Introduction

I stuttered severely. I needed an hour to say what a non-stutterer could say in five minutes. I could block on a word for five minutes.

My speech wasn't just slow. I jerked my head, rolled my eyes, and my body shook in spasms. Some listeners asked if I needed medical attention. More often they laughed at me.

Worst, my speech was incomprehensible. Listeners guessed what I was trying to say, usually wrong. Or they ignored me and walked away.

I'm now forty-four. People ask me to speak at events. I perform acting and stand-up comedy. In stressful conversations I sound confident and relaxed. And I still stutter.

Wait a minute! How can I stutter and have listeners say that it's a pleasure to hear me speak? Let me tell you about some other stutterers.

Demosthenes stuttered, and became the greatest orator of ancient Greece. Winston Churchill and Aneurin Bevan were the best orators in the British Parliament in the 1930s and 1940s. Both men stuttered.

James Earl Jones, John Stossel, Bruce Willis, Nicholas Brendan, Mel Tillis, Carly Simon, and hundreds of other actors, singers, politicians, and business leaders have stuttered.

Not many paraplegics win marathons. Few blind persons become famous painters. Not a lot of deaf persons are great musicians.

But stuttering is a different kind of disability. Treating stuttering trains you to improve your speech. You'll learn to handle stressful situations calmly. You'll learn to relax your breathing and your voice. Years after reading this book, you'll look back over many life successes and say that stuttering was a gift.

Developmental Disorders

Stuttering isn't a physical disorder. It's not a psychological disorder. Stuttering is a developmental disorder. The primary reason that adults stutter is that we stuttered as children.

Children grow up in a certain order. They crawl before they walk. They walk before they run. They run before they ride bicycles. They ride bicycles before they borrow your car keys.

Usually. Some children walk before they crawl. My three-year-old nephew borrows my car all the time. Just joking. I don't own a car.

At each stage of physical development, a child's brain develops too. For example, crawling helps the child develop communication between the left and right hemispheres of his brain. If all goes well, the child's physical, neurological, and psychological systems develop together.

A small, sometimes imperceptible, developmental misstep in early childhood can nudge a child off the normal developmental track. The child then grows on an abnormal developmental track. A minor problem can develop into a major disability as the child grows up.

Language-Learning Impairment

Another developmental communications disorder is better understood than stuttering. Children with language-learning impairment (LLI, also called specific language impairment or SLI) experience difficulties in understanding and producing spoken language despite normal intelligence, normal hearing, and normal opportunities to learn language.

LLI results when a child can't hear the difference between short duration speech sounds. The difference between /b/ and /d/ sounds occurs within a few milliseconds (thousands of a second). Some children's brains' auditory processing isn't fast enough to hear fast speech sounds. To these kids, "bad" and "dad" are the same word, "bug" and "dug" are the same, and so are "buck" and "duck." This is a form of central auditory processing disorder, or CAPD.

You'd think this would be a minor problem. After all, you know the difference between "sew" and "so." But it's not a minor problem. These children develop speech slower than other children. Slow speech development causes them to miss other developmental stages. Their grammar develops poorly. Listeners have difficulty understanding these children's speech. These children understand the difference between boys and girls, but interchange "he" and "she." They mix up past, present, and future tense.

Then these children are labeled mentally retarded, even though they're normal or even excel at non-language activities (e.g., building with Legos). They're put into special ed classes, with children who really are mentally retarded.

The children miss more developmental stages. As adults, these individuals may be unable to read, or have poor social skills, or be unable to work at more than menial jobs.

Ten years ago a treatment was developed for LLI. These children can distinguish /b/ from /d/ if the words are slowed down. Children with LLI now play a computer game that trains them to hear the difference between short-duration speech sounds.

When their auditory dysfunction is corrected, the children develop normally. The children usually catch up with their peers, e.g., advancing four reading grade levels in six months.

Analogously, children's brains are like a railroad going from New York to Los Angeles. A little dysfunction can bump a child onto a sidetrack. The sidetrack may start out only a few feet from the main track, but twenty years later he's lost somewhere in South America. Treatment is like giving the child a shove back onto the main railroad track. The child then zooms ahead to catch up with his peers.

Factors that Contribute to Stuttering

Functional brain scans show three abnormalities during stuttering:

• Overactive motor (muscle movement) areas.
• Underactive auditory processing areas.
• Speech-related brain areas that typically have left-hemisphere dominance in fluent speakers are active bilaterally or with right-hemisphere dominance in stutterers.

Anatomical brain scans of stutterers have found abnormalities in the left hemisphere superior temporal gyrus (the location of the primary auditory cortex and Wernicke's area, associated with speech and language processing ) and Rolandic operculum (the location of Broca's area, associated with speech production).

All brain scan studies have examined adult male stutterers. We don't know whether some children are born with these abnormali-ties, which then cause stuttering; or if children have normal brain activity and anatomy when they begin stuttering, and stuttering causes their brains to develop (grow) abnormally.

These results suggest that stuttering doesn't have a single cause, but rather several factors contribute to stuttering. Two of the three functional brain abnormalities correspond roughly to treatments for stuttering; the third is more ambiguous.

Speech Motor Overactivity

Stutterers overtense their respiration (breathing); vocal folds; and lips, jaws, and tongues (articulators). These overtense muscles lock up or fail to coordinate, making speech impossible. Fluency shaping therapy (page 28) trains stutterers to speak with relaxed speech production muscles, to counteract our overactive speech motor activity. You learn to consciously relax your breathing; vocal folds; and lips, jaw, and tongue. That's relatively easy. The following chapter ("Beyond Fluency Shaping," page 57) is about the more difÞcult task of making this ßuent speech automatic and effortless.

The neurotransmitter dopamine is related to motor activity. Dopamine antagonist medications diminish stuttering. These treatments are presented in the chapter "Anti-Stuttering Medications" (page 100).

Auditory Processing Underactivity

Like LLI, stuttering appears to be related to a central auditory processing disorder.

Changes in how stutterers hear our voice, such as choral speech and anti-stuttering devices (page 11) appear to correct the auditory processing underactivity associated with stuttering.

Right Hemisphere Lateralization

The anomalous lateralization doesn't yet have a clear explanation. The right frontal operculum may relate to production and perception of vocal fundamental frequency, which is a key part of fluency shaping therapy (e.g., "easy onsets" or "gentle onsets").

But similar frontal operculum activity is seen in Tourette's syndrome (see pages 100, 122), so perhaps this brain activity relates to features common to both disorders. For example, both disorders tend to decrease when a person is relaxed, but increase when the person experiences certain types of stress. The chapter "Responding to Stress" (page 76) describes how our brains unconsciously select different ways of speaking (speech motor parameters) depending on environmental cues. That chapter also presents treatments to help you make this process conscious, so that you can choose to speak ßuently in situations that previously caused you to stutter.

The brain's right hemisphere is generally associated with emotions (the left hemisphere is associated more with logic and reasoning). Possibly the abnormal right-hemisphere activity indicates emotional activity associated with stuttering. For some individuals, speech-related fears and anxieties are more disabling than their physical stuttering. Some individuals use stuttering as an excuse for deeper psychological problems. Some individuals obsessively try to hide their stuttering, e.g., counterproductively refusing to go to speech therapy for fear that someone may see them entering the speech clinic. The chapter "Psychological Issues" (page 107) addresses these feelings, attitudes, and other emotions.

Multifactoral Treatment and Additional Factors

Speech-language pathologists usually treat one or more of three factors: speech motor skills, stress management, and/or psycho-logical counseling. Electronic anti-stuttering devices treat one or two factors: auditory processing and/or speech motor skills. Dopamine-antagonist medications treat one factor. You may have to go to several speech clinics, and possibly buy an electronic device or get a medication prescription, to treat all of the factors that contribute to your stuttering.

I expect that additional stuttering factors will be discovered. Future advances will also include be treatments for co-existing conditions. E.g., a child with stuttering and phonological dysfunc-tion will be treated differently than a child with stuttering and ADHD. An adult with stuttering and social phobia will be treated differently from an outgoing mentally retarded adult who stutters.

What is Stuttering?

Speech begins with breathing, also called respiration. Your lungs fill with air, more air than you would inhale if you weren't talking. You expand your upper chest and your diaphragm (belly) to get all this air in. Your lung pressure and respiration muscle tension increase.

Next, you release air through your throat, past your vocal folds (also called vocal cords). Your vocal folds are a pair of small muscles in your larynx. If you tense these muscles slightly, and release a little air, your vocal folds vibrate. This is called phonation. It's also called the fundamental frequency of your voice. If you place your fingers on the front of your throat, then hum or talk, you can feel your vocal folds vibrating.

Adult men vibrate their vocal folds about 125 Hz (125 times per second). Women vibrate their vocal folds about 200 Hz. Children's voices are even higher. This is too fast for your brain to control. Vocal fold vibraÂtion is the only muscle activity that your brain doesn't directly control. Instead, phonation results from the coordination of respiration muscles to release air with slight tensing of your vocal fold muscles.

The key word in that last sentence was coordination. Stuttering is largely a disorder of poorly coordinated speech production muscles.

If you tense your vocal folds too much, you block off your throat and stop air from escaping your lungs. This is a good when lifting heavy weights. By blocking your larynx and tensing your respiration muscles, you increase lung pressure, which strengthens your chest and you can lift more weight. Similarly, tires inflated to high pressure can carry a heavier car. But that's what stutterers do when they talk, and it's not a good idea.

The space in your throat above your larynx is called the pharynx. Above your pharynx are your oral and nasal cavities. These spaces create vocal resonation. This is like the echoing of a cathedral or tunnel. The unique shape of these spaces makes each of our voices sound unique.

Your jaw and lips and tongue, collectively called the articulation muscles, modify your voice into intelligible speech.

Vowels and voiced consonants (such as /b/ and /d/) are produced by your vocal folds, and modified by your articulation muscles (jaw, lips, tongue).

Other consonants are voiceless, such as /p/ and /t/, produced by your articulation muscles modifying airflow, without your vocal folds vibrating. When you whisper, you don't vibrate your vocal folds. You just modify airflow with your articulation muscles.

Speech requires coordination of over 100 muscles. The average person speaks about 150 words per minute. Each word requires a different configuration of most of those muscles. Speech is our most complex neuromuscular activity.

Core Stuttering Behaviors

Core stuttering behaviors include:

• Disordered breathing, including antagonism between abdominal (belly) and thoracic (upper chest) respiratory muscles; complete cessation of breathing, and interrupting exhalation with inhalation.
• Disordered vocal folds, including high levels of muscle activity or muscle tension; poor laryngeal muscle timing, such as starting phonation too late or holding tension too long; and poor coordination of laryngeal muscles, e.g., incompatible contractions of opposing muscles.
• Disordered articulation, including dysfunctions of the lips, jaw, and tongue in stuttering. In general, stutterers place their articulators in the right positions (in contrast to other speech disorders such as lisping), but time the movements wrong.
• Low-frequency tremors in the neck, jaw, and lip muscles of adult stutterers. These are found to a lesser extent in older children, and not found in young children who stutter.

Secondary Stuttering Behaviors

Secondary stuttering behaviors are unrelated to speech production:

• Physical movements such as eye-blinking, forehead wrinkling, sudden exhaustion of breath, frowning, or nostril quivering.
• Gross (large) muscle movements such as head jerks or slapping one's thigh in an attempt to release a vocal fold block or other overtense speech-production muscle.
• Fear of certain words or sounds, avoidance of feared words, substitution of another word, or postponement of a feared word by adding pauses or filler words.
• Interjected "starter" sounds and words, such as "um," "ah," "you know," or "in other words."
• Repeating a sentence or phrase "to get a running start."
• Vocal abnormalities to prevent stuttering, such as speaking in a rapid monotone, affecting an accent, or using odd inflections.
• Looking away, not maintaining eye contact.
• Articulating an unrelated sound, e.g., forming a /t/ sound when trying to say /s/.

Secondary behaviors may help you get around stuttering at first, but then lose their effectiveness. The secondary behavior is then retained out of habit.

Incidence and Prevalence

About 2.5% of preschool children stutter now (prevalence). The incidence of preschool stuttering is about 5%. In other words, about one in twenty of children stutter at some point in childhood.

Less than 1% of adults stutter. 0.73%, or about one in 135 adults, was the figure found in a recent study. That suggests that about two million Americans stutter. On the other hand:

• The largest stuttering therapy program, the National Center for Stuttering, has treated about 10,000 stutterers.
• The second-largest stuttering therapy program, the Hollins Communication Research Institute, treats 180Ð200 stutterers a year. Founded in 1972, HCRI has treated about 5,000 stutterers.
• Other stuttering therapy programs are much smaller. Less than 400 speech-language pathologists are board-certified Fluency Specialists. Most treat only a handful of adult stutterers each year.
• About 2500 Edinburgh Masker anti-stuttering devices were sold in the United States in the 1980s. My company and one other company have each sold about three thousand anti-stuttering devices.
• The National Stuttering Association has between two and three thousand members. The biggest stuttering support e-mail list has about three thousand members.

How many stutterers have you met? You likely hear thousands of people talking every year. Outside of speech clinics, support groups, etc., I've met three or four stutterers in my life. These numbers suggest that there may be about 20,000 adult stutterers, not two million.

A Wikibook and a Discussion Forum

I put a version of this book on the Wikibooks website. The Stuttering Wikibook is longer than No Miracle Cures. With zero cost for paper or printing, there was no reason to leave out material of interest to only a few individuals, e.g., stuttering therapy for mentally retarded individuals.

The wikibook includes hyperlinks to related material, e.g., a link to an article about Tourette's syndrome.

The wikibook includes criticism. In No Miracle Cures, if I felt that a popular theory was wrong, I left it out. In the wikibook, I included the theory, and then detailed why it's wrong.

Most important, the wikibook is interactive. You can add material, correct my mistakes, or even edit any part of the book. What matters isn't whether I got every fact right or referenced every study. What matters is that you can fix my mistakes.

Certain chapters are set up to encourage reader participation. For example, the chapter "How We Treat Stuttering" encourages speech-language pathologists to describe what they do. The chapters "What Worked For Me" and "My Life in Stuttering" encourage stutterers to add material.

And every page has a discussion area. You just click on a tab to ask questions or make comments.

And No Miracle Cures has its own discussion forum. That's the place to ask any questions you have while reading this book.

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