Recent brain scan research has found abnormalities in the brains of stutterers, and promises new treatments for stuttering using drugs and computerized devices. No differences between stutterers and non-stutterers have been found during silent rest (Ingham, 1996). During fluent speech, stutterers’ brains look similar to non-stutterers’ brains. But during stuttering, cerebral activity changes dramatically. The most striking difference is that left-hemisphere areas active during normal speech become less active, and areas in the right hemisphere not normally active during speech become active (Braun, 1997; Ingham, 1997).
This abnormal right-hemisphere dominance has produced a variety of speculative hypotheses from researchers. Note that brain scans can show relative activity in different areas of the brain, but can’t show what the person is thinking or what each area is doing. Researchers often hypothesize on the functions of various brain areas, but this is at best educated speculation. One hypothesis is that there is something wrong with stutterers’ left-brain speech areas, and so right-brain areas not developed for speech take over. This seems unlikely, given that most stutterers are capable of normal, fluent speech in some conditions. Another hypothesis is that the right-hemisphere activity is the fears and anxieties that stutterers experience, generated by the limbic and paralimbic structures.
But these areas don’t seem to be abnormally active during stuttering. Another hypothesis is base on the decreased central auditory processing during stuttering seen in all studies (Wu, 1995; Fox, 1996; Ingham, 1997). One study also found decreased activity in the area that integrates auditory and somatic (body) sensation (Braun, 1997). These are all rear-brain areas. The researchers hypothesized that stuttering reduces this rear-brain sensory processing, and reduces the left-brain communication of this sensory information to frontal speech and language areas. The abnormal right-brain activity may be an alternative pathway for rear-brain sensory information to travel to the front of the brain.
Another team of researchers believes that the key to stuttering lies in the different functions of the lateral and medial systems (Goldberg, 1985; Maguire, 1997). The lateral system is part of the cortex, where our consciousness is, and we have conscious awareness and control of lateral functions. This area produces and understands language (Wernicke’s area), forms words (Broca’s area), and forms muscle movements (supplementary motor areas). These areas can produce speech under closed-loop motor control. Even severe stutterers can speak fluently under closed-loop motor control, but high attention demands and abnormally-slow speech (Shea, 1993) make this an undesirable way to talk. Another closed-loop motor activity is threading a needle — and talking under closed-loop motor control takes as much attention and is as slow as threading a needle. The medial or striatal system produces open-loop or normal speech.
This system includes the caudate and putamen. Preprogrammed motor programs are retrieved from long-term memory and executed, without sensory feedback. Open-loop control can produce rapid movements, with little or no attention. The disadvantage is that there’s no error regulation — if your speech motor programs contain stuttering, you’ll continue stuttering rather than correct your speech. Open-loop motor control responds to stimuli, without conscious thought. Stutterers can speak fluently in certain situations, such as speaking to a pet, but when they experience stimuli such as time pressure or speak to an authority figure, their medial systems pull stuttering speech motor programs from long-term memory.
Stutterers have decreased medial system activity during both stuttering and fluent speech (chorus reading). They have decreased lateral system activity during stuttering, and increased lateral activity during fluent speech (Wu, 1997). Glyndon Riley, Joseph Wu, and Gerald Maguire (1997) propose that the medial system is affected by the D2 dopamine modulation system. This includes the substantia nigra and its circuit to the striatum. Dopamine is the neurotransmitter that produces alertness, motivation, and mental acuity. In stutterers, excess dopamine may reach the striatum and reduce activation, making these areas less effective. The dopamine system may explain why stutterers have “good days,” when they easily speak fluently, and “bad days,” when they can’t get a word out without a hard block.
Dopamine levels vary with diet and other factors. A study of three genes that control dopamine in persons with Tourette’s Syndrome and their relatives found that these genes correlate with attention deficit hyperactive disorder (ADHD), stuttering, and Tourette’s Syndrome (Comings, 1996). Riley, Wu, and Maguire point out that stuttering therapy works almost entirely with the lateral system, teaching stutterers to consciously control their speech, stuttering behaviors, and/or feeling and attitudes. The result too often is fluency in the speech clinic, when the stutterer is paying close attention to his speech, but when he returns to his usual environmental, cues to stutter cause him to lose control of his speech.
