Interview with Dr. Jason Davidow of Hofstra University

Note: You should consult with your doctor or speech pathologist for recommendations on treatment. The views and opinions expressed in this article are those of Dr. Davidow and do not necessarily reflect the official policy or position of SpeechPathologyMastersPrograms.com

What do we know about why Fluency-Inducing Conditions (FICs) such as singing and prolonged speech reduce stuttering?

Overall, I would say that we don’t know too much about why the most powerful fluency-inducing conditions (FICs), such as singing, prolonged speech (i.e., speech produced at a slow rate [at least initially] that involves elongating sounds, syllables, and words, in addition to continuous phonation across word and syllable articulatory boundaries), metronomic speech (i.e., speaking one syllable or word per beat of a metronome), and chorus reading (i.e., reading or speaking the same words simultaneously with another speaker) work. For some, we do know that when persons who stutter (PWS) speak in these conditions, brain activations move towards those of normally-fluent speakers. That is, the atypical activations often seen in PWS (compared to normally-fluent speakers) will move towards those of normally-fluent speakers. There is also a sufficient amount of evidence that the speech articulators move differently (e.g., longer vowel durations, a reduction in short intervals of phonation) during these conditions compared to when PWS speak in their habitual manner. However, similar to the changing neural activations, we cannot yet conclude that the changes are necessary for the stuttering reductions.

Do FICs just reduce stuttering in the moment or can they be used to improve a patient’s fluency over the long term? If so, how might they be used in treatment?

FICs can be used to improve a patient’s fluency over the long term. For example, metronomic speech and prolonged speech have been used as the foundation for several treatment programs. Prolonged speech-based programs, especially for adults, have produced solid evidence for reducing the various symptoms of stuttering (i.e., behavioral, social, emotional, and cognitive).  Although metronomic speech, specifically syllable-timed speech (i.e., producing one syllable per beat), is being studied with preschoolers and school-age children, it has fallen out of favor due to the unnatural sound (i.e., robotic) it typically results in. I think it could be fruitful to study ways to make metronomic speech more natural, and we are currently doing this in my lab at Hofstra University.

In the treatment context, clients typically begin using prolonged speech in a very slow manner and eventually speed up to sound natural. In the most successful programs, clients spend many hours practicing the pattern with reading, monologues, in-person conversations, and phone conversations. In addition, there are several transfer and maintenance activities and criteria for meeting goals of low levels of stuttering and naturalness during the different stages of the programs. All of these treatment components seem critical to the success of the programs in reducing the various symptoms of stuttering.  

Some PWS use certain components of prolonged speech (e.g., gentle onsets or light articulatory contacts) in order to make an anticipated stuttering moment less severe, instead of using a treatment protocol that calls for reshaping their speech pattern, as described above.  The manner in which prolonged speech will be used depends on several factors, including, for example, the needs of the client, past treatment experiences, and the amount of time the client can commit to practicing the skill.   

People do not always realize the total impact that a stutter can have on a person, such as the stress of avoiding language that may lead to a stutter. What are some of the effects of stuttering that people do not know about?

Yes, it can be stressful to try to avoid troublesome words. For full disclosure, I am a person who stutters, and I used to avoid sounds, words, and situations, as many other PWS have done. Trying to always be fluent, especially when you do not have the tools to do so, can be extremely taxing. The available literature, in particular qualitative studies, can give the reader a detailed picture of some of the underlying issues (i.e., the non-behavioral components) with stuttering. As can be seen from this literature, and from speaking to many PWS, the disorder can be debilitating. For some it is constantly on their mind, prevents them from entering desired situations, meeting people, etc. Think about not ordering what you want to eat, and ordering something you do not really like, because you are embarrassed to stutter in front of a stranger. Stuttering may also prevent a person from applying for a job they want and are qualified for due to the amount of speaking that may be required. As can be seen by these examples, stuttering may prevent many desired activities and place PWS in a “confined space.”

It should also be mentioned that stuttering may be the impetus for someone to become an advocate for other PWS. Many PWS have turned their negative experiences with stuttering into positive ones. For example, PWS lead self-help groups for children, teens, and adults who stutter and/or are part of the administration in self-help organizations. I also know several PWS who specialize in stuttering in their private practices.       

What are some obstacles to motivating a patient who is trying to improve a stutter?

I will speak about this in general as there are different obstacles with different age groups. I think a big issue is that there is no fast solution. If a client wants to make a big dent in the components of stuttering that trouble him or her, it takes time and a long-term commitment. This needs to be explained to the client (or the client’s parent) at the start of treatment, so unrealistic expectations do not derail the treatment chosen. In addition, many clients have already had a treatment experience that did not go well. This often puts a “bad taste in their mouth” for treatment. It is important to discuss this at the outset of treatment and let them know how the current program will be different. For example, there are many ways to implement a particular treatment strategy, and one may work better than another for a particular client. Also, as discussed above, there are many parts to a program (e.g., transfer and maintenance activities) other than the main technique used, and this could be a reason for a failed past treatment.    

You have started to research stutter anticipation and measurement. What are you hoping to accomplish from this new research?

For the anticipation research line, we are hoping to discover how PWS can predict an upcoming stutter. We have proposed how this occurs in a previous paper, and we are currently testing our hypothesis. Our long-term goal is to take our findings and apply them to treatment. That is, we would like to be able to help people anticipate their stuttering moments better and earlier.  Although many PWS can anticipate their stuttering moments quite well, others have more difficulty. If clients can anticipate stuttering moments, they can better use learned techniques when approaching a potential stutter. This skill may be applicable to behaviorally-based treatments and those in which the foundation is directed more towards the social, emotional, and cognitive components of stuttering. In addition, discovering how anticipation occurs can provide a better understanding of the stuttering experience, particularly the part that listeners do not see.  

The literature is filled with how difficult it is to be a reliable judge of stuttering moments. Current research in my lab is focused on trying to improve reliability and keeping the task functional for busy clinicians. We are currently examining the reliability of a computer program that allows the simultaneous collection of the number of syllables stuttered, total number syllables stuttered (stuttered and nonstuttered; total syllables value is used to calculate speech rate), and speech naturalness. Our students are trained on this program, and we would like some to be more reliable at the end of training. Stuttering frequency, speech rate, and naturalness are important stuttering treatment outcome variables, and we need to enhance the reliability of judges to provide the best service delivery to clients.

What is your advice to future graduate SLP students?

I assume your question refers to advice when working with PWS. I will provide some suggestions, but they are certainly not all that needs to be considered. First, it is important to remember that each person who stutters has a different experience with stuttering. For example, just because someone can be considered mild in regard to the behavioral components of stuttering, this does not mean that the social, emotional, and cognitive components will also be mild. Second, keep an open mind when new information comes in. I think students can get stuck on what they were taught in their graduate courses and not continue to update themselves and change assessment and/or treatment strategies when needed. I stress this to my students; that is, I tell them to not just believe what I say, but to look at the information themselves and continue learning about stuttering when they leave my classroom. Third, be up-to-date on the latest treatment techniques. Although one treatment will not work for all clients, there are those that have far better evidence than others. It is important for clinicians to be aware of these treatments in order to provide their clients with the best options, if those options are suitable for a particular client. Lastly, if you don’t feel comfortable treating a person who stutters, refer the client to someone who is. The literature is filled with data showing that many clinicians are uneasy about treating PWS. If this is the case, refer to an expert who is experienced, and has had success with, PWS.

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