In D. Ward & K. Scaler Scott (Eds. https://doi.org/10.1016/j.jfludis.2013.03.001, Coifman, K. G., & Bonanno, G. A. The person is having difficulty communicating messages in an efficient, effective manner. Emotional reactivity and regulation associated with fluent and stuttered utterances of preschool-age children who stutter. Family historyAnecdotal reports indicating the presence of cluttering in more than one family member suggest that family history may be a risk factor. https://doi.org/10.1044/1058-0360.0704.62. Evaluation of speech-related attitude by means of the KiddyCAT, CAT, and BigCAT, within a larger behavior assessment battery framework for children and adults who stutter. American Journal of Speech-Language Pathology, 2(2), 6573. Self-report of self-disclosure statements for stuttering. The person is experiencing negative reactions from others (e.g., peers, classmates, coworkers, family members). Journal of Fluency Disorders, 36(2), 122129. Scaler Scott, K., & St. Louis, K. O. Individuals may experience stuttering in different ways with siblings, their spouse, or other family members. For example, an individual might elect to self-disclose in a workplace and educate coworkers about fluency disorders via a group presentation followed by a question-and-answer period. Covert stuttering: Investigation of the paradigm shift from covertly stuttering to overtly stuttering. https://doi.org/10.1044/2017_LSHSS-17-0028. Journal of Fluency Disorders, 38(4), 342355. Treatment approaches for preschool children who stutter include the following. practice monitoring each others speech and secondary behaviors. modifying instructions to accommodate the home language, using exemplars in audio or video format in the home language, and. Often, the main reason for seeking advice from an SLP and initiating services is to eliminate or greatly reduce disfluent speech. Behavioral treatments that address improved speech fluency appear to be effective across a range of cultures and languages (Finn & Cordes, 1997). Persons who stutter may appear to have expressive language problems because of a tendency to avoid speaking or speak in a way thats unclear to the listener. Arnold, H. S., Conture, E. G., Key, A. P., & Walden, T. (2011). Journal of Fluency Disorders, 29(4), 255273. Causes of stuttering are thought to be multifactorial and include genetic and neurophysiological factors that contribute to its emergence (Smith & Weber, 2017). Evaluating stuttering in young children: Diagnostic data. A comprehensive fluency assessment typically includes the following: See ASHAs resource on assessment procedures: parallel with CPT codes for a breakdown of pre-evaluation, intra-service, and post-service procedures. discussion of personal issues (e.g., prior to, or in addition to, targeting generalization of skills in a group setting). Perspectives on Fluency and Fluency Disorders, 23(2), 5469. Cluttering and stuttering do not need to occur in all situations or even a majority of the time to be diagnosable disorders. The primary provider of fluency treatment is the SLP. In addition, some persons who stutter substitute words, omit words, or use circumlocution to hide stuttering symptoms (B. Murphy et al., 2007). Human Brain Mapping, 38(4), 18651874. 1997- American Speech-Language-Hearing Association. Arnold, G. E. (1960). avoidance behaviors (i.e., avoidance of sounds, words, people, or situations that involve speaking); escape behaviors, such as secondary mannerisms (e.g., eye blinking and head nodding or other movements of the extremities, body, or face); and. Individuals with disfluencies are seen in all of the typical speech-language pathology service settings, including private practices, university clinics, hospitals, and schools. www.asha.org/policy/, American Speech-Language-Hearing Association. Individuals learn to identify the thoughts underlying their negative attitudes and emotional reactions and examine the link between these thoughts, attitudes, and emotional reactions and their speech. SIG 16 Perspectives on School-Based Issues, 15(2), 7580. Features of cluttering are sometimes observed in conjunction with other neurological disorders (e.g., autism spectrum disorder, Tourettes syndrome, and attention-deficit/hyperactivity disorder). Such strategies include simulating a fast rate of speech and applying pausing and/or simulating overarticulated speech and applying increased emphasis to increase intelligibility. auditory processing disorders (Molt, 1996). The clinical applications of Acceptance and Commitment Therapy with clients who stutter. https://doi.org/10.1016/0094-730X(86)90028-8, St. Louis, K. O., & Hinzman, A. R. (1988). Both procedures help the client decrease the sense of loss of control experienced during moments of stuttering by demonstrating their ability to stop and modify moments of stuttering, anxiety, and other emotional reactivity. This study reviews data from a school-age child with an atypical stuttering profile consisting predominantly of word-final disfluencies (WFDs). For students who stutter, the impact goes beyond the communication domain. Journal of Fluency Disorders, 21(34), 201214. https://doi.org/10.1016/S0094-730X(97)00009-0, Yaruss, J. S. (2007). The ability to use speech strategies; to make choices to speak and participate, regardless of the level of fluency; and to take risks is greatly reduced outside of the treatment setting when time