Understanding variability in stuttering

The recent study, which observed 143 speech language pathologists (SLPs) who reported practicing and being certified in the United States, found clinicians consistently observed changes in a client’s stuttering from appointment to appointment, but generalist practitioners were more likely to rely on reactive management than their expert counterparts. 

The study was conducted by researchers at Charles Darwin University (CDU) and Michigan State University (MSU).

Dr Hamid Karimi is a course coordinator and lecturer in speech pathology at CDU. 

“Stuttering is a neurodevelopmental condition affecting almost 8% of children and 1% of adults. Variability of stuttering is a major source of frustration and concern for people who stutter, and their families,” said Dr Karimi.

“We found that both generalists and experts recognised variability, but that experts were more likely to view variability in stuttering holistically, not just as changes in speech fluency, but also changes in emotions, changing in confidence, avoidance, and even participation of people who stutter in everyday life activities.”

“That broader perspective can shape how assessment and treatment can be carried out.”

More than words

Dr Kamiri said that stuttering variability — which refers to changes in the way people stutter, such as increases in disfluency — is ultimately about the holistic experience of stuttering.

“At a surface level, I might have some repetition of some of the words. So the number of times that I repeated myself, and the more severe, the amount of time that it takes me to finish repetition, might be one aspect of variability.”

“The other aspect is how my feelings about myself, as a person who has a stutter, might change over time.”

“I might be more interested in talking at some times, but not at others. There might be a specific situation that I prefer to avoid due to my perception of my condition, and my previous experience of interacting with people.” 

“A more holistic view is seeing how stuttering affects emotions and social reactions.”

Dr Karimi said that variability may cause emotional reactions such as anger, guilt, or frustration, both for people who stutter and also for caregivers.

“These happen over time, due to the perceptions that we have about ourselves and reactions from those around us, including bullying, teasing, or comments. Sometimes some people want to help us by completing our sentences. These reactions might add extra layers of difficulty and complexity to our disfluency and cause lots of emotional and cognitive aspects to stuttering.”

The study found that experts usually pay more attention to holistic aspects of stuttering.

Experience leads to a holistic view

Dr Karimi highlighted three main findings from the research.

“Firstly: stuttering is not static, and clinicians know that. All clinicians, regardless of their level of expertise, have seen variability in stuttering.”

“Second, variability goes beyond speech disruptions. It also affects emotions, beliefs, and everyday participation in people who stutter.” 

“Those who have more experience of working with people who stutter can see this more holistically, and can see changes in emotions, changes in beliefs, and changes in participation of people who stutter, compared to those with less experience working with people who stutter.”

“Third — and perhaps most importantly — experts tend to use variability as clinically meaningful information. They consider it as something that they can use to the benefit of the person who stutters, to discover how stuttering is for that specific person, and work as a scientist-clinician who works with the person who stutters to discover what factors might affect the stuttering, and how they can deal with those factors.”

“At the same time, they can understand and accept it, rather than see it as something to fight against all the time; as something that people accept as normal variation, as many of us have good days and bad days.”

Deep cognitive-emotional roots

Dr Karimi refers to the deep cognitive-emotional roots of stuttering, and how the research points to an opportunity to look more holistically at the effects of stuttering.

“Over time, people may develop beliefs, expectations, fears, or emotional reactions shaped by years of communication experiences.”

“Those deeper layers can be more stable than moment-to-moment speech variability, and they often influence how a person lives with stuttering.”

“If you study preschool-age children who stutter — because we know that 95% of people who stutter develop stuttering between the ages of 2 and 4 — in people at this age, there is no difference between the number of people who stutter and those who do not stutter, in terms of them having an anxiety disorder, for example.”

“But around teenage age, and especially in adults, the probability of having uncommitted social anxiety disorder increases significantly.”

“And that's mostly because of the reactions that people receive about their stuttering in everyday life. And also their self-perception as a person who stutters.” 

“It has a very clear root in their beliefs and emotions, sometimes they prefer not to talk in specific situations, and sometimes they have some beliefs about themselves that with stuttering you cannot be successful.”

Dr Karimi said there is a lot of evidence showing that cognitive behavioural therapy conducted by a psychologist, alongside treatment from an SLP for stuttering, means that relapse can be less likely.

“We can improve care when we broaden how we think about stuttering. It's not only as a speech disorder but as a variable human experience. Perhaps the biggest public message is that variability in stuttering is normal. It doesn't mean something is failing and it should not be mistaken for lack of progress.”

Gaining visibility and acceptance

Dr Karimi said that it’s important to improve opportunities for speech therapists in training to work with people who stutter. 

“Speech pathology is a very broad area. The next step is how universities can improve their training, and give students more opportunity to work with people who stutter in simulated settings, and in real settings with real clients.”

“At CDU, we are working on our program. So we have introduced multiple simulation scenarios and simulation clinic opportunities for our students to practice with different types of communication disorders.”

Dr Karimi and his team have done several studies (here and here) on how stuttering is represented on social media, and says that stuttering is gaining visibility.

“We also have a treatment which is called the Lidcombe Program, developed in Australia, which has the highest level of evidence for treatment of stuttering in pre-school age children.”

“I should emphasise that Australia is one of the countries most well-known for contributing to knowledge about the stuttering assessment and treatment globally during the last 50 years. I'm very optimistic about that.”