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Stuttering An Integrated Approach to Its Nature and Treatment FIFTH EDITION 1 Stuttering An Integrated Approach to Its Nature and Treatment FIFTH EDITION BARRY GUITAR, PhD Professor Department of Communication Sciences University of Vermont Burlington, Vermont 2 Acquisitions Editor: Matt Hauber Development Editor: Amy Millholen Editorial Coordinators: Andrea Klingler and Kerry McShane Editorial Assistant: Parisa Saranj Production Project Manager: Kim Cox Marketing Manager: Jason Oberacker Designer: Stephen Druding Artist: Bot Roda Compositor: SPi Global 5th Edition Copyright © 2019 Wolters Kluwer Copyright © 2014 Lippincott Williams & Wilkins, a Wolters Kluwer business. Copyright © 2006 by Lippincott Williams & Wilkins. Copyright © 1999, 1991 by Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at shop.lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China Library of Congress Cataloging-in-Publication Data Names: Guitar, Barry, author. Title: Stuttering : an integrated approach to its nature and treatment / Barry Guitar. Description: Fifth edition. | Philadelphia : Wolters Kluwer, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2018049600 | ISBN 9781496346124 (paperback) Subjects: | MESH: Stuttering—therapy | Stuttering—etiology | Stuttering—diagnosis Classification: LCC RC424 | NLM WM 475.7 | DDC 616.85/54—dc23 LC record available at https://lccn.loc.gov/2018049600 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. shop.lww.com 3 Preface Stuttering is an intriguing and mysterious disorder. In the past 50 years, we have learned many secrets about what is different in the brains of those of us who stutter. Yet many unanswered questions remain. For example, we don’t know exactly how these brain differences result in the speech disfluencies that we see in the onset of stuttering in children. We also don’t know how the usually mild beginnings of stuttering become—for some children—severe, struggled behaviors accompanied by avoidance and emotional turmoil. This book is an attempt to present the latest scientific findings and theoretical perspectives and integrate them with the best clinical approaches for evaluating and treating stuttering. As I worked on this new edition, I realized that my current thinking has been influenced deeply by my own stuttering therapist, Charles Van Riper, who summarized his final thoughts (1990) about stuttering in this way: Stuttering begins when the brain mistimes the complex movements required for fluent speech. The child’s responses to these mistimings are the repetitions and prolongations that we observe as stuttering begins. Most children recover from stuttering “because of maturation or because they do not react to their lags, repetitions, or prolongations by struggle or avoidance” (Van Riper, 1990, 317 [italics mine]). The struggle and avoidance are learned and can be modified, although the mistimings are always there. Some of my thinking in this edition focuses on the children who do not recover because they do react to their repetitions and prolongations. I view our therapies for preschool children as preventing these struggle and avoidance reactions and minimizing the stuttering they would be reacting to. We do this by helping them feel ok about their stuttering and teaching them how to talk more fluently. I also think that once the struggle and avoidance reactions are learned, they can be modified by reducing the (nonconscious) threat and (conscious) fear of stuttering that trigger these reactions. A combination of a strong, supportive client-clinician relationship and a program of reducing fear and shame, and confronting and tolerating the moment of stuttering to reduce tension, and then easing out of it will diminish struggle and avoidance. The resulting experience of feeling in control of stutters will further reduce maladaptive behaviors and negative feelings. Have I anything more to say? Yes. I hope if you have suggestions for improving the next edition of this text, you’ll let me know. — B���� G����� [email protected] 4 Acknowledgments Thank you to all my clients and students. You taught me as much as I taught you. And thanks to my colleagues in Communication Sciences and Disorders and in Psychological Sciences whose writings and conversations, in person and via e-mail, have helped me become woke. A round of applause for Andrea Klingler, Mike Nobel, Kerry McShane, and Amy Millholen, whose editorial talents made this book what it is. Cheers for Bot Roda—the talented illustrator who gave life to all my notions about what might be helpful to put in visual form. Kudos to Adinarayanan Lakshmanan Sivakumar (Siva) and his team who have done a wonderfully thorough job of compositing my manuscript into the printed page. Hooray! Rebecca McCauley and Charlie Barasch, who have edited each chapter, making them more readable, updated, and cogent than my original drafts. As with all the earlier editions, I bestow love and appreciation to my wife, Carroll. She has used her librarian and literary skills to edit, find references, keep databases, get permissions, help with videos, and keep me moving so this edition will finally see the light of day. 5 Contents Preface Acknowledgments Section I Nature of Stuttering 1. Introduction to Stuttering Perspective Overview of the Disorder Definitions The Human Face of Stuttering Basic Facts about Stuttering and Their Implications for the Nature of Stuttering 2. Primary Etiological Factors in Stuttering What Do We Know About Constitutional Factors in Stuttering? Hereditary Factors Congenital and Early Childhood Trauma Studies Brain Structure and Function 3. Sensorimotor, Emotional, and Language Factors in Stuttering Sensorimotor Factors Language Factors Emotional Factors 4. Developmental and Environmental Factors in Stuttering