pressure and conditioned negative feelings may trigger fear and old behaviors. Journal of Fluency Disorders, 54, 1423. However, fluency shaping approaches, such as easy onset or continuous phonation, may not be appropriate for the treatment of cluttering. Reasonable accommodations would vary by work setting and type of work. Factors that contribute to the perception of overt stuttering severity include frequency, duration, effort, naturalness, and the ability of the person who stutters to communicate effectively and efficiently. Emotional reactivity and regulation in preschool-age children who stutter. Providing prevention information to individuals and groups known to be at risk for fluency disorders and to individuals working with those at risk. Brain, 131(1), 5059. Scaler Scott, K. (2011). Please enable it in order to use the full functionality of our website. Genetic bases of stuttering: The state of the art, 2011. Although some people with cluttering are not aware of their communication difficulties, many are aware that others have difficulty understanding them. frequency of exposure to all languages used by the child and their proficiency (comprehension and production) in each language; family history of stuttering or cluttering; description of disfluency and rating of severity; age of onset of disfluency and patterns of disfluency since onset (e.g., continuous or variable); previous fluency treatment and treatment outcomes; exploration of parental reactions to the childs moments of disfluency or speaking frustration; and. Language assessment and intervention for the learning disabled. United States Department of Labor. (2016b). Early childhood stuttering and electrophysiological indices of language processing. Support (both giving and receiving) can be valuable for improving attitudes, boosting self-confidence, and reducing feelings of isolation (Yaruss et al., 2007). The role of attention in therapy for children and adolescents who stutter: Cognitive behavioral therapy and mindfulness-based interventions. Avoidance or escape behaviors may also be used and can temporarily conceal stuttering (Constantino et al., 2017; Douglass et al., 2019, 2018; B. Murphy et al., 2007; Starkweather, 1987; Tichenor et al., 2017; Tichenor & Yaruss, 2018, 2019a, 2019b, 2020). (2005). ASHA also extends its gratitude to the following subject matter experts who were involved in the reviewand development of thispage: In addition, ASHA thanks the members of the Steering Committee of ASHAs Special Interest Division on Fluency and Fluency Disorders (Division 4) whose work preceded this content. https://doi.org/10.1044/sbi15.2.75, Constantino, C. D., Manning, W. H., & Nordstrom, S. N. (2017). Motivational interviewing: Helping people change. Gupta, S., Yashodharakumar, G. Y., & Vasudha, H. H. (2016). What is motivational interviewing? Video self-modeling as a post-treatment fluency recovery strategy for adults. Specific standardized tests can be used to rule out word-finding difficulties. The impact of stuttering on adults who stutter and their partners. This includes the impact on functional communication in key school situations and on quality of life (Beilby et al., 2012b; Yaruss et al., 2012). (2009). Person- and family-centered practice is a collaborative approach that fosters an alliance-style partnership among individuals, families, and clinicians. Singular. Stages of change and stuttering: A preliminary view. Daniels, D. (2007). ), More than fluency: The social, emotional, and cognitive dimensions of stuttering (pp. Persons who stutter may appear friendlier when they self-disclose their stuttering, and self-disclosure may help put listeners more at ease (Healey et al., 2007). Sex of childIt appears that the disorder is more common in males than in females; the male-to-female ratio for cluttering has been reported to range from 3:1 to 6:1 (G. E. Arnold, 1960; St. Louis & Hinzman, 1986; St. Louis & Rustin, 1996). Children with language difficulties at the sentence, narrative, or conversational discourse level may exhibit increased speech disfluencies. production of words with an excess of physical tension or struggle. However, several likely gene mutations have been linked to stuttering (Frigerio-Domingues & Drayna, 2017). Disclosing a fluency disorder may be done a number of ways, such as verbally stating I stutter/have a speech disorder or by pseudostuttering or openly stuttering, while doing so confidently (McGill et al., 2018). Genetics and neurophysiology appear to be related to the underlying causes of stuttering. Typical vs Atypical Pneumonia in Tabular Form 6. As children who stutter get older, they may become adept at word and situational avoidances that result in a low frequency of overt stuttering. Areas of the brain that were studied and the technologies used to conduct the research (e.g., PET, MEG, MRI, fMRI, NIRS, DCS) also varied widely. Donaher, J., & Richels, C. (2012). Despite these challenges, some of the therapy that applies to adults can be just as effective with teens/adolescents. Prevalence of stuttering in primary school children in Cairo-Egypt. Assessment and treatment of stuttering in bilingual speakers. https://doi.org/10.1016/j.cub.2016.02.068, Beilby, J. M., & Byrnes, M. L. (2012). Posted at 23:22h . The scope of this page includes stuttering and cluttering across the life span. Prevalence and trends of developmental disabilities among