In Stuttering:
An Integrated Approach to Its Nature and Treatment (1998),
Barry Guitar presents a model of how stuttering develops
and why it should be treated differently at different stages.
It is a hierarchical model of five levels, the first level
being normal disfluency. The next four levels- borderline
stuttering, beginning stuttering, intermediate stuttering
and advanced stuttering- reflect the progressive stages
of the development of the disorder.
The following
table clearly defines each of the five developmental levels.
Within each level the characteristics are divided into four
subgroups: core behaviors, secondary behaviors, feelings
and attitudes, and underlying processes. The last subgroup
describes factors that explain why the symptoms progress
from level to level. Children who stutter will not always
fit neatly into a single category; rather, you may see some
behaviors that reflect one level and other behaviors that
reflect another.
Level
of Dysfluency |
Core
Behaviors
|
Secondary
Behaviors |
Feelings
and Attitudes |
Underlying
Processes |
|
Disfluency
less tban 10% of the time 1 to 2 repetitions per instance
Slow, even behaviors |
None |
None |
Developing
language
Pragmatics
Speech/ motor control
Environmental
stress |
|
Frequency
of disfluency increases to more than 10%.
Repetitions increase to more than 2 per instance.
Repetitions remain loose and relaxed. |
None |
Little
awareness Little concern |
Same
as above |
|
Tense,
abrupt multiple part-word repetitions
Tense prolongations |
Pitch
rise
Articulatory posturing with increased tension
Difficulty initiating airflow and voicing
Escape behaviors |
Awareness
Early fear
Anticipation
Frustration
|
Response
to awareness |
|
Blocks
Repetitions and prolongations continue |
Avoidance
of words and situations
Starters
|
Fear
Shame Embarrassment
|
Classically
conditioned tension
Classically conditioned fear
Avoidance conditioning |
Advanced
Stuttering |
Blocks
Stoppage of air flow
Tremors from increased duration of blocks |
Avoidance
of words and situations
Scanning (i.e., thinking ahead to identify potentially
difficult or feared words or sounds)
|
Helplessness
Anger
Frustration
Strong negative feelings about self |
Stronger
conditioning
Developed sense of self
as a stutterer
|
Source: Adapted
with permission from information in Guitar, B., Stuttering:
An Integrated Approach to Its Nature and Treatment. Copyright
1998 by Waverly.
Normal
Disfluency: For the child to be diagnosed
as having normal disfluency, all characteristics of this
level must be met. A child who shows any of the characteristics
of more advanced levels should be considered borderline
or above. Frequency of disfluency must be less than ten
per one hundred words. The disfluencies consist of multisyllabic
and phrase repetitions, revisions and interjections. Repetitions
are slow and even, and two or fewer occur per repetitive
instance. In general, the child’s disfluencies appear
relatively relaxed and the child hardly seems aware of them.
Borderline
Stuttering: This child exhibits more than
two disfluencies per one hundred words. This level is characterized
by part-word repetitions and single-syllable whole-word
repetitions. More than two repetitions may occur per instance,
but the disfluencies at this level remain loose and relaxed.
Beginning
Stuttering:
The important features at this level are the presence of
tension and “hurry” in the stuttering, as well
as the emergence of prolongations. The repetitions may be
rapid and abrupt, and pitch and loudness rise may be observed
during repetitions and prolongations. The child may display
facial tension and difficulty initiating airflow or voicing.
At the beginning stuttering level, the child will show signs
of awareness or the stuttering and may be quite frustrated
by it. The child may begin using escape behaviors- such
as head nods or eye blinks- in an attempt to terminate the
stuttering. The child’s developing negative response
to the awareness of stuttering is the factor that leads
to continued progression of the disorder.
Intermediate
Stuttering: This
child will have all of the preceding characteristics plus
avoidance behaviors. Conditioning to the experience of stuttering
occurs at this level; intolerance of the stuttering and
avoidance of words and situations begin to appear. Feelings
of shame and fear also emerge at this level.
Advanced
Stuttering:
The child who falls in this category is typically fourteen
years or older and requires a generally adult-oriented treatment
approach.
An important
point is that a child may progress through these levels
without it necessarily being apparent, especially to untrained
listeners, that the stuttering is getting worse.
Developmental Levels of Disfluency: