Fluency refers to the rate and rhythm, or the flow, of speech. Disorders of fluency have different names, and the definition of each may vary slightly depending on the context in which it is used.
Stuttering is probably the most common term used to describe speaking disfluency. Stuttering refers to disruptions of fluency which can be described as hesitations, repetitions, or prolongations of speech sounds. It is estimated that about 1% of the general population experience this problem (Shames, 1986, p. 246). Stammering is another term that is used to describe disorders of speaking fluency. It is synonymous with stuttering in most contexts, although the majority of professional literature uses the term stuttering.
Developmental disfluency appears between the ages of two and four, with four percent to five percent of the population affected (Zebrowski, 2003). The ratio is approximately equal between girls and boys, but girls are more likely to regain fluency. The rate of males to females who continue to experience disfluency is three to one. Males are more likely to have additional communication disorders (Blood, et al., 2003).
Stuttering is often accompanied by secondary symptoms. Persons who are disfluent may experience eye blinking, facial grimacing, postural abnormalities, and patting themselves (usually on the leg). Some times the 'patting' can be strong enough to leave bruises. It is the secondary symptoms that are sometimes more disconcerting to the listener than the disfluencies of speech.
Cluttering is another term used to describe fluency disruptions. Cluttering is usually less severe than stuttering in that it is characterized by words and sounds being omitted. Those who clutter usually speak at a rate that is more rapid than the normal speaking rate. Cluttering is much less common than stuttering, and is often associated with a neurological disorder, such as a stroke, or other types of brain disfunction.
All of us are disfluent at times. Often the person who is labeled a “stutterer” has no more disfluencies than others, but is identified as such because the person demonstrates an emotional reaction when a disfluency occurs. Persons who stutter do not experience disfluency when they sing or during choral reading. The presence of a structure in the speaking situation encourages fluency.
There are many theories as to the reason individuals become disfluent. I'll emphasize from the start that none of the theories are more than that; they are just theories. No one theory is predominant in the literature. Skinner and Shelton (1985) suggested "Few disorders are as intriguing or perplexing as those involving disruption of the fluent flow of speech" (p. 307).
Early literature noted that persons who were disfluent were more likely to be left-handed. Also, clinical observation for patients with stroke or head trauma over the years suggest that the left hemisphere of the brain is dominant for speech and language. These findings lead to the suggestion that fluency might be the result of neither hemisphere being dominant for language (Orton & Travis, 1929). The rationale is as follows: When one hemisphere is dominant, the neurological control to the speech mechanism is decisive. We have left and right sides for most movement of the body, but the musculature involved in the production of speech is on the midline. If neither side is dominant, each side may send conflicting messages to the muscles resulting in disfluency.
This can be likened to the driver of an automobile getting conflicting directions from other persons in the car. He steers whichever way the one giving instructions tells him, which can result in less than a smooth trip.
Research has not given significant support to this theory. However, there is still much that is not known about the workings of the nervous system. The characteristics of disfluency (repetition, hesitations) are suggestions of a “confusion” of the controlling nervous system. So, the concept of conflicting neurological control still has attractive face value.
The characteristics of fluency that suggest a confusion, or disorganization, of neurological activity to the speech mechanism have also been related to the basic disfunction of the neurophysiological processes (West, 1958). An act of disfluency may be viewed as a temporary breakdown in the organization of the nervous system, similar to the motor disorganization that accompanies a seizure. This observation lead persons in the field to theorize that disfluency was the result of temporary breakdown in the nervous system that controls speech.
While research has shown that there may be differences in blood chemistry and brain wave activity between those who are disfluent and those who have normal fluency, the evidence is not convincing (Bloodstein, 1975). It is equally believable to suggest that the changes in neurophysiological activities are the result of stuttering, rather than its cause.
One of the obvious factors observed in clinical work is that often there are other family members who are disfluent. It is not unusual for parents to be disfluent, more often the father. Also, it is common for stuttering to be reported for uncles of individuals who stutter. Based on the higher incidence of relatives who stutter, we can predict that a child will be more likely to stutter. However, here we are faced with another dilemma, which is "is the disfluency a genetic trait, or does the child learn to be disfluent from the model in his environment?"
