*Treating the tongue-tied*

Stuttering affects five percent of the world’s population at some time in their lives and disappears in most young children. But while treatable, it is incurable and a lifelong condition in adults.

By JUDY SIEGEL-ITZKOVICH
DR. ESTI MAKAI (photo credit: Courtesy)
DR. ESTI MAKAI
(photo credit: Courtesy)
What did Marilyn Monroe, Demosthenes, Winston Churchill, Jimmy Stewart, King George VI, Elvis Presley, Lewis Carroll, Nicole Kidman, Joe Biden and James Earl Jones have in common? Some might add to this list of sometime or long-time stutterers the great Jewish prophet and deliverer of Israel – Moses. But others argue he just spoke slowly and deliberately, was not fluent in either Hebrew or Egyptian, had another speech impediment from putting a hot coal into his mouth as a child or was just humble.
Jones is quoted as saying something that all would have probably agreed with: “One of the hardest things in life is having words in your heart that you can’t utter.”
Stammering or stuttering is a speech disorder in which the flow of speech is disrupted by involuntary repetitions and prolongations of sounds, syllables, words or phrases and involuntary silent pauses or blocks in which the person who stutters is unable to produce sounds. It affects some one percent of all human beings at any given moment, but about 5% of all ethnic and racial backgrounds will have it at one time in their lives.
An estimated 70 million people around the world are stutterers.
The speech problem is much more common in boys than in girls – four or five times more common, as in autism – and when stuttering strikes girls, it is much more likely to disappear by itself. About 75% of preschoolers who begin to stutter will eventually stop.
Many children who “recover” from stuttering do so within months of the onset.
The condition most commonly involves involuntary repetition of sounds, but it may also involve abnormal hesitation before speech known as “blocks” and the prolongation of certain sounds, usually vowels. Stuttering is generally not a problem with the actual physical production of speech sounds or putting thoughts into words. The term encompasses a wide range of severity, including impediments that are barely perceptible and others that are severe and make it very difficult to communicate.
Following World Voice Day in April, The Jerusalem Post interviewed two speech and language pathologists (SLPs) – one of them a specialist who spends most of her time diagnosing and treating stammerers. Dr. Esti Makai, director of the hearing and speech institute at Tel Aviv Sourasky Medical Center, also lectures in the field of clinical communications at Tel Aviv University’s School of Health Professions.
“I originally wanted to be a physician, but when I was not accepted, I decided to go in this field, which has lots of medicine and focuses on treatment. Today, the vast number of speech and language pathologists are women and must undergo examinations that when passed entitles them to an official certificate from the Health Ministry,” she said.
NAAMA SHACHAR, chairman of the Israel Speech, Hearing and Language Association (the professional organization representing the country’s certified specialists) noted that every certified graduate of schools for SLPs have the right to work in any related field.
These range from the treatment of stammering to lisps, hearing disabilities and voice problems, as there are no sub-specialties in the field. There are hundreds of specialists who treat stammerers, said Shachar.
However, her professional organization is aware of “many” people without ministry authorization who do not claim to be specialists but nevertheless offer treatment.
“They are sometimes cheaper, but not always. They may not work in public institutions like hospitals and health funds, which don’t accept anyone without a certificate.
But they offer services from private offices or their own homes,” she added with consternation.
Asked by the Post to comment, the Health Ministry confirmed that if someone did not claim to be an SLP but offered treatment for stuttering, she (or he) could legally do so.
“A 2008 law prohibits someone from presenting himself as a clinical communications specialist if he does not have a certificate from the Health Ministry,” according to the ministry spokeswoman.
If anyone can put up a sign offering “treatment for stuttering,” one wonders why others would bother to study the field as academics and take qualifying tests for a ministry certificate. But at the same time, the ministry recommended that the public go to speech therapists with ministry certificates to get treatment for hearing or speech.
MAKAI SAID she didn’t intentionally go into the field to focus on stammering.
“Some young people go right into it, while others avoid it. You need to have a great deal of patience to go into this field, and you can’t promise a cure.”
Aside from neurophysiology and environment, there is also probably a genetic influence, the Sourasky expert said. The condition tends to run in families and may be shared in identical twins, but not necessarily.
