Most speech and language problems follow a linear course of change over time. Skills are relatively consistent and can be reliably described and quantified. Once new skills have been acquired there is little chance that they will be replaced by previous patterns. Stuttering, however, does not obey linear predictive rules. Awareness of the non-linear nature of stuttering can be helpful for people who stutter and SLPs who work with them.

Over time, stuttering is more likely to follow a path which resembles that of a "roller coaster". From the start, it twists and turns, climbs and falls, slows down and speeds up. Ongoing surprises combined with the feeling of being out of control creates fear and uncertainty. The roller coaster rider knows that one moment does not predict the next. We all seek to make sense of our life experiences by building causal bridges which attempt to predict future events from previous ones. Stuttering does not allow that.

Stuttering is not a static condition. The person who stutters also speaks normally much of the time. This condition cannot be adequately described or measured at a particular moment in time. It is characterized by sudden, unpredictable shifts in the efficiency of vocal tract adjustments. There is always the likelihood that something abnormal will occur in the future regardless of what happened in the past and what is happening in the present. The stronger the drive to express oneself, the more likely the body will refuse to do so. Efforts to predict and prepare often increase difficulty.

The degree of handicap related to stuttering may be more closely linked to the unreliable nature of speech production than to the description of any particular event. The experience of vulnerability can be constant regardless of the frequency or magnitude of interruptions. Living with fluency instability is, in some ways, analogous to living with asthma. After having an asthma "attack", one can no longer assume that their respiratory system will keep them alive. The secure feeling of reliability may be gone forever. Maintaining awareness of the non-linear nature of "fluency instability" (stuttering) can provide wisdom and perspective for speakers who live with it and for professionals who seek to help them. For the speaker, fluency instability can pose unique challenges to the development of self-image and speech motor planning. For the professional it poses challenges to diagnosis, prognosis, prescription and assessment of treatment effects.

Impact of fluency instability on speakers' self image

Discovering who we are is an important developmental journey. The speaker with fluency instability may have difficulty developing a clear sense of the "real me". Is it the person who can speak normally, or is it the person who cannot? It is difficult for the speaker to know if their fear of "speech breakdown" is a normal response to a real risk, or if it is the cause of the problem. While the person with fluency instability experiences this condition, others may not be able to see it, comprehend it, or empathize with its impact on the speaker 's life.

If the degree of speech difficulty were constant, speakers and listeners might find it easier to adapt. When faced with a static condition, such as cerebral palsy, speakers and listeners come to know what to expect and accommodate accordingly. But it can be difficult to adapt to something which is constantly changing. It is hard to develop a sense of your "true" ability if that ability shifts from competence to incompetence in an unpredictable instant.

Impact of fluency instability on speech motor planning

Previous experiences of fluency instability present a challenge for future speech motor planning. The brain anticipates, regulates and self-adjusts timing dynamics and effort levels for vocal tract valving and respiratory drive. A history of instability informs the motor planning system that certain timing-effort patterns may be adequate at one moment and not at others. This makes it difficult to be confident about predicting, preparing and executing motor plans. This is analogous to walking on a boat which has been rocking from side to side. While the boat is rocking, people adapt a wide stance to prevent falling. When the boat is not rocking, they may continue to walk with a "guarded" pattern, to prevent the possibility of falling, just in case the boat rocks in the future. The boat may only rock occasionally, but the sense of uncertainty and instability is ongoing.

Impact of fluency instability on SLPs -- Diagnosis (Labels are for Cans)

The diagnostic process attempts to describe and quantify a condition and to assess its impact on communicative function and quality of life. Fluency instability, however, is not characterized by its central tendencies. It is more meaningfully characterized by its variability. Observations made at any one moment, are not necessarily indicative of future function.

Several years ago a colleague invited me into a diagnostic session to meet a young man who was exhibiting severe stuttering. My colleague stepped out of the room while I conversed with the young man. During my interaction, this man spoke effortlessly without any speech interruptions. The diagnostic descriptions formed by my colleague did not seem to come from the same speaker I observed in the same room a few minutes later. Our different observations lead to different diagnostic impressions and different recommendations. If both of our observations were valid, then it is the diversity between them (the variability and not the average) which characterizes his fluency. Observations made during diagnostic sessions are at risk for underestimating or over estimating the extent of fluency instability. Some speakers with significant instability may appear normally fluent during a diagnostic session while others with mild instability may appear severely impaired depending on the speech sample observed.

Observations of fluency instability can also be misleading with regard to assumptions regarding their impact on the speaker's communicative ability and life experience. Some speakers with fluency instability do not seem aware or concerned while others are quite upset. Some speakers with fluency instability are highly effective communicators while others are not. Some have strong self-esteem and others experience chronic shame.

Impact of fluency instability on SLPs -- Prognosis (Prediction or Prophesy?)

Reports about past function, combined with observations of present function are usually combined to form predictions about future function. With regard to fluency instability, past function combined with present function does not predict future function. Unlike most other speech and language issues, fluency instability can increase or decrease at any point in time. Often it vacillates episodically. In the financial world, we are reminded that yesterday's performance is no prediction of tomorrow's. Over short time frames there are inevitable upward and downward episodes. However, if we hold on the the long term, things improve.

Severity of fluency instability does not predict future function. Research data about young dysfluent children, indicate that children whose fluency interruptions are more severe are not more likely to retain fluency instability than children whose symptoms are less severe. Similarly, symptom severity does not predict recovery of fluency stability, level of self esteem or communicative effectiveness for adults. Perspective, attitude and adaptive strategies continuously changes as does the degree of fluency instability. Given all of the factors which change and interact with each other, making predictions is a risky business.

Impact of fluency instability on SLPs -- Recommendations ("What to do?")

It is wise for SLPs to be flexible and responsive when making recommendations. Different approaches seem better suited for different individuals and what seems best for a particular person at one moment may not be best at another. On the most basic level, it is not always easy to know whether or not to recommend treatment. Each individual's desires, needs, and schedule influence their readiness for particular therapeutic experiences. Sometimes children, teens and adults want to be left alone. Efforts to push them, at those times, could increase their sense of having a problem before they are ready to deal with it. Others need a supportive push. We need to customize the blend of therapy approaches which include; fluency shaping, stuttering modification, anti-avoidance, contingency management and counseling.

SLPs need to consider the relative effectiveness of approaches, including intensive or non intensive; residential or non residential; group or individual. Should the treatment setting be the school, home or work place? Should it include organized self-help groups, family and friends? Is there a particular professional that you think would be the best fit?

Impact of fluency instability on SLPs -- Assessing Change (Are our efforts helping, hurting or doing nothing?)

When assessing the meaningfulness and durability of change resulting from therapy, SLPs need to consider sources of variability outside of the therapy process. Positive change evidenced shortly after beginning therapy may be a "false positive" related to "regression to the mean ". Fluency sensitive individuals often begin therapy shortly after their speech difficulty has increased. Since the degree of fluency difficulty is often phasic, there is a strong probability that a phase of improved fluency will follow shortly after the negative phase regardless of intervention. A "false positive" can also come from a renewed sense of optimism combined with a feeling of safety and relief as they share their story with the therapist. Negative effects may also appear shortly after the onset of therapy. Some individuals report having more fluency difficulty after beginning therapy. This apparent "regression", may serve to fuel change and form the path which ultimately leads to positive change.

Our interpretation of the positive or negative nature of observed change needs to consider the speaker's perspective and the point in time. What seems neutral or negative at a particular point in time, may be viewed as positive in the future. There is a play off between the continuum of acceptance-fear and the amount of overt fluency struggle versus avoidance. If a person comes to therapy with a fear of stuttering, they may avoid speaking in order to hide it. If their attitude improves and they become more self-accepting, they may exhibit more fluency interruptions. The reverse is also true. If a person begins therapy as self accepting and works on fluency control, they may begin to exhibit fewer interruptions, but report feeling more inhibited and uncomfortable.

When we are dealing with the fluency instability roller coaster, we need to stay aware that regardless of whether we think things are gong well or poorly at one moment, we cannot predict where the ride is going next. We must guard against premature optimistic and pessimistic interpretations. Fluency instability is NOT FAIR. Sometime when fluency issues are ignored, individuals feel better and function better. Sometimes when a person works hard in therapy they experience more discomfort and difficulty. This lack of correlation between effort and outcome can diminish treatment compliance and efforts to move forward.

Assessment of treatment effects are also confounded by non-linear developmental phenomena. Children evolve into adolescents, adolescents into young adults, young adults into mature adults. There are many inevitable changes which affect neuromotor control, cognition, linguistic skills, and psycho-social outlook. Awareness, attitudes, needs, and goals change continuously. A particular behavioral-attitudinal adaptation may feel acceptable at one point in time and unacceptable at another. Young child may lack awareness. Adolescents may develop fear and shame. Young adults may develop acceptance and a drive to change while mature adults often make peace with it and tend to view the lessons learned from challenge and struggle as a "blessing".

The non-linear nature of fluency instability dictates that the thoughts, feelings and behaviors from yesterday and today do not predict those of tomorrow. Rather than viewing ourselves as "human beings" definable at a moment in time, fluency instability teaches us that we are "human becomings". We continuously driven by difficult challenges and wonderful surprises. Our job is to help individuals balance self-acceptance with a drive to grow and change. As we hang to the fluency roller coaster, we should never loss awareness of the infinite range of illogical, unpredictable, possibilities. Never give up.

-Discussion-

August 24, 2004