Stuttering has a history of treatment by persons with background in psychology/psychiatry as well as speech-language pathology. Theories that claim a psychological basis for disfluency suggest the disfluency is a means of dealing with life, e.g., using it as a defense mechanism, a form of control, a way of repressing feelings, or an approach-avoidance conflict to speaking. I doubt that anyone who has worked with persons who stutter would have any doubts that there is a great deal of anxiety and emotion attached to the act of disfluent speaking. However, the cyclic nature of logic associated with disfluency again asserts itself. Is the person disfluent because of the anxiety, or is the anxiety the result of the act of being disfluent? Treatments with psychological bases have not been demonstrated to be more effective than other treatments, and there is a lack of evidence to support the general theory of psychological causes (Goldstein, 1958).
We have learned that persons who have fluency problems can learn to be more fluent in structured behavioral management situations (Flanagan, Goldiamond, & Azrin, 1958). If fluency can be learned, then it follows that disfluency can be learned. Learning takes place as a result of feedback from our environment. Children who are in anxious situations are more likely to be disfluent. For example, the child who breaks a dish may be disfluent when confronted with the evidence.
Most children demonstrate a significant amount of disfluency while learning to speak. It can be suggested that children may learn to be disfluent in an environment in which the persons around them expect them to be disfluent. This theory grew from the observation that often disfluent children have parents who place strong demands on them to achieve (Johnson, 1961). The development of the speech of a child is a major milestone and one which might be interpreted to be a predictor of later achievement. The child who does not develop speech according to the schedule the parents feel appropriate may find parents making corrections and indicating disappointment in response to the child's efforts.
Disfluency may become the focus of criticism and family members may make strong efforts to correct it, not realizing that almost all young children have disfluent periods while they learn the organization of speech and language. The attention called to the disfluency may create anxiety toward speech and cause the child to be disfluent in response to the expectations of the parents.
This theory draws some support from the success of treatment with younger children. Disfluency will normally be reduced significantly if the family can be taught to reduce the anxiety associated with speaking and to be more accepting of a child's speech.
As is the case with other theories, this theory also lacks research support. However, research would be difficult as it would be unethical to conduct an experiment to determine if a child can be made to stutter. We have to base the findings on events that have already occurred and for which we cannot validate the data. Also, if the theory is completely true, all children coming from such an environment would stutter. This is not the case. Not all children who grow up in a demanding home become disfluent.
We still do not know the underlying mechanisms that cause persons to be disfluent. Disfluency is a heavily researched area, but results are far from conclusive in determining causes. There are probably many different conditions that can cause an individual to be disfluent. As the following case reports will suggest, disfluency is a unique phenomenon.
The following are three experiences that I have had in dealing with individuals with disorders of fluency. They may not be 'typical,' but they reflect the broad spectrum of types of fluency problems. The names and incidental information have been changed for obvious reasons.
The first case history I'll report here is of two brothers. My work with them was early in my career and what I learned working with them helped to shape my reactions to disfluency. Ricky and Randy were two grades apart in elementary school, fourth and sixth. They were referred by their teachers because both exhibited consistent patterns of moderate disfluency. By consistent I mean they had about the same degree of disfluency regardless of the time of day or speaking circumstance. Anxious situations raised the disfluency slightly, but no more so than would be the case for a normal speaker.
Their disfluencies were very similar. There was a lot of sound and word repetition, but few blocks or prolongations. Their speech rate was slightly on the slow side, but not to the point of being distracting. They were easily understood, and the disfluency they experienced was not accompanied by any show of anxiety or concern. They were extremely likable kids, very awkward and 'clutzy', and almost always happy.
Treatment took place in a school system where I saw them twice a week. They came to treatment together and we started the program by discussing their disfluency. Both were aware that they had trouble getting words out, but had a difficult time understanding why it was a problem. They had no trouble communicating with others, their parents weren't concerned, and they were well liked. It was only by getting them to look ahead to what they might face in the adult world that I was able to generate any motivation for making changes.
As was the usual case in my early years as a clinician, I launched into the treatment program fully focused on erasing the communication disorder and not looking as carefully as I should for contributing causes. We did many of the accepted techniques of the day; pull-outs (sustaining phonation to terminate or “pull out” of a moment of disfluency), negative practice (speaking with disfluency on purpose to try to learn to control it better), breath control (sustained breathing while talking), among others, and achieved good results. At least in the treatment room. By the end of almost every session I would rejoice in the fact that they were speaking with a high degree of fluency, only to see an immediate return to the disfluent pattern as soon as they were out the door at the end of the period.
We tried to get generalization by making book marks, posters, cards to be place on mirrors at home and taped to bicycles which reminded them "SPEAK SMOOTH." It was our motto. They became very "smooth" speakers with me, but generalization to the real world came painfully slow. By the end of the academic year the teachers reported an observable decrease in the degree of disfluency, but it was still noticeable.
It concerned me that the year had come and gone and the problem had not been corrected. It was only then that I did what I should have done at the beginning of the program, which was collect more information. In this case, collecting more information meant making a visit to their home.
They lived with their mother and father and had many relatives in the area. The parents were as likeable as the kids, and listened with genuine concern as I talked about what we had tried to do during the year.
Their father said little until I finished. Then he described the problems he had with speech at their age, which were remarkably similar. He still had some disfluency in his speech, identical in characteristics to that of his sons. He reported that two of their uncles spoke the same way, and they all sounded like his own father who had the same disfluencies. It was a part of the family history. Their mother confirmed this. They said they had encouraged the boys to speak as clearly and fluently as possible, and I believe they had.
I left that meeting with a fresh appreciation for the influence of the family on communication skills of children. It must have been difficult for the boys to see what all the fuss was about when their role models in life spoke the same way. I met with the boys the following year, but with a different focus to treatment. I knew they could be more fluent when paying attention to their speech, so we discussed the importance of fluency in different situations and identified situations in which they should take extra care to monitor themselves.
Susan came to the clinic with her mother. She was referred by her elementary school teacher, who felt Susan's speech was becoming progressively more disfluent. Susan was the only child in a single parent family. She was a pleasant 12 year-old whose disfluency during the evaluation could be described as mild to moderate. She was doing well in school, had friends, and participated in an expected amount of extracurricular activities. She had been disfluent from early childhood, with some periods during which she was more fluent than others. Her mother had come to accept the disfluency, but was concerned because of the school's referral and because she had also noticed the speech becoming increasingly more disfluent.
Susan was passing through puberty with all the accompanying anxieties, but she seemed to be well balanced for her age and situation. The notable aspect of her disfluency was its inconsistency. It was reported that she would be fluent for days, and then become noticeably disfluent. There did not seem to be a clear trigger to the disfluency, although both the school personnel and her mother agreed that she was more likely to be disfluent in anxious situations (such as before a test). This, too, appeared to be inconsistent.
I worked with Susan a few weeks and found her to be an excellent learner. We discussed the problem in a straightforward manner and talked about ways of dealing with it in equally open terms. She was bright and motivated, but not overly concerned with her disfluency. Her friends accepted her and disfluency did not seem to have a particularly negative effect on her life. She knew that her mother and teacher were concerned, and she was trying to become more fluent to please them.
Susan responded well to the treatment, which was basically teaching breathing for speech and monitoring for disfluencies. Within a few weeks she was completely fluent when at the clinic. We followed up with generalization exercises and had short meetings every week. The intent was to gradually increase the periods between sessions, as long as she was fluent.
However, establishing consistent fluency tended to be elusive. As before, she would do very well for a period of days, and sometimes even weeks, then the disfluency would return. She continued to be completely fluent when I worked with her at the clinic.
