Recovery from Stuttering 1st Edition
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Recovery from
Stuttering
Peter Howell
Psychology Press
New York London
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Library of Congress Cataloging‑in‑Publication Data
Howell, Peter, 1947-
Recovery from stuttering / Peter Howell.
p. ; cm. -- (Language and speech disorders)
Includes bibliographical references and index.
ISBN 978-1-84872-916-2 (hardcover : alk. paper)
1. Stuttering. I. Title. II. Series: Language and speech disorders.
[DNLM: 1. Stuttering. 2. Adolescent. 3. Child. WM 475]
RC424.H75 2011
616.85’54--dc22 2010032472
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ISBN 0-203-84740-7 Master e-book ISBN
Dedicated to Stan and Bill Yarrow
Contents
Preface.................................................................................................................. ix
SECTiON I General Aspects of Developmental
Stuttering
Chapter 1 Definitions, Stuttering Severity, and Categorization
Instruments....................................................................................... 3
Chapter 2 Epidemiology................................................................................. 33
Chapter 3 Symptomatology............................................................................ 47
SECTiON II Factors Related to Developmental
Stuttering Based on Experimental
Studies
Chapter 4 Genetic Factors and Their Impact on Onset and Recovery of
Stuttering........................................................................................ 65
Chapter 5 CNS Factors in Investigations Into Persistent and Recovered
Stuttering........................................................................................ 87
Chapter 6 Cognitive Factors.......................................................................... 105
Chapter 7 Language Factors..........................................................................115
Chapter 8 Motor Factors............................................................................... 169
Chapter 9 Environmental, Personality, and Emotional Factors.................... 193
vii
viii Contents
SECTiON III Theoretical Frameworks on
Developmental Stuttering
Chapter 10 Models That Attribute Stuttering to Language Factors Alone.....211
Chapter 11 Theories That Explain Why Altered Feedback Improves
the Speech Control of Speakers Who Stutter and General
Theories of Speech Production That Include Accounts of
Stuttering...................................................................................... 235
Chapter 12 Model That Proposes an Interaction Between Language and
Motor Factors: EXPLAN............................................................. 259
SECTiON IV Practical Issues in Developmental
Stuttering
Chapter 13 Early Diagnosis of Stuttering and Its Prognosis to Teenage
Years and Beyond......................................................................... 293
Chapter 14 Subtyping......................................................................................319
Chapter 15 Application to Treatment and General Issues About
Recovery....................................................................................... 325
References......................................................................................................... 343
Author Index.................................................................................................... 375
Subject Index.................................................................................................... 385
Preface
This book seeks to summarize what is known about stuttering in its early stages
and, to a lesser extent, to the changes in fluency that occur when various treat-
ments are given. These two aspects are loosely referred to when fluency improves
as “recovery.” I set out with the intention of establishing how these forms of stut-
tering contrasted with those that are less transigent (referred to as persistent). The
book is written by an experimental psychologist who is not involved in delivering
treatments. It seeks to provide the reader with information that will allow one to
interpret the research literature and evaluate findings.
The text introduces some fundamental methodological principles needed to
understand different areas of research. Studies that employ these methods are
selected and examined in detail. The book does not attempt a complete coverage
of everything that has been written about stuttering, as it is not a handbook; it
goes for depth of understanding rather than breadth of coverage. A wide range
of topics is covered in the book. The 15 chapters are ordered into four sections
(general aspects of developmental stuttering, topic areas ranging from genetics
through to emotional aspects affected by stuttering, theoretical frameworks, and
practical issues). These topics were based on courses I have taught and a new one
that is being established at University College London and will be offered in the
fall of 2010. Although the topics reflect the areas I am interested in, I believe that
they also may serve as the basis for other courses. Thus, courses for clinicians
might use just the chapters in the first and last sections. Broader courses that take
the view that stuttering is language-based or others that consider it is motor-based
would select the appropriate chapters from the second and third sections as well.
Courses in the psychology of language disorders could use chapters in the first
three sections. The detailed examination of theory (Section III) is a novel feature
of this book.
Exercises are included at the end of each chapter. The questions are provided
as an invitation to consider different perspectives about stuttering. They often
ask the reader to consider positions to which I do not subscribe. Also, there are
no right or wrong answers to some of the questions, so arguments from opposing
positions are possible. Some of the questions are invitations to make research pro-
posals that would go beyond the literature reviewed in the text. In case it helps, I
would find some of these questions hard to answer as well. Though the questions
are phrased for students, I hope professionals find them inviting ways to formulate
their own positions or to explore alternative points of view that they may have
cherished. They also should serve as a check about what they have learned from
the text.
There are many people to thank who have provided help and support that
allowed me to write this book. The particular clinicians to mention are Lena
Rustin (Michael Palin Centre) and Roberta Williams (City University). The
Wellcome Trust has funded my research for many years and I would like to
ix
x Preface
single out John Williams of the Trust for his help and guidance over the years.
A number of individuals have worked with me for a long time, many of whom
have shown high levels of dedication. Dr. Stephen Davis, OBE, and Stevie Sackin
liaised with clinicians and families and also played significant research roles.
Pippa Bark, Mike Johnson, and Karima Kadi-Hanifi worked out the coding con-
ventions for the speech data used in our own work. Mark Huckvale has always
been prepared to modify his Speech Filing System software for our particular
needs. Andy Anderson brought new perspectives about measurement of motor
actions in people who stutter, Katharina Dworzynski introduced a range of new
ideas including genetics, Kate Watkins facilitated work on scanning, and Ceri
Savage raised new ideas about testing language development in children who stut-
ter. Helen Jefferson-Brown’s support in a range of ways has been crucial. Many
other students have worked with me and their contribution is gratefully acknowl-
edged. Collaborators at University College and in Europe, the United States,
Africa, China, Japan, South America, and Iran are also too many to mention
individually, but thanks goes out to them all. The support of Bob Audley and all
subsequent heads of departments that I have worked under is gratefully acknowl-
edged. A special thank you is expressed to all the families who have tolerated us
in their homes as regular visitors, who have traveled to our lab and elsewhere so
we can conduct tests with nonportable equipment. Finally, thanks to my family
who should have had a fairer share of my time than they did.
Section I
General Aspects of
Developmental Stuttering
1 Definitions,
Stuttering Severity,
and Categorization
Instruments
This book is about recovery from stuttering. Each chapter provides specific infor-
mation that adds to our knowledge about this topic. The relevance of the information
in each chapter is given at the beginning of each chapter. Chapter 1 provides defini-
tions and tools that allow persistence and recovery of stuttering to be established.
1.1 Introduction
The primary goal of this book is to document how stuttering changes once it has
begun (whether the individual recovers spontaneously or recovers after a treat-
ment, or if the condition persists). Stuttering usually arises close to when a child
starts to talk and if the child has not recovered by the teenage years, the chance
of a full recovery dramatically reduces. Consequently, the majority of this work
relates to children. The research findings on groups of children who recover or
persist are examined to see what insights they can provide about the development
of stuttering. There are many proposals that maintain that this or that limitation
reflects the underlying cause of stuttering during development. For instance, it has
been proposed that the high proportion of left-handers in the stuttering population
indicates potential problems in brain lateralization that affects language perfor-
mance as well as handedness. Though handedness is relatively easy to assess,
other aspects of performance that are clearly affected in people who continue to
stutter, such as self esteem, are difficult to measure directly with children (and
usually it is less clear whether these aspects are causes or effects of stuttering).
The emphasis is on language, speech motor, and sensory abilities. Information on
genetics, central nervous system, and emotional and cognitive functioning are also
included. The main questions are whether these abilities are involved at the time
stuttering starts and whether they are implicated in changes in the patterns of stut-
tering over the period that stuttering resolves into persistent or recovered forms.
The words stuttering, recover, and persist need to be defined. To address the
first of these terms, two widely accepted definitions of stuttering are presented in
section 1.2. Following this, the standard method for assessing the severity of stut-
tering is described (Riley’s, 1994, Stuttering Severity Instrument, SSI-3; a fourth
revision, SSI-4, has recently been produced, but is not currently in widespread
3
4 Recovery from Stuttering
use). Assessment of stuttering severity is required at the outset, as it has been used
to validate some of the assessment instruments used to determine persistence
and recovery. Also, severity might be implicated in persistence and recovery in
its own right. For example, it might be hypothesized that speakers with severe
problems persist in their stuttering while those with milder problems recover. A
thorough understanding of how to measure severity is essential in order to evalu-
ate hypotheses such as this.
This chapter then examines methods and procedural problems associated
with studies into the persistence and recovery of stuttering that are operationally
defined (section 1.3). Generally speaking, designs of studies that track individuals
over a period of time (longitudinal) and determine persistence or recovery at the
end of the period are preferred over other, less robust, methods for obtaining simi-
lar information (e.g., retrospective studies). This is because there are drawbacks
to retrospective studies because, although it can be verified whether a person per-
sists in stuttering, usually it cannot be confirmed whether a “recovered” person
did, in fact, stutter in the first instance. This and other issues about the various
measures and designs used to investigate these phenomena are discussed. One
of the problems faced by longitudinal designs is practicality. Following children
for long periods of time is difficult and expensive to conduct. The problem has
been made somewhat more tractable by investigating different subranges over
the period that most recovery happens. The logic of such approaches and their
drawbacks are considered.
As stated above, stuttering severity instruments, such as SSI-3, have been used
in development and validation of methods that are used on longitudinal data to
classify individuals as persistent or recovered. Two of these methods are described
in section 1.4 after the essential information about severity measurement has been
presented. The first of these methods, developed and described most recently by
Yairi and Ambrose (2005), is appropriate for younger children who stutter (from
onset of the disorder in early childhood to about age 8). The second was devel-
oped by my team (Howell, Davis, & Williams, 2008a) for use with older children
who stutter (8 to teenage years). The chapter finishes with a discussion about
attrition, which conceivably could be a problem if it biased the sample that is
studied. Consequently, when examining longitudinal data, it is important to know
what the attrition rate is and whether this might affect results. For instance, are
the individuals who withdraw from an investigation different in some way from
those who continue in the study? The methods used to characterize persistent and
recovered stutterers allow epidemiological studies into stuttering to be described
and evaluated; the epidemiological studies are discussed in Chapter 2.
1.2 Definitions of Stuttering
Despite many years of research, it may be surprising to learn that there is no
definitive method of determining whether a child stutters or is language fluent.
In most cases where a child stutters, there are indications of stuttering in the
child’s speech attempts. Some of these children also have problems in social or
Definitions, Stuttering Severity, and Categorization Instruments 5
emotional adjustment. The speech symptoms and other features that may help
determine whether or not a child is stuttering are shown in some of the classic
definitions of stuttering, such as the following two.
The American Psychiatric Association in its Diagnostic and Statistical Manual
of Mental Disorders (DSM) gives a definition of stuttering that emphasizes that
speech is a feature of stuttering. DSM version IV Text Revision (American
Psychiatric Association, 2000, p. 67) characterizes stuttering in terms of “fre-
quent repetitions or prolongations of sounds or syllables”). DSM-IV-TR discusses
the speech symptoms of stuttering, whether speakers who stutter differ in fre-
quency and/or severity of these symptoms relative to fluent speakers and speak-
ers with other disorders, and what happens over the period of time that speakers
recover or persist in the disorder.
Caution is necessary. Although it has been stated that a child attending a clinic
who is suspected of stuttering usually presents with overt speech difficulties, this
is not always the case. Thus, for instance, some children who stutter avoid speak-
ing in public. In acute cases, such children can meet all but one of the criteria for a
diagnosis of selective mutism (Howell, 2007a). The one criterion they do not meet
is that a child cannot be classified as a selective mute if he or she stutters (APA,
2000). This criterion is only included as a way of separating the two disorders
(Howell, 2007a), not as an inherent characteristic of mutism. The example shows
that different disorders can be confused to some degree with stuttering as they
can have similar diagnostic profiles. As another example, Wingate (2002, p. 50)
discusses the similarity between stuttering and tic disorders, although the simi-
larity between these disorders has also been disputed.
The emphasis on speech as a defining characteristic of stuttering, which is a
feature of DSM-IV, is also a feature of Wingate’s well-respected “standard” defini-
tion of stuttering (Wingate, 1964, p. 488). His definition has seven separate interre-
lated, elements that are arranged under three headings, and is given in full below:
I. (a) Disruption in the fluency of verbal expression, which is (b) characterized by
involuntary, audible or silent, repetitions or prolongations in the utterance of short
speech elements, namely: sounds, syllables, and words of one syllable. These dis-
ruptions (c) usually occur frequently or are marked in character and (d) are not
readily controllable.
II. Sometimes the disruptions are (e) accompanied by accessory activities involving
the speech apparatus, related or unrelated body structures, or stereotyped speech
utterances. These activities give the appearance of being speech-related struggle.
III. Also, there are not infrequently (f) indications or report of the presence of an
emotional state, ranging from a general condition of “excitement” or “tension” to
more specific emotions of a negative nature, such as fear, embarrassment, irritation,
or the like. (g) The immediate source of stuttering is some incoordination expressed
in the peripheral speech mechanism; the ultimate cause is presently unknown and
may be complex or compound.
Although Wingate’s emphasis was on speech, he also recognized “accessory
activity” and problems of socioemotional adjustment. Accessory features are acts
6 Recovery from Stuttering
that do not necessarily involve speaking and Wingate (2002) suggests they are
idiosyncratic. Wingate gives a list of accessory features (p. 46), which includes
all the “physical concomitants” that Riley (1994) uses in calculating an SSI-3
score, so the two terms refer to the same features (Riley’s work is considered later
in this chapter). Like DSM-IV and Wingate (1964), the present book emphasizes
speech–language characteristics as symptoms of stuttering. Motor coordination
abilities of speakers who stutter are also documented, which appear under (g) in
Wingate’s scheme. In this volume, following common usage in psychology, the
factors referring to the experience of emotion are termed affect. Although it is
recognized that people who stutter may differ in affect relative to fluent speak-
ers, these aspects are difficult to measure in children and it is not clear whether
affect factors are causes or effects of stuttering. For instance, it is not apparent
whether anxious people stutter or whether people are anxious because they stut-
ter. Comparatively little will be said about affect.
1.3 RileY’s Assessment of SeVeritY of Stuttering
Riley’s SSI-3 (1994) provided a measure of how seriously affected an individual
is by stuttering. As mentioned, SSI-4 has recently appeared. It is beginning to
be used, but no studies to date have reported results with this version. It will be
used more widely in the future and Riley has ensured that SSI-4 is downward
compatible with SSI-3 (so results with SSI-3 are valid). Severity estimates in the
current edition of this book all refer to SSI-3. Along with its application to esti-
mating severity of stuttering, Riley (1994) considers that SSI-3 also can be used
as part of the diagnostic process as well as for estimating severity, but mentions
that such decisions need to be augmented by other information. This includes
in-depth interviews with the person who stutters, direct observation about the
person, description of the person’s speech and language, interviews with parents,
reports of prior speech and language evaluations, audiological assessment, exam-
ination of medical records and reports, and interviews with teachers and other
professionals who have worked with the individual. Although SSI-3 is not a diag-
nostic instrument per se, most peer-reviewed articles report SSI-3 estimates for
participants who stutter and even for fluent controls in some cases (Davis, Shisca,
& Howell, 2007). SSI-3 has been standardized for U.S. and U.K. English. It has
also been translated into, although not necessarily standardized for, many other
languages. An important use of SSI-3 in connection with the issue of recovery
from stuttering is that it has been employed to validate instruments specifically
designed to classify participants who have provided longitudinal data from age
8 to teenage years as persistent or recovered (these investigations are described
later in this chapter).
1.3.1 ADMINISTRaTION OF SSI-3
SSI-3 can be administered to children and adults. Assessment for adults and
children who can read involves obtaining samples of elicited and read speech.
