward manner with such issues as the guilt and shame that may be associated with stuttering.
Another major trend taking place in recent years has been the growth and increasing influence of support and advocacy groups. The Stuttering Foundation of America celebrated its 50th anniversary in 1997 and has increased its ability to provide information to the general public, consumers, and professionals in the form of public service announcements, advertising, workshops, videos, and written materials. Support groups, in particular the National Stuttering Project (NSP), have worked to increase the cooperation between consumers and professionals and have helped to facilitate meaningful interaction between parents, children and professionals.
Increased technology has resulted in a number of clinical innovations. User friendly video and computer systems have permitted the development of innovative educational and clinical activities. A variety of interactive computer and software programs continue to be created that facilitate monitoring and modifying of stuttering behavior. Access to the internet has increased the ability of consumers and professionals to obtain information about stuttering and sources of help. Of course, it might also be pointed out, that the internet increased the availability of information about stuttering that is, at the very least, erroneous and, at the most, unethical.
The intricacies of long-term recovery (both assisted and unassisted) and the persistent problem of relapse following treatment have become a focus of research in recent years. We are beginning to obtain information concerning the long-term treatment effects with adults and, more recently, with adolescents and children.
Conclusion and Future Trends
The next time someone asks me whether or not we are doing the same old things in the understanding and treatment of stuttering I'll have a better answer. I'll still have to say that we don't know for sure what causes the problem, that we have no cure available, and that we do not have a single unifying theory that links together our understanding of the problem. Although there has been no break-through discoveries, we do more fully understand the complexity of the biological and environmental interactions that influence spoken language. I can continue saying what I have always believed, that, as a specialists in working with those who stutter, we are really effective at helping many people who are interested in working through the process of changing their stuttering and all that goes with this problem. I may also add that I think it is a good thing that people who stutter are becoming more aware of their rights as a result of the Americans with Disabilities Act. We are starting to identify preferred treatment outcomes and documenting the efficacy of our treatment, driven in part, by the need to satisfy third-party payers. I can say that we are just beginning to realize the importance of investigating the multicultural factors that may impact the effectiveness of our assessment and treatment. I'll tell them that the research in genetics and brain imaging are likely to provide us with many good answers concerning etiology. And finally, I'll say that because specialty recognition in fluency disorders is now becoming a reality, consumers will have a greater chance of being served by more qualified professionals.
August 18, 1998