As I got to know Susan better, I felt that the disfluency was related to something bothering her, or perhaps stated in more professional terms, some unresolved conflict. She was one of those persons who seemed to have a cloud following her. She was not disfluent in our sessions, so I turned our direction in them to talking about her and how she felt about things in life.
Because she was an open and honest type of person, it didn't take long to find the major unresolved conflict in her life, which was her father. Her parents had divorced when she was six years old. She had not understood the problems of the marriage, and was increasingly uneasy about the relationship with her father. She could recall only generally his physical characteristics, but she remembered that she had loved him and when they were separated it was painful for her. She was at an age at which she wanted to get to know her father, but was unsure how to approach the situation. Her mother never spoke of her father and Susan learned early on after the divorce that her mother would react negatively when Susan started talking about her father. Because of this, she had not spoken with her mother about her father since soon after the divorce.
I spoke with the mother about the father and the divorce (separately from Susan, of course) and found that there had been major conflicts between the two of them. The divorce was bitter, and though the father had visitation rights, Susan's mother had moved away with Susan soon after the divorce so visitation would be difficult. She also made it clear to the father that she did not think it was in Susan's best interest for him to maintain contact and he respected her wishes.
When I asked about Susan's relationship with her father, the mother indicated that he had been a good father and one of the most difficult parts of ending the marriage was breaking the relationship between him and Susan. The mother felt it would be in Susan's best interest to have a 'clean break' and not look back. She also knew that if he continued to see Susan, she would have to deal with him and she felt that would aggravate the situation.
It is time for another 'aside' discussion, as way of explanation. I have only a minor in psychology, and am well aware of my limitations as a counselor. Most professionals in my field are well trained in the communication sciences, but not in dealing with personal or family situations. We normally tread lightly in those areas and only become involved when it affects the course of treatment for the communication disorder. However, I have come to believe that anyone who deals with any populations with handicapping conditions should have a strong background in dealing with family and person situations. A communication difference of any kind causes an individual to react differently to the world around them, and obviously communication difficulties evoke a significant difference in how the world reacts to the person with the difficulty. This spills over into the family relationships. Any kind of handicapping conditions creates a strain on the whole family and is very often going to create conflicts in personal and family relationships.
Back to Susan and her mother. I began spending half of each session with Susan's mother, mainly letting her do the talking about Susan. My main goal, however, was to direct the discussion to Susan's father. Many of the wounds of the divorce seemed to have healed, and after a while Susan's mother talked about her ex-husband with a degree of objectivity that was credible. The conflicts of the marriage appeared to be one related to differences in basic beliefs, rather than negative characteristics. He had been a good provider, a good father, and not abusive to either her or Susan. He had provided financial support for the child since the time of the divorce.
Gradually Susan's mother came to accept the possibility that Susan's feelings about her father could be a part of the problem. She indicated that she would be willing to try to re-establish contact with him, if it was in Susan's best interest. We decided together that there would be no way to know what the outcome would be, but it was worth a try to re-establish it.
The mother talked with Susan about calling her father on her birthday. The mother reported to me that Susan thought it was a good idea, but was nonchalant in reaction to the suggestion. In the following session with me, however, Susan was anything but nonchalant. She was very excited, to the point I was afraid the actual event might not meet her expectations.
The call went well. Susan's mother had spoken to the father about the reason for calling and Susan's problem with fluency. The father was delighted to have the contact. The calls became a monthly event that had a very positive affect on Susan. Her mother was accepting of the situation, and committed to encourage the relationship, although she, herself, was not enthusiastic about contact with her former spouse.
I met with Susan every week, then every two weeks, throughout the rest of the year. Her fluency in school was consistently good, with only slight disfluency in situations which were identifiably anxiety provoking (again, just before a big test). There had been no more major periods of disfluency. The last session time I saw her she was in great spirits. She was going to spend part of her summer vacation with her father. It was her dream come-true.