But because stuttering occurs in the medial system, they suggest developing therapies that work on the medial system. They suggest drug treatments, but electronic anti-stuttering devices also effect the medial system. The drug treatments are discussed in the next chapter, Drug Treatments for Stuttering. Delayed auditory feedback (DAF) electronic devices have been used to treat stuttering for over 30 years.
The stutterer hears his speech in the headphones with a long delay, which forces the stutterer into closed-loop speech motor control, producing slow but fluent speech. More recently, researchers have explored short delays, which reduce stuttering about 75-80% without training, mental effort, or abnormal-sounding or slow speech. These researchers also discovered that shifting the frequency of the stutterer’s voice in his headphones (FAF) produces the same effect (Kalinowski, 1993, 1994, 1995; Ingham, 1997; Zimmerman, 1997). Electroencephalograph (EEG) brain scans found that DAF and FAF reduce right-hemisphere cerebral activity (Kalinowski, 1997). Apparently — and this is another speculative model — the rear-brain sensory areas notice that the auditory and somatic sensations are not matching. Extra blood flow is devoted to these areas, correcting stutterers’ deficient auditory processing and integration.
This information is sent with a “red flag” to the frontal speech and language areas. But the frontal areas don’t check frequencies, and are too slow to detect a short delay, so they “OK” the information and your speech is not disrupted. The result is extra information for improved motor control and fluent speech. Future stuttering therapies may begin with drugs and electronic devices to get the stutterer fluent, and then continue with retraining speech motor programs and reconditionStuttering Modification Therapy Stuttering: Science, Therapy & PracticeStuttering modification therapy is primarily associated with Charles Van Riper. The therapy is also associated with Oliver Bloodstein, Edward Conture, and Joseph Sheehan. These men were stutterers, who became speech pathologists.
The goal of stuttering modification therapy is not to eliminate stuttering. Instead, the two goals are: 1. Modify your moments of stuttering, so that your stuttering is less severe. 2. Reduce your fear of stuttering, and eliminate avoidance behaviors associated with this fear.
The therapy has four phases: identification, desensitization, modification, and stabilization. Stuttering is a vicious cycle. In situations where you want to speak well you try too hard, tense your speech-production muscles, stutter, try harder, tense more, and stutter more. Stuttering modification therapy takes you out of this vicious cycle. When you stutter, you stop, sense what muscles are tense, relax these muscles, sense your fears and anxieties, eliminate these fears, and go on. This isn’t an instant cure for stuttering — making this reaction automatic takes years.
But as time goes on you stutter less and less. You begin by identifying the core behaviors, secondary behaviors, and feelings and attitudes that characterize your stuttering. Your speech pathologist points out your “easy or effortless stuttering” first. You learn to identify when you do these behaviors. The goal is to improve your awareness of what you do when you stutter.
Next, your speech pathologist trains you to identify and become aware of your avoidance behaviors, postponement behaviors, starting behaviors, word and sound fears, situation fears, core stuttering behaviors, and escape behaviors. Finally, you learn to identify feelings of frustration, shame, and hostility associated with your speech. At first, identifying these behaviors is done in the speech clinic. Later, your speech pathologist takes you out of the clinic, to identify what you do in everyday conversations.
Edward Conture suggests beginning the “identification” process with recordings of other stutterers, then moving to recording of your speech, and finally moving to identification as you talk. Van Riper called this “toughening the stutterer to his stuttering.” You do this in three stages. The goal is for you to become comfortable with all three of these aspects of your stuttering.
1. Confrontation, or accepting that you stutter. If you’ve read this far, you’ve probably accepted that you stutter.
But reading a book or enrolling in a therapy program is not enough. You are expected to tell people that you stutter, and talk about what you are doing in therapy to change your stuttering. 2. Freeze your core behaviors — repetitions, prolongations, and blocks. When you stutter, your speech pathologist raises a finger. You hold what you are doing, until she drops her finger.