Yet researchers believe there is not a single gene involved and that environmental influences must be present to cause stuttering, not genes alone. It’s rare for adult sufferers of stroke, physical trauma or a brain tumor to start stammering, but when it does occur, the condition is very hard to treat. For some people who stutter, congenital factors such as cerebral palsy, physical trauma at or around birth and learning disabilities may play a role. In others, there could be added impact from stressful situations such as the birth of a sibling, moving to a new home or even a sudden growth in linguistic ability.
While nervousness and stress do not cause stuttering, the condition can have a serious effect on a person’s functioning and emotional condition. The stutterer may be afraid to enunciate specific vowels or consonants, and of stammering in social situations, and may isolate himself to avoid verbal contact with others. He may even rearrange words in a sentence or substitute words for those he has difficulty pronouncing.
The condition is variable, and sufferers may stutter one day and be free of it on the next.
Interestingly, stutterers don’t have a problem when they sing or speak to themselves, and it is less apparent when they speak in a language that is not their mother tongue, apparently because they do this more slowly than in their regular language, Makai said.
Stuttering is also less common in deaf and those who are hard of hearing. Some people stammer more when they speak publicly to a large audience and less when talking on the phone, but for others, it is the opposite – all depending on whether or not the stammerer is self-conscious.
They may not only repeat syllables but also add unnecessary “ums” or “uhs,” go back and correct what they originally said, clear their throats or smack their lips.
BUT AS shown by the list of famous stutterers, the defect doesn’t have to hold anyone back. Even Israel Defense Forces soldiers may stutter. They can’t easily be commanding officers, who need to quickly shout out orders, but can serve in many other capacities.
At least today they don’t have to speak with pebbles in their mouths or shout at waves at the beach like the Greek orator Demosthenes, suggested Makai.
Very young children who stutter usually don’t suffer from their impediment, as everyone at this age has some problems when they start to speak. But in kindergarten or even pre-kindergarten, their peers identify those who are different and may make fun of them.
At older ages, stutterers may be bullied by their peers. Their teachers should be taught at least to identify speech problems and to refer parents to help. Health funds pay for counseling sessions by specialists, but often the treatment period is not long enough, and the queue can be months long unless families decide to go to private clinics, said Makai.
In the periphery of the country, the queues are longer, and families tend to be less able to pay for private treatment.
“We advise parents on how to help children who stutter. From about age four, a child will feel he is stuck and can’t say everything he wants, but he is not ashamed of it,” she said.
Most treatment programs for stutters are behavioral. They are designed to teach the person specific skills or behaviors that lead to improved oral communication. SLP treatments focus on reducing stuttering by slowing down the speed of speech, regulating breathing and gradual advancement from single-syllable responses to longer words and eventually more complex sentences.
(Hebrew speakers are notorious for speaking too fast or using only parts of words, she added.) Other therapies focus on relaxation, aiming to reduce the anxiety that usually results from stuttering.
Patients may be taught to speak more slowly by stretching out their consonants and vowels, or by using other techniques. As they improve, they can speak faster and improve their intonation and fluency.
“The health funds generally don’t give enough treatment. The condition, when it does not disappear in early childhood, is usually for life, and sufferers need maintenance. If it is s small child, I usually want to work with him for six months to a year. If he moves to a new school or kindergarten, the situation could get worse, so he needs to be followed up,” said Makai.
ALTHOUGH THERE has been much research abroad – and even in Israel – into stammering, the US Food and Drug Administration has not approved any drug for treatment of stuttering. Eventually, said Makai, it will probably happen that stutterers take a pill to stop their stammering. Today, there are, however, medications that release muscles and reduce stress, and these may help. There are also electronic devices, such as those that aid in auditory feedback or biofeedback.
There are also computer programs and workshops, she added, some more helpful and some less.
Stuttering used to be regarded by parents as a tragedy, said Makai, “but not so much today. The calmer the family when the problem is diagnosed, the bigger the chance that it will pass. Don’t be afraid of getting a diagnosis of stammering,” she advised. “When they grow up, they find work and get married. Attitude is very important. I receive a lot of satisfaction from my profession and especially from helping stutterers.”