Terminology – How should stuttering be defined? And why?
To be cited as: Irwin, M (2006). Terminology – How Should Stuttering be Defined? and Why? Published in J. Au-Yeung & M.M. Leahy (Eds.), Research, Treatment, and Self-Help in Fluency Disorders: New Horizons (pp. 41-45). Dublin: The International Fluency Association.
The word stuttering is currently used to describe dysfluent speech, a speech syndrome and the symptoms of a speech disorder. This is confusing resulting in difficulties with public awareness and professional communication. Existing dictionary definitions are very limited in scope, do not mention covert behaviour, and do not always cross reference stuttering with stammering. Academic definitions where they are comprehensive are also cumbersome and there is confusion between the terms covert features, covert symptoms, covert stuttering and interiorized stuttering. A new definition, classification and diagnostic term (Stuttered Speech Syndrome) are proposed. The aim is to provide clarity and allow stuttering to be more easily and accurately discussed from both the listeners and the speakers perspective.
A review of stuttering literature over the last 50 years shows the word stuttering to have a variety of meanings. Generally it is used to describe a type of dysfluent speech, but it is also used to describe a speech syndrome (Cooper, 1993) (Guntupalli et al., 2006) and also to describe symptoms of a speech disorder (Moore and Rigo, 1983). This leads to lack of clarity with stuttering definitions that in turn leads to difficulties with public awareness, difficulties in communication between members of the speech pathology profession, and difficulties in communication between speech pathologists and their clients. A commonly agreed and comprehensive definition would bring understanding as well as increasing the sophistication of diagnosis and appropriateness of applied treatment modalities to people who stutter. I use my own personal story in providing an example of how improved labeling and awareness would help diagnosis and treatment.
For many years I shared a classroom with a boy with an obvious stutter marked by repetitions and prolongations. This boy was teased but outwardly confident enough to ask questions in class. On the other hand I never voluntarily spoke in class knowing that if I tried to speak I would block. Occasionally I had to respond to questions and the occasional block would occur in spite of my attempts with substitution and circumlocution. My classmate was thought to have a severe stutter. I was not. If I did not have a severe stutter, then what did I have? Certainly my stutter/stammer was not described in a dictionary then or now, nor is it currently clearly described on the websites of the various stuttering associations throughout the world. Since this same situation affects many people who stutter, covert behaviour and associated phobic reactions need to be more closely connected to stuttering. Also it is also important to recognise that a covert stutterer’s speech pattern may remain even though there are no longer negative attitudinal and emotional reactions to stuttering. That is speech like other human activity becomes habitual and avoidance of certain words and sounds may remain even when there is no longer an inability to articulate them. It is clear an appreciation of covert stuttering by parents, teachers and speech language pathologists would also give guidance to the severity of the disorder, the consequent emotional impact and the need for counseling and therapy. A new definition of stuttering and the application of commonly used labels would go along way to achieving this awareness.
2. Current Situation
There is no doubt the current situation is limiting and confused. Little has happened since Culatta and Goldberg (1995) concluded that if 10 speech –language pathologists were put in a room, 11 different definitions of stuttering would emerge. This is largely because there is confusion over the term covert when applied to stuttering. Shapiro (1999) refers to covert as internalized thoughts and feelings. Gregory (1986) refers to covert features of stuttering as the expectation of difficulty and frustration, which lead to avoidance and inhibitory behaviours. Moore and Rigo (1983) refer to covert symptoms of stuttering and Guntupalli et al (2006) refer to covert forms of stuttering. In addition following the work of Douglas and Quarrington (1952) British commonwealth countries use the label “interiorized” to signify masked stutterers who are currently also referred to as covert or closet stutterers. However it is clear the covert features of expectation of difficulty and frustration mentioned by Shapiro and Gregory also may apply to both interiorized and exteriorized stammerers, and as such a clear distinction between covert features and covert behaviour needs to be drawn. That is covert behaviour is a speech event. The speaker avoids , substitutes or circumlocute as away to hide an overt stutter. On the other hand frustration and anticipation of difficulty are emotional reactions to speech events. It is not necessary to label these as covert features since we would expect emotions to be hidden from view. In any case the word covert is usually applied to give the meaning of secretive or deliberately hidden as opposed to the simple meaning of hidden. Describing emotional responses as covert introduces inaccuracy. Emotional responses may be covert if they are secretive or deliberately hidden, but they cannot be regarded as covert simply because they are not on view.
Also not all people who demonstrate covert stuttering behaviour will have negative emotional reactions consistent with diagnosis of social phobia, so a separation of these terms allows greater accuracy with diagnosis.