Developmental Factors Environmental Factors 5. Learning and Unlearning Learning Unlearning 6. Theories about Stuttering Theoretical Perspectives About Constitutional Factors in Stuttering Theoretical Perspectives on Developmental and Environmental Factors Integration of Perspectives on Stuttering 7. Typical Disfluency and the Development of Stuttering Overview Typical Disfluency Younger Preschool Children: Borderline Stuttering Older Preschool Children: Beginning Stuttering School-Age Children: Intermediate Stuttering Older Teens and Adults: Advanced Stuttering Section II Assessment and Treatment of Stuttering 8. Preliminaries to Assessment The Client’s Needs Insurance Considerations The Client’s Right to Privacy Multicultural and Multilingual Considerations The Clinician’s Expertise Assessing Stuttering Behavior Assessing Speech Naturalness Assessing Speaking and Reading Rate FluencyBank Assessing Feelings and Attitudes Continuing Assessment 9. Assessment and Diagnosis Preschool Child School-age Child Adolescent/Adult 10. Preliminaries to Treatment Clinician’s Attributes Clinician’s Beliefs Treatment Goals Therapy Procedures 11. Treatment of Younger Preschool Children: Borderline Stuttering An Integrated Approach Other Clinicians 12. Treatment of Older Preschool Children: Beginning Stuttering An Integrated Approach 6 Another Clinician’s Approach: Sheryl Gottwald Treatment of Concomitant Speech and Language Problems 13. Treatment of School-Age Children: Intermediate Stuttering An Integrated Approach Approaches of Other Clinicians 14. Treatment of Adolescents and Adults: Advanced Stuttering An Integrated Approach Other Approaches 15. Related Disorders of Fluency Neurogenic Acquired Stuttering Psychogenic Acquired Stuttering Malingering Cluttering References Author Index Subject Index 7 I Nature of Stuttering 8 1 Introduction to Stuttering Perspective The Words We Use People Who Stutter Disfluency Overview of the Disorder Do All Cultures Have Stuttering? What Causes People to Stutter? Can Stuttering Be Cured? Definitions Fluency Stuttering General Description Core Behaviors Secondary Behaviors Feelings and Attitudes Functioning, Disability, and Health The Human Face of Stuttering Basic Facts about Stuttering and Their Implications for the Nature of Stuttering Onset Prevalence Incidence Recovery from Stuttering Recovery versus Persistence of Stuttering Sex Ratio Variability and Predictability of Stuttering Anticipation, Consistency, and Adaptation Language Factors Fluency-Inducing Conditions An Integration Chapter Objectives After studying this chapter, readers should be able to: Explain why it is good practice to use the term “person who stutters” rather than “stutterer” Describe factors that may (1) predispose a child to stutter, (2) precipitate stuttering, and (3) make stuttering persistent Name and describe the core behaviors of stuttering Name and describe the two major categories of secondary stuttering behaviors Name and describe different feelings and attitudes that can accompany stuttering Describe the elements of the new International Classification of Functioning, Disability, and Health (ICF) system that are most relevant to stuttering Discuss the age range of stuttering onset and the types of onset, and explain why the onset of stuttering is often difficult to pinpoint Describe the meanings of the terms “prevalence” and “incidence,” and give current best estimates of each of these characteristics for stuttering Give an estimate of the number of children who recover without treatment, and describe factors that predict this recovery Give an estimate of the sex ratio in stuttering at onset and in the school-age population Explain what is meant by “anticipation,” “consistency,” and “adaptation” in stuttering Explain some relationships between stuttering and language, and suggest what they mean about the nature of the disorder Describe several conditions under which stuttering is usually reduced or absent, and suggest why this may be so Key Terms Adaptation: The tendency for speakers to stutter less and less (up to a point) when repeatedly reading a passage Anticipation: An individual’s ability to predict on which words or sounds he or she will stutter Attitude: A feeling that has become a pervasive part of a person’s beliefs Avoidance behavior: A speaker’s attempt to prevent stuttering when he or she anticipates stuttering on a word or in a situation. Word-based avoidances are commonly interjections of extra sounds, like “uh,” said before the word on which stuttering is expected. Block: A disfluency that is an inappropriate stoppage of the flow of air or voice and often the movement of articulators as well Consistency: The tendency for speakers to stutter on the same words when reading a passage several times Core behaviors: The basic speech behaviors of stuttering—repetition, prolongation, and block Developmental stuttering: A term used to denote the most common form of stuttering that develops during childhood (in contrast to stuttering that develops in response to a neurological event or trauma or emotional stress) Disfluency: An interruption of speech—such as a repetition, hesitancy, or prolongation of sound—that may occur in both individuals who are developing typically and those who stutter Escape behavior: A speaker’s attempts to terminate a stutter and finish the word. This occurs when the speaker is already in a moment of stuttering. Fluency: The effortless flow of speech Heterogeneity: Differences among various types of a disorder Incidence: An index of how many people have stuttered at some time in their lives Normal disfluency: An interruption of speech in a typically developing individual Prevalence: A term used to indicate how widespread a disorder is over a relatively limited period of time 9
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