Looking back on the experience, I don't believe the results would have been as successful if Susan had come in at an earlier time. By the time she did come in, the marriage and divorce was almost a thing of the past. Her mother had established a new life for herself and the anger generated by the marriage was pretty much spent. Because of this, Susan’s mother was able to deal with Susan re-establishing a relationship with her father. At an earlier time, she might not have been capable of accepting that.
This points out the fact that a myriad of circumstances come into play in the development and maintenance of a communication disorder. The success those of us who work with communication disorders experience is often mediated by the circumstances under which the client lives.
Jack came to our speech and hearing clinic to participate in an experimental regimen of treatment that we were developing in our speech and hearing science laboratory. He was a college student with a likeable appearance and demeanor. Jack had the most severe stuttering problem I had ever encountered. During the initial session of approximately an hour, he uttered no more than a dozen complete words. Most of his communication was written. When he did try to speak, it was with a great deal of anxiety and anguish. It seemed to build to a certain point at which he resigned himself to the fact that he was not going to get the message out. At that point he would sigh, relax, and start writing the message.
I worked directly with Jack for the first six months. Initially we put him on a program of delayed auditory feedback (DAF). While now a commonly available clinical tool, DAF was just beginning to be used and we were not sure exactly how to apply it.
DAF works in the following manner. The client speaks into a microphone that is plugged into a tape recorder/player. Speech is recorded and played back to the speaker through headphones after a slight delay. The headphones help to block out the real time speech, so the speech the person produced is heard after a delay. The delay can be set to any length of time, normally in tenths of a second.
When normally fluent people speak under DAF, it generally disrupts their speech. A delay of about .2 second will produce a maximum disruption. We are used to hearing ourselves in real time, meaning we hear what we say at the time we say it. When we hear ourselves on DAF, it disrupts the feedback loop that controls speech and we experience disfluency. Repetitions, prolongations, and hesitations, all of the characteristics of stuttering usually occur.
If you are reading this book as a part of an academic course, I hope your instructor has access to a DAF unit so you can experience talking under delayed auditory feedback. It is without a doubt the experience that best simulates what it is like to have a true disfluency.
Now back to the story of Jack. Jack was a conscientious client who came to every session, was always on time, and worked diligently at whatever task he was assigned. During the DAF training time he was placed in a sound treated booth by himself. We monitored his speech on the outside of the booth. To increase his awareness, we switched on a small light in his field of vision to signal when he was being fluent, and switched it off for a period of time when a disfluency occurred. The DAF forced him to slow his rate and develop a steady rhythm to his speech.
He responded well to this treatment and after several weeks we changed to having him speak in time to a metronome. The metronome provides a 'beat' or rhythm for speech that helps many persons with disfluency speak more fluently.
A few weeks on the metronome yielded even more improvement and we began spending more time in face-to-face treatment, discussing fluency and ways of dealing with it. Much of this was devoted to developing conscious control of sustained breathing.
Breathing for the normal purpose of gas exchange is under control of the autonomic nervous system. The period of time for inhalation and exhalation is about 50%-50% for life support. Speech, however, requires a more rapid inhalation and sustained exhalation. The inhalation to exhalation portion changes dramatically. Inhalation is only about 10% and exhalation is 90%. Breathing for speech is under control of the voluntary nervous system.
Jack responded well to all instructions and was achieving a level of fluency that allowed us to get to know him as an individual. He was a loner, extremely intelligent, and possessed a sharp wit. He was generally cynical about human nature and the way the world works. Students in training worked with him for a good amount of the treatment time and we found he was very quick to pick up on the least trace of insincerity or lack of commitment on the part of students with whom he worked. He generally tried to please us and seemed to enjoy our company. Perhaps it was gratitude for having persons who understood his problem and helped him deal with it. He did have a distinct dark side, telling us that the world was not a great place and as soon as he could legally buy a gun, he was going to do so and shoot himself. The idea of a person waiting until he could legally purchase a gun to commit suicide always drew a laugh from the new person working with him.
Jack was a sophomore majoring in a science and was carrying close to an A average in his courses. One of his primary concerns was not being able to talk in classes. He indicated that he often had the answer when the professor asked the class a question, but didn't respond because of fear of stuttering. He had aspirations of getting a teaching assistantship in graduate school, which, of course, would require a degree of fluency.
After six months Jack was fluent enough to begin generalization work. Generalization exercises consisted of several activities in which Jack used speech in more normal every day speaking situations. One such exercise was having persons with whom he was not familiar sit in the session with us. Speaking with strangers is anxiety provoking and something the person who is disfluent must learn to deal with. Another activity was making telephone calls to different agencies and asking questions on the telephone. The telephone is another anxiety situation for persons who are disfluent. Then we would go to businesses where he would ask sales people questions.
A few months of these types of exercises and he was fluent in almost all situations. He reported that he had begun responding in class and on occasion had gone to the chalkboard to write out and explain an equation. He reported still having a lot of anxiety, but felt in control of his speech. I can remember the pride we felt for him when he reported going on his first date as a college student. We even got a smile from his usually serious face when he told us about it.
One area in which we did not get cooperation from Jack was in counseling. Our intent was to have all persons who participated in our treatment regimen also attend counseling. The reason for this is that many persons who have disfluent speech also have problems that are emotional in nature. As indicated earlier, there is a great deal of speculation about whether the disfluency causes the emotional distress, or the emotional distress causes the disfluency. The best guess is that they are mutually reinforcing of one another.
We referred all of the fluency clients in this program to the university health clinic. This was because our own clinic was affiliated with a university and there would be no cost to our clients. Jack went two or three times and then stopped. He claimed first that the times the clinic scheduled him were inconvenient. We worked this out with the clinic, but found that he stopped again. When we asked him about why he was not going to counseling, he said that his counselor was really not interested in him. Because he was doing so well in treatment, we overlooked the counseling portion of his treatment.
I knew Jack over a three-year period. After working with him directly in the initial stages, I usually was the supervisor for students to whom he was later assigned. He was released after two years as his speaking fluency was well within normal limits.
Jack continued to come to my office a couple of times a month just to visit. My concern lessened over time as his speech became almost totally fluent. He was still very anxious about disfluency, but felt in control of it. I completed my doctoral studies during this time and took a position at another university. We had a long talk about how well he had done and how far he would go in life. I could tell him honestly that he was one of the most intelligent persons I had every known. He was in line for a teaching assistantship in graduate school and could not have been doing better.
Less than a year after I left, I received a letter from a former student who had worked with Jack at the university. She reported that on his twenty-first birthday, the first day he could legally do so, he bought a pistol and committed suicide.
I cannot reflect on this happening without a great deal of regret, remorse, and guilt. The fact that I will never know what happened, and the fact that I obviously did not do something that I should have to prevent it, will always haunts me. I have a strong belief in the sanctity of life, and I cannot imagine the motivations that cause people to take their own lives. In this case the signs were there and those of us who worked with him missed them. As the individual who was closest to him in the treatment program, I should have recognized the fact that disfluent speech was only part of the problem, and the development of fluent speech was nowhere near meeting his total needs.
As you have read the cases I have just presented, I hope have developed feeling for the uniqueness of each. That may well be the hallmark of disfluency. There is a wide range of types and degrees of disfluency. Likewise, there appears to be a wide range of etiologies. There is still a great deal to learn about fluency differences, but there is little doubt that the final analysis will still reflect a case-to-case uniqueness.
First of all, it is important to remember the above lesson about persons with fluency differences. They are all different. Fluency differences exist across age and gender and know no social boundaries. Persons with fluency differences are persons first of all, and getting to know them as people is important. And it may be difficult to get to know them. Many people with fluency differences avoid talking. It will take a patient person to break through the barrier.
If you really want to develop empathy for persons with fluency differences, try the following. Go to a busy fast-food restaurant and place an order using speech that is disfluent. Practice ahead of time to make it as convincing as possible. Have someone go with you and watch the reactions of the restaurant personnel and the other customers. Do this one time and you will experience a microcosm of the world of the person with a fluency difference.