While dictionary definitions are expected to be limited it can be argued that the problems with current dictionary definitions in terms of public awareness of the stuttering condition are that they only define stuttering from the listeners perspective, they do not mention covert behaviour, or refer to the potentially negative emotional impact that stuttering has on the speaker. In addition they do not cross reference stutter and stammer. Consider two dictionary definitions as examples of this.
- Stutter -(verb) 1. to utter sounds in which the rhythm is interrupted by blocks or spasms, repetitions or prolongations of sounds or syllables, sometimes accompanied by facial contortions. -(noun) 2. distorted speech characterized principally by blocks or spasms interrupting the rhythm. (Macquarie Dictionary)
- Stammer –(verb) to speak with involuntary breaks and pauses or with spasmodic repetitions of syllables or sounds. (Oxford Dictionary)
Academic definitions while showing an understanding of stuttering are often either vague or cumbersome. They do not specifically mention covert stuttering and use very general terms when describing the attitudinal and emotional components. Examples with comments follow:
- “Stuttering is a diagnostic label referring to a clinical syndrome characterized most frequently by abnormal and persistent dysfluencies in speech accompanied by characteristic affective, behavioural and cognitive patterns. Cooper (1993, p.382)”. Comments: the characteristic affective, behavioural and cognitive patterns are not described. This is important because without it the statement is too vague as all human conscious behaviour has characteristic affective, behavioural and cognitive patterns.
- “Stuttering is the involuntary disruption of a continuing attempt to produce a spoken utterance. Perkins (1990, p.376)” Comments: There is no reference to covert behaviour (word avoidance substitution and circumlocution) which if used by the speaker results in no such disruption in a spoken utterance.
- “Stuttering is a disorder which affects the fluency of speech production. This may also affect the individuals attitude to communication and to themselves. Disorders of fluency are usually characterized by both overt features eg. blocking , and covert features eg. avoidance behaviours and feelings such as anxiety. RCSLT (1996, p.177)”. Comments: A distinction between the covert form of stuttering (word avoidance, substitution and circumlocution) and the covert features of avoidance and anxiety is not made.This is important since overt stuttering and covert stuttering may both be associated with avoidance behaviours and feelings such as anxiety.
- “Stuttering refers to individualized and involuntary interruptions in the forward flow of speech and learned reactions thereto interacting with and generating associated thoughts and feelings about one’s speech, oneself as a communicator, and the communicative world in which we live. Shapiro (1999, p.14)”. Comments: As with the previous definition there is no clear distinction between overt and covert stuttering. In addition there is no clear reference to the negative psychosocial impact of involuntary disruptions and the possibility that this negative psychosocial impact may not necessarily be present in all people who stutter.
In summary it seems:
- Dictionary definitions describe stuttering from the listeners perspective only.
- Most definitions do not cross reference stuttering and stammering.
- Many academic definitions do not directly mention covert behaviour
- There is confusion between covert features of stuttering and covert stuttering behaviour.
- Covert stuttering is a term not universally applied within the speech pathology profession
3. Suggested Criteria for a Definition of Stuttering
While it has traditionally been defined from the listeners perspective it is proposed there is benefit from defining stuttering from the speakers perspective. Considering this there are 3 types of stuttering which may or may not overlap, which can be said to be experienced by a speaker. These are 1. overt stuttering, 2. covert stuttering, and 3. stuttering with negative emotional and attitudinal reactions. These types of stuttering can be included in definitions while also including reference to stuttering the listener hears and sees. In addition the fact that stuttering and stammering have the same meaning is another worthwhile feature of the definition.
Therefore suggested criteria for an improved and universal definition of stuttering include the following.
- Describes overt and covert behaviour
- Describes secondary stuttering behaviour
- Describes Affective and Cognitive Component
- Links stuttering and stammering
- Uses plain (non-academic) English
4. A Proposed Definition
Stutter: (verb), to produce dysfluent speech characterized in overt form by repetitions, prolongations, blocks, or in covert form by word substitutions, avoidances and circumlocutions. (noun) a chronic speech impediment with both overt and covert forms often linked to struggle behaviour , negative emotional reactions, and social anxiety. Synonymous with stammer.
A key element of this definition is the drawing of attention to covert stuttering behaviour as word substitution, avoidance and circumlocutions. This allows stuttering behaviour to be seen beyond just repetitions, prolongations and blocks, while at the same time making a distinction between stuttering and the reactions to it. It is therefore more comprehensive in describing the experience of a person who stutters. The definition draws attention to the well recognized potentially negative affective and cognitive consequences of stuttering and points the way towards developing a new term to differentiate those people who stutter and who have negative emotional and attitudinal reactions (social anxiety disorder), from those people who do not.
5. A Proposed New Term: Stuttered Speech Syndrome
The use of stutter as a noun as it is defined above addresses the symptoms of the stuttering syndrome. However since negative emotional reactions and social anxiety disorder are not always linked to stuttering, then it is proposed that a new term Stuttered Speech Syndrome would assist in making this distinction. That is two people may stutter but only one has Stuttered Speech Syndrome (stuttering plus negative emotional reactions and social anxiety disorder.) Stuttered Speech Syndrome would be defined as responses resulting from the complex interplay between stuttered speech (overt and covert) and negative emotional and attitudinal reactions to it. The presence or absence of Stuttered Speech Syndrome has clear implications for treatment. It is also important to distinguish between the terms overt stuttering and covert stuttering (as defined above) for similar reasons. This concept is not new. Cooper (1993, p.383) noted
“While dysfluent speech behaviour is most frequently observed characteristic of stuttering syndromes, an individual’s affective or cognitive states, irrespective of the presence or lack thereof of observably dysfluent speech, may warrant the use of a stuttering syndrome diagnostic label.”
The proposed use of the terms covert stuttering and Stuttered Speech Syndrome now bring more clarity to Cooper’s insights and could easily be included in new dictionaries as a way to bring public awareness to stuttering and its likely consequences.
6. A Proposed New Classification
The degree of overt stuttering, covert stuttering, and the severity of psychosocial impact could be used to bring a classification system to stuttering. In this way it would no longer be appropriate to classify someone as having a mild stutter simply because overt stuttering was infrequent. Instead the classification mild stutter would only apply if overt stuttering , covert stuttering and psychosocial impact were ALL mild. This is obviously a much more accurate description of the situation for the person who stutters.
The following classification is proposed.
- Chronic overt stuttering (repetitions, prolongations and blocks)
- Associated covert stuttering (avoidance, substitution and circumlocution)
- Associated struggle behaviour (facial contortions, blinking, head jerking etc)
- Associated speaking phobia (fear, anxiety re loss of control)
- Associated stuttering phobia (fear, anxiety re shame, embarrassment,)
- Associated social phobia (generalized fear of social situations as a result of above)
The presence of 4, 5 or 6 in association with 1, 2 or 3 would give rise to the diagnosis of Stuttered Speech Syndrome. The absence of 4, 5 or 6 leads to the diagnosis of chronic stuttering either primarily overt or covert with or without struggle behaviour. The new classification system would assist evaluations of treatment protocols. It would seem clear that behavioural approaches could well suit those not affected by phobia, while group therapy, desensitization, and counseling are all necessary where Stuttered Speech Syndrome exists.
7. Where To Next
It is appreciated that definitions of stuttering have been a recurring debate in speech pathology for the past 50 years. Nevertheless it is hoped an interested group comprising key people in the International Stuttering Association and the International Fluency Association could work together to develop the definition and classification proposed above. The expectation is that this issue can be taken from the “too hard basket” to the “possibility box”.
- Cooper, E.B. (1993) Red herrings, dead horses, straw men, and blind alleys: Escaping the stuttering conundrum. Journal of Fluency Disorders, 18, 375 –387.
- Culatta, R., & Goldberg, S.A. (1995) Stuttering therapy :An integrated approach to theory and practice. Needham Heights, MA: Allyn & Bacon
- Douglass, E., & Quarrington, B. (1952) The differentiation of interiorized and exteriorized secondary stuttering. Journal of Speech and Hearing Disorders, 17, 377-385.
- Gregory, H.H. (1986) Stuttering: Differential evaluation and therapy. Austin TX: Pro-Ed Inc.
- Guntupalli,V. K., Kalinowski, J. & Saltuklaroglu T. (2006). The need for self-report data in the assessment of stuttering therapy efficacy: repetitions and prolongations. The stuttering syndrome. Journal of Language and Communication Disorders 41, No1 1-18
- Moore J. A. & Rigo T. G.(1983) An Awareness of the Covert Symptoms of Stuttering. Journal of Fluency Disorders, 8. 133-145
- Perkins, W. H. (1990) What is stuttering? Journal of Speech and Hearing Disorders, 55, 370-382.
- Royal College of Speech and Language Therapists (1996): Communicating Quality 2. Professional standards for speech and language therapists. 2nd Ed. RCSLT
- Shapiro, D.A. (1999) Stuttering Intervention: a collaborative journey to fluency freedom. Austin TX: Pro-Ed Inc