For example, if you were repeating a syllable, you have to continue to repeat that syllable. Your speech pathologist will make you freeze these core behaviors for longer and longer periods. The goal is for you to become less emotional or more tolerant of these behaviors.
3. Voluntary stuttering, or stuttering on purpose. This helps you remain calm when you stutter. This is where you learn “easy stuttering” or “fluent stuttering,” in 3 stages: 1. Cancellations.
When you stutter, you stop, pause for a few seconds, and say the word again. You say the word slowly, with reduced articulatory pressure, and blending the sounds together. 2. Pull-outs. After you master freezing and cancellations, you use your “easy stuttering” while you are in a stutter, to pull yourself out of the stutter and say the word fluently. 3.
Preparatory sets. After mastering pull-outs, you look ahead to words you’re going to stutter on, and you use “easy stuttering” on those words. These techniques are difficult if you have severe physical stuttering. Some stutterers lack the vocal control to do these techniques.
Additionally, preparatory sets can reinforce your fears of certain words and sounds. The last stage of stuttering modification therapy seeks to stabilize or solidify your speech gains. This is accomplished through sub-goals: The first is for you to become your own speech therapist. You take responsibility for making your own assignments and prescribed therapy activities. “Becoming your own speech pathologist” doesn’t mean reading books about stuttering, taking a class, going to conventions, or learning about new research and therapies.
“Becoming your own speech pathologist” means motivating yourself to do therapy activities indefinitely. There’s a presumption that you wouldn’t do these therapy activities on your own, because you don’t perceive resulting benefits. You need a speech pathologist to get you to do the activities. Another sub-goal is “the automatization of preparatory sets and pull-outs.” Unfortunately, stuttering modification therapy was developed before motor learning theory. Stuttering modification therapies just tell you to practice, and don’t include any techniques to maximize autonomous motor learning. The last subgoal is for you to change your self-concept from being a person who stutters to being a person who speaks fluently most of the time but who occasionally stutters mildly.
Stuttering Modification Self-Therapy Stuttering modification can be done as self-therapy, as opposed to going to a speech clinic. There is an excellent book for this: Self-Therapy For The Stutterer, by Malcolm Fraser. The book is short and extremely easy to read. You work on your feelings and emotions, on relaxation, speaking slowly, stuttering easily, eliminating secondary behaviors and avoidances, listening to your voice, and talking more. You also do voluntary stuttering, cancellations and pull-outs.
I met a stutterer who bought the book, did the exercises, and was cured. I bought the book, tried to do the exercises, and wasn’t helped a bit. Hopefully you’ll have better luck. Your local library probably has the book. If not, it is available for $3 from the Stuttering Foundation of America, P.
O. Box 11749, Memphis, TN 38111-0749, 800/992-9392. Problems With Stuttering Modification Therapy One reviewer criticized this book for being “unbalanced” with more pages about fluency shaping therapy than about stuttering modification therapy. This edition corrects that problem, if you count the recommendation to read Malcolm Fraser’s Self-Therapy For The Stutterer as equivalent to the self-therapy chapter “Fluency Shaping Techniques.” This leaves the chapter “Problems with Fluency Shaping Therapy” without an analogous chapter about problems with stuttering modification therapy (aside from the minor criticisms included in this chapter).
There have been few published critiques of stuttering therapy programs, by other speech pathologists. The exceptions are the two papers referenced in the chapter “Problems With Fluency Shaping” (Kuhr and Perkins). To my knowledge, there have been no published critiques of stuttering modification therapies, so this book remains “unbalanced” in that respect. Whether this book is unbalanced for or against stuttering modification therapy or fluency shaping therapy I will leave to the book reviewers! ing psychological cues to stutter, reducing and then eliminating the stutterer’s reliance on the drugs and electronic devices. Bibliography: