Stuttering (Stammering)

What is Stuttering (Stammering)?

Stuttering, also known as stammering, is a condition that affects a person’s flow and rhythm of speech. People stuttering can experience pauses, hesitations, or repeat parts of words or sounds while speaking. Even when their voice-producing parts work properly, they have trouble maintaining smooth and continuous speech. Fluent speech, meaning the ability to speak smoothly and easily, is a complicated process. It requires the perfect choice of words and well-coordinated actions of various muscles including those involved in breathing, voice production, and speech articulation. Keeping up the flow of speech involves complex brain mechanisms which help in formulating language, proper pronunciation, and desired intonation.

There are two main types of stuttering: developmental and acquired. People who stutter often find it hard to maintain the flow of their speech despite knowing exactly what they want to say. They may also blink their eyes rapidly or their lips might shake, making it even harder to communicate. This can impact their personal relationships and their quality of life.

Being able to speak fluently is an important part of growing up and cognitive development in humans. Children in preschool often have difficulty speaking fluently as they are still learning the intricate processes necessary for smooth speech. Some kids might show ‘disfluencies’ that are considered typical for their age and are expected to improve with time. However, it’s important to differentiate these from stutter-like disfluencies, which are signs of a speech disorder that may start in childhood.

Disfluencies might involve repeating words in sentences, like ‘I see, I see her’, while stutter-like disfluencies tend to involve repeating a single word or part of a word, like ‘her-her-her’ or ‘w-w-want’. Disfluencies might also include interjections, like ‘oh’, or changing phrases mid-sentence. Stutter-like disfluencies also include instances like pausing within words, blocking the flow of speech, and prolonging sounds. Stutter-like disfluencies could continue into adolescence and adulthood.

Regardless of the reasons behind it, stuttering can significantly affect a person’s life, including job opportunities and career advancement. Therefore, it’s important to recognize and treat stuttering promptly to manage the condition effectively.

What Causes Stuttering (Stammering)?

Stuttering happens due to two main reasons: it’s either developmental or acquired. Developmental stuttering is more common and it happens in young children when they are still learning to speak. When a child’s speaking abilities can’t meet with their demand to express themselves, they might stutter. Some genetic disorders like Prader-Willi syndrome, Down syndrome, and Fragile X syndrome can also cause stuttering. With acquired stuttering, it happens later in life due to several reasons.

Acquired stuttering can be divided further into neurogenic, psychogenic, and drug-induced types. Neurogenic stuttering occurs when a part of the brain that controls speech gets damaged. This could be from a stroke, a traumatic brain injury, brain diseases, Parkinson’s disease, multiple sclerosis, epilepsy, and others. A person’s stuttering pattern might vary since different parts of the brain can be affected. Interestingly, stuttering is more common when the left side of the brain, typically responsible for language, is impacted.

Psychogenic stuttering is classified as a mental health disorder; psychological symptoms leading to physical ones. For stuttering to be considered psychogenic, the changes in speech need to be linked to an emotional issue. Also, this type of stuttering normally happens with other mental health problems and the stuttering reactions aren’t consistent in different situations.

Drug-induced stuttering happens when certain drugs cause a person to stutter. Some mechanisms that can cause stuttering include increased dopamine levels, decreased GABA levels, medications with anticholinergic properties, and drugs affecting serotonin levels. Interestingly, while some medications may cause stuttering in some individuals, they might alleviate it in others. Instances of stuttering have been reported with stimulants, antidepressants, anti-seizure medications, montelukast, asenapine, and guanfacine.

Genetic factors in developmental stuttering have been researched for several years. At present, a few genes have been identified. However, these genes collectively account for less than 20% of persistent stuttering. These genes help to target enzymes in the lysosome, an organelle in the cell. Meanwhile, a new gene related to stuttering has been discovered in a family who inherit stuttering. This gene relates to heat shock proteins, which play a crucial role in cellular functions. Regardless, further investigation is necessary to know more about how this gene might cause stuttering.

Risk Factors and Frequency for Stuttering (Stammering)

Stuttering is a common condition that affects roughly 80 million people worldwide and poses a considerable challenge for healthcare providers. The rate at which stuttering occurs depends on its root cause, and there are several different types:

• Developmental stuttering is also called childhood-onset fluency disorder and is the most common type of stuttering. This condition primarily affects children aged 2 to 6, with roughly 5% to 10% of preschoolers being affected. While the consistently reported lifetime occurrence is 5%, recent data suggests it may be nearer to 10%. While many cases of developmental stuttering eventually resolve, about 1% of adults experience persistent stuttering.
• Neurogenic stuttering is not well-understood and the data on it are incomplete. Most of the current research comes from individual case reports or small series of cases. While it’s generally thought to be a rare form of stuttering, disparities between reported instances and clinical observations question this. It is commonly seen in adults and affects men more than women, with the reported gender ratios varying from 2:1 to 10:1.
• Psychogenic stuttering has a gender ratio that is more balanced than neurogenic stuttering. However, compared to organic stuttering, men greatly outnumber women with a ratio of 3:1. This type of stuttering is often seen in tandem with functional movement disorders, making it one of the most reported functional speech disorders in this patient group.
• Pharmacological stuttering is extremely rare. As of May 2020, there were only 724 cases reported in the World Health Organization’s global individual case Safety Reports database (VigiBase).

Signs and Symptoms of Stuttering (Stammering)

Talking about stuttering and closely observing how a person speaks are two very important steps doctors use to better understand stuttering and the behaviors associated with it. This is very helpful in telling different causes of stuttering apart.

When doctors look at stuttering that develops during childhood and continues into adulthood, they look out for certain signs:

• Stuttering or other speaking difficulties usually happening at the start of sentences.
• A person’s speech becomes smoother after reading the same thing multiple times, a phenomenon known as the “adaptation effect”.
• Stuttering lessens or disappears when a person sings or speaks in unison with others, a phenomenon better known as the “choral effect”.
• A greater chance of stuttering with longer and more complex sentences.
• New behaviors associated with stuttering start to appear.
• Negative reactions related to stuttering and these related behaviors.

Prolonged stuttering can lead to new behaviors like strange facial expressions and movements of the head or jaw, which people use to try and reduce their stuttering. However, these behaviors can cause negative reactions, resulting in more stress for people who stutter. Therefore, doctors need to be aware of this during evaluations.

Stuttering that starts in adulthood can begin suddenly after an injury (neurogenic stuttering) or due to psychological causes (psychogenic stuttering), and it can start at any age. A recent neurological event like a stroke usually comes before neurogenic stuttering, and other symptoms such as shaking, headaches, problems with coordination, or weakness on one side of the body can help doctors confirm the diagnosis.

When doctors look at neurogenic stuttering, they watch for these characteristics:

• Repeating sounds and syllables
• Stops in speech, which can occur anywhere, though not as commonly as in developmental stuttering
• No change in stuttering after reading the same material multiple times
• Predictability of stuttering with different speech tasks such as talking, reading, and repeating
• Signs of other speech disorders along with stuttering
• Associated behaviors like blinking and making faces are rare, and if they do occur, they are not usually connected to active stuttering
• The person may struggle with the stuttering, but habitual or repeated speech does not usually cause anxiety.

When doctors look at psychogenic stuttering, they take these factors into account:

• Sudden start
• Uniformity of stuttering in different tasks, such as conversation, reading, and repetition
• Saying words in a halting manner, no matter where in the speech it occurs
• Unusual voice quality
• Lack of signs suggesting a problem with the nervous system
• No other speech or language disorders, such as dysarthria
• An improvement in fluency after expressing emotions
• Persistent stuttering even in situations that would typically reduce it
• Unusual body movements and signs of nervousness not related to speech
• Use of broken English, for example, “me not well”
• Consistency or excessive changes in stuttering patterns

Because neurogenic and psychogenic stuttering have similarities, telling them apart can be quite difficult. This is why it’s important to check for any mention of emotional distress when taking a patient’s medical history.

Doctors can find out more about stuttering by getting a detailed personal history and talking with the person who stutters and those close to them. They can ask about their experiences and feelings about stuttering and what they hope to gain from treatment. Information about speech, language, temperament, and other relevant areas can be acquired through standardized tests, questionnaires, and observations, especially in younger children. Reviewing a patient’s medication history is also crucial, as some drugs that affect the brain might cause stuttering.

Testing for Stuttering (Stammering)

When a person is believed to be stuttering, doctors conduct a careful and complete review by asking detailed questions about the person’s medical history. This is followed by various assessments to confirm if the person is indeed stuttering, understand the cause of the stutter, note any negative effects, and understand the individual’s concerns. These findings then help the doctors to plan the best treatment.

In 2021, experts agreed on six crucial areas that need to be checked during a stuttering evaluation. These involve using a variety of tools like questionnaires and tests across different assessment areas:

• Gathering case history.
• Interviewing the person who stutters and people who are important in their life.
• Observing how the person speaks and how fluent they are in different situations.
• Screening and testing of language and speech development, general temperament, hearing, and any other relevant capabilities.
• Studying their stuttering behavior and understanding their response to stuttering and its impacts.
• Identifying any risk factors.

Doctors evaluate how a person stutters and their behavior during episodes of stuttering. As stuttering can be different for each person, speaking across various tasks and settings is useful in understanding the individual’s specific stuttering patterns. Inputs from people close to the patient can give more details about the stuttering.

Various standardized tests and scoring systems are used to measure how severely a person stutters, like the Stuttering Severity Instrument and the Speech Situation Checklist. The latter has separate tests for speech disturbance and emotional reaction.

Doctors also consider how the person and others react to the stuttering. Those who stutter may alter their behavior or make decisions based on their stuttering and how they think others will react. This can negatively affect their interactions with others and their confidence. Speaking about areas such as anticipation, coping strategies, and behaviors to avoid stuttering is important. Also, doctors should investigate any reports of being bullied because of the stutter or other negative reactions.

Another important aspect is understanding how stuttering affects a person’s life, including work, education, social interaction, and overall life quality. Standardized tests like the Overall Assessment of the Speaker’s Experience of Stuttering (OASES) and Wright and Ayre Stuttering Self-rating Profile (WASSP) are helpful tools for determining this.

Testing must always be personalized to match each person’s unique needs and circumstances. No two people are the same, so there’s no “one size fits all” approach. Once case reviews and assessments are complete, goals are set together with the person who stutters to determine successful therapy outcomes.

In addition to an in-depth stuttering assessment, it’s critical to rule out a neurological cause for the stuttering, a condition known as ‘neurogenic stuttering’, with a comprehensive neurological examination. Brain scans such as computed tomography or magnetic resonance imaging may be helpful in this regard. Any cognitive issues (difficulties with thinking, reasoning) might give doctors clues on the possible location of any brain damage.

No matter what’s causing the stutter, it’s essential to consider a psychiatric evaluation and counseling for the mental health impacts that stuttering can cause. This is important for preventing future mental health issues and for ruling out ‘psychogenic stuttering’, a rare psychological condition where emotional distress causes stuttering.

Treatment Options for Stuttering (Stammering)

Treatment plans should always align with the goals and concerns of the patient. If a child is showing signs of stuttering, whether reported by parents or noticed during medical check-ups, the child should be sent to see a speech and language specialist. Referrals become more urgent if the stuttering persists for a year or more, or if the stuttering seems to be getting worse over time.

Usually, speech therapy is started early on in children to take advantage of the brain’s ability to change and adapt. The goal of therapy is to help the brain compensate, and hopefully eliminate the stuttering. Starting therapy early can help the child avoid developing negative associations with speaking and socializing, which are common among individuals who have been stuttering for a long time.

If a person continues to stutter into adulthood, therapy would focus on managing any other behaviors related to stuttering, developing effective compensation techniques, helping the person accept their stuttering, and regaining control of their speech. A variety of speech and behavioral therapies are available, each one designed to suit the patient’s needs. However, for some reason, medications don’t seem to be effective in treating stuttering.

Speech therapies for stuttering can be divided into two categories: direct and indirect. Indirect therapy tries to create an environment that promotes fluent speech and tries to remove factors that interfere with speech fluency. On the other hand, direct therapy works with the stuttering person directly, focusing on speech fluency and other negative effects of stuttering.

There are many types of therapies used for stuttering. Some of these therapies include the Lidcombe program, which involves training parents to praise the child’s fluent speech, and the RESTART-DCM treatment, which helps parents make changes in the home environment to help reduce the child’s stuttering. The Palin PC treatment focuses on interaction strategies and family-based approaches, and the family-focused treatment approach improves communication and comprehension between parents and children.

Sometimes, stuttering might be caused by something other than the typical developmental process in children. For instance, stuttering can be neurogenic, which means it is caused by trauma or damage to the nervous system. For this type of stuttering, medication – alongside speech therapy – might be used. Some of the types of medications used for treating neurogenic stuttering include haloperidol, chlorpromazine, trifluoperazine, thioridazine, carbamazepine, sodium valproate, levetiracetam, risperidone, and olanzapine. Though these medicines may be beneficial, they can have side effects and are not usually the first choice of treatment. Speech therapy remains the main treatment for stuttering of all types.

There’s also something called functional stuttering, which is typically diagnosed after other physical causes have been ruled out. In this case, most of the treatment will focus on speech and language therapy. It is also important to reassure the patient that there’s no underlying brain condition causing the stuttering. Partnerships between the patient and the speech- language therapist help them understand the nature of the condition and manage it. This understanding can also help the patient explain their situation to others. If stuttering is caused by a medication, the best approach to treatment would be to stop or adjust the dosage of the medication under a doctor’s guidance.

What else can Stuttering (Stammering) be?

It’s important to understand that developmental stuttering is different from the usual hesitations and repetitions in speech that kids often have. Health professionals can tell the difference between these types of stuttering by watching and assessing the child’s speech and understanding their medical history.

It’s not always straightforward to identify neurogenic stuttering (a stutter caused by issues in the nervous system) because it might present similarly to other conditions that affect speech. These can include disorders like:

• Tourette syndrome
• Palilalia (repeating your own words or sounds)
• Dysarthria (trouble articulating words)
• Apraxia of speech (difficulty making the correct movements when speaking)
• Anomia (trouble naming objects) and
• Aphasia (difficulty with understanding or producing speech).

Furthermore, neurogenic stuttering can be mistaken for other speech disorders that are related to brain function. A thorough understanding of stuttering disorders is absolutely necessary to correctly identify and differentiate the various forms of stuttering.

What to expect with Stuttering (Stammering)

Generally speaking, children who start to stutter at a young age have a good chance of stopping as they grow, with 65% to 87% of young children showing improvement regardless of whether they receive treatment. This is primarily due to neural plasticity, or the brain’s ability to change and adapt as it learns.

However, as we age, our brains become less flexible, or “plastic.” So, older individuals who still stutter often have less chance of complete recovery.

There are different types of stuttering. For example, psychogenic stuttering, which is related to stress or psychological factors, tends to improve quickly once therapy starts. On the other hand, neurogenic stuttering, which is caused by brain damage or neurological issues, generally takes more time and the improvements can fluctuate and may not be as significant.

Possible Complications When Diagnosed with Stuttering (Stammering)

People who stutter often use heightened speech preparation as a coping mechanism for their stutter. They pay extra attention to their speaking, though stress can make their stuttering worse. Starting to stutter can make a person anxious, making it more difficult for them to consciously control their speech, thus making the stuttering worse. This can form a cycle where anxiety and stuttering keep worsening each other.

Children who stutter might limit their social interaction, which could affect their social growth and decrease their overall speech. Adults who stutter can be seen negatively by those who speak fluently and viewed as quiet, lacking self-assuredness, and uneasy. Research in the United States shows that stuttering can negatively impact success in careers and education. One research showed that stuttering had a negative effect on work performance and job satisfaction.

Negative reactions to stuttering can lead to anxiety, depression, and a negative self-image in those who stutter. Children who stutter might face bullying and mockery, which adds to their difficulties. Additionally, there’s been a link found between stuttering and increased thoughts of suicide.

In situations where stuttering begins in adulthood, it’s crucial to quickly find the underlying cause and adjust treatment accordingly.

Common Effects and Risks Associated With Stuttering:

• Heightened speech preparation
• Increase in anxiety
• Limited social interaction and verbal output in children
• Negative perceptions in adults
• Negative impact on career and education
• Anxiety, depression, and negative self perception
• Bullying and teasing for children
• Increased thoughts of suicide

Preventing Stuttering (Stammering)

Doctors should take the time to explain everything about stuttering to the patient thoroughly. They should make it clear that a condition known as childhood-onset fluency disorder, which is often the cause of stuttering, is due to a developmental issue in the brain. This means that if a person stutters, it’s not their fault.

It’s also important for doctors to talk to the people around the patient about how to best support and help people who stutter. They should inform the patient that a variety of treatments can help with stuttering. The treatment plan will be personalized, aiming at addressing the patient’s specific needs. Hence, it’s vital for the patient to openly discuss their concerns and hopes regarding their stuttering treatment.

Some patients might be unsure about needing mental health therapy. It’s the doctor’s responsibility to help them understand the significance of these treatments. The doctor should explain how these treatments can potentially improve their day-to-day life substantially.