children in the United States: 20092017. a sense of loss of control/cognitive dissociations; negative thoughts/feelings about oneself and ones communication abilities; rumination on perceived communication failures; a decreased sense of self-worth (report feeling less than human); avoidance of words/sounds, speaking, and social interactions; perceived judgment of communication by others (e.g., being mocked, laughed at, made fun of, pitied, talked over/for, ignored, or hung-up on); perceived negative effects on social/romantic relationships; and. Prevalence of anxiety disorders among children who stutter. ET MondayFriday, Site Help | AZ Topic Index | Privacy Statement | Terms of Use Plural. To facilitate generalization of skills, the clinician can help the individual use a variety of therapeutic activities outside of the treatment room, such as. https://doi.org/10.1044/1058-0360(2003/070), Arenas, R. M., Walker, E. A., & Oleson, J. J. https://doi.org/10.1016/0094-730X(88)90003-4. With this approach, parents are trained to provide verbal contingencies based on whether a childs speech is fluent or stuttered (M. Jones et al., 2005; Onslow et al., 2003). St. Louis, K. O., Myers, F., Bakker, K., & Raphael, L. (2007). Purpose Disfluencies associated with stuttering generally occur in the initial position of words. Journal of Fluency Disorders, 43, 1727. For example, when selecting reading passages, it may be difficult to determine the linguistic complexity of a text in a language unfamiliar to the clinician. Universitetsforlaget. Onset may be progressive or sudden. https://doi.org/10.1044/jshr.3605.906. typical vs atypical disfluencies asha. https://doi.org/10.1044/ffd23.2.54, Plexico, L. W., Hamilton, M. B., Hawkins, H., & Erath, S. (2019). Nurturing a resilient mindset in school-aged children who stutter. Differential treatment of stuttering in the early stages of development. Reading slowly may be perceived as a reading problem, even though the underlying cause is stuttering. Journal of Fluency Disorders, 34(4), 368381. Journal of Speech, Language, and Hearing Research, 61(7), 16491663. The individual who stutters becomes desensitized to their fears by performing activities (e.g., self-disclosing, going to a place where they fear speaking) using a fear hierarchy. This hierarchy represents situations or activities that range from low risk to high risk. https://doi.org/10.1159/000331073, Kuhn, M. R., & Stahl, S. A. information regarding family, personal, and cultural perception of fluency. being more comfortable and open with stuttering and pseudostuttering; reporting experiencing decreased anxiety while communicating; reporting less adverse psychological, emotional, social, and functional impacts; reporting enjoying social communication, including with strangers; and. https://doi.org/10.1111/jpc.12034. Early childhood stuttering therapy: A practical guide. may show increased disfluency rates (decreased reading fluency) because they cannot change the words to avoid moments of stuttering as easily as they can in conversation, and. SLPs may want to relate personal experiences when asking clients to share such vulnerable information. There are benefits of both individual and group treatment. Speech modification approaches to stuttering treatment in schools. The clinical process for an adult involves. It is helpful to know that typical bilingual or multilingual children tend to produce higher rates of monosyllabic word repetitions, sound repetitions, and syllable repetitions than monolingual speakers. Approximately 88%91% of these children will recover spontaneously with or without intervention (Yairi & Ambrose, 2013). seizure disorders (Briley & Ellis, 2018). Phonological working memory in developmental stuttering: Potential insights from the neurobiology of language and cognition. With adults, initiation of treatment depends on the individuals previous positive or negative intervention experiences and current needs pertaining to their fluency and the impact of their fluency disorder on communication in day-to-day activities and participation in various settings (e.g., community or work). Treatment for fluency disorders is highly individualized and based on a thorough assessment of speech fluency, language factors, emotional/attitudinal components, and life impact (Byrd & Donaher, 2018). https://doi.org/10.1044/2018_JSLHR-S-17-0353, Guitar, B. St. Louis, K. O., & Schulte, K. (2011). On the other hand, stuttering symptoms may decrease in more comfortable situations. Some families may decide to send children to live with relatives or ask children not to speak in public (Shenker, 2013). 255279). In E. Conture & R. F. Curlee (Eds. ), More than fluency: The social, emotional, and cognitive dimensions of stuttering (pp. 155192). Journal of Fluency Disorders, 50, 7284. Dosage depends largely on the nature of the treatment (e.g., direct, indirect), age group, and the task level (e.g., learning basic skills requires more clinic room practice than does generalization). Alm, P. A. They are likely to use interjections, repeat phrases, and revise what they are saying. When a bilingual SLP is not available, using an interpreter is a viable option. their reason for seeking treatment at the current time. Effortful control, an aspect of temperament that supports self-regulation, may be predictive of stuttering severity and may facilitate positive change in treatment (Kraft et al., 2019). Perspectives on Fluency and Fluency Disorders, 17(2), 49. The validity of reading assessment tools for children who stutter is questionable because it is difficult to differentiate the cause (decoding or stuttering) of oral reading fluency problems. Van Borsel, J., Maes, E., & Foulon, S. (2001). The attitudes of high school peers toward stuttering and toward persons who stutter can be improved through education in the form of classroom presentations about stuttering (Flynn & St. Louis, 2011). American Journal of Speech-Language Pathology, 27(3S), 12351243. Academic Press. Some example of stuttering (or atypical dysfluencies) would be: Monosyllabic whole word repetitions: (e.g. Erlbaum. Qualitative investigation of the speech-language therapy experiences of individuals who covertly stutter. Journal of Fluency Disorders, 32(2), 139162. See also ASHAs resources titled Person-Centered Focus on Function: Preschool Stuttering [PDF], Person-Centered Focus on Function: School-Age Stuttering [PDF], and Person-Centered Focus on Function: Adult Stuttering [PDF] for examples of treatment goals consistent with the ICF framework. Peer support for people who stutter: History, benefits, and accessibility. Journal of Fluency Disorders, 35(3), 216234. Starkweather, Janice Westbrook. American Journal of Speech-Language Pathology, 27(2), 721736. Seminars in Speech and Language, 24(1), 2732. Multicultural issues in school settings. Wolk, L., Edwards, M. L., & Conture, E. G. (1993). There are limited data on the age of onset of cluttering; however, the age of onset of cluttering appears to be similar to that of stuttering (Howell & Davis, 2011). Contemporary Issues in Communication Science and Disorders, 25(Spring), 820. https://doi.org/10.1044/2017_AJSLP-17-0146, St. Louis, K. O., & Hinzman, A. R. (1986). Time and expense are considerations along with attention to generalization and treatment needs following an intensive program (Cooper, 1979). It is important to distinguish stuttering from other possible diagnoses (e.g., language formulation difficulties, cluttering, and reading disorders) and to distinguish cluttering from language-related difficulties (e.g., word finding and organization of discourse) and other disorders that have an impact on speech intelligibility (e.g., apraxia of speech and other speech sound disorders). Journal of Fluency Disorders, 34(3), 187200. A phenomenological analysis of the moment of stuttering. https://doi.org/10.1016/j.jfludis.2016.09.005, Gerlach, H., Hollister, J., Caggiano, L., & Zebrowski, P. M. (2019). https://doi.org/10.1044/leader.FTR2.19072014.44, American Speech-Language-Hearing Association. Our primary goals were to identify patterns in overt features of WFDs and to extend our understanding of this clinical profile by focusing on aspects of . In this way, positive reinforcement is used to increase or strengthen the response of fluency (the desired behavior). Measuring lexical diversity in children who stutter: Application of vocd. Treatment may include strategies to reduce negative reactions to stuttering in the individual and others (Yaruss et al., 2012). Journal of Fluency Disorders, 59, 120.https://doi.org/10.1016/j.jfludis.2018.11.003. Application of the ICF in fluency disorders. Referring the individual to other professionals to rule out other conditions and facilitate access to comprehensive services. Assessment of other communication dimensions, including speech sound production, receptive and expressive language, pragmatic language, voice, hearing, and oralmotor function/structure. Review of previous fluency evaluations and educational records. (2007) for a description of how the stages of change model can be applied to fluency therapy. Journal of Fluency Disorders, 63, 105746. https://doi.org/10.1016/j.jfludis.2020.105746, Boyle, M. P., Milewski, K. M., & Beita-Ell, C. (2018). Structural and functional abnormalities of the motor system in developmental stuttering. Management of childhood stuttering. https://doi.org/10.1177/1525740117702454. Journal of Speech, Language, and Hearing Research, 44(2), 368380. ), Cluttering: Research, intervention and education (pp. Individuals who clutter may exhibit more errors related to reduced speech intelligibility secondary to rapid rate of speech. https://doi.org/10.1177/1073858418803594, Chang, S.-E., & Zhu, D. C. (2013). Students who improve their attitudes toward stuttering tend to maintain these views years later (St. Louis & Flynn, 2018). (2018). Disclosure of stuttering and quality of life in people who stutter. The interview process and work environment can be challenging for individuals who stutter. Journal of Fluency Disorders, 37(4), 289299. Brain, 136(12), 37093726. Stuttering in relation to lexical diversity, syntactic complexity, and utterance length. Acceptance; Constantino et al., 2017. Because the theory behind cluttering is that speakers are talking at a rate that is too fast for their systems to handle, techniques that help regulate speech rate, such as increased pausing, often are helpful. Overall, these indicators demonstrate progression from avoidance and negative impact to acceptance, openness, and increased socialization (V. M. Sheehan & Sisskin, 2001). We believe it is past time to standardize the symptom assessment for MI so that proper and rapid diagnostic testing can be undertaken; however, we cannot standardize . Testing, and 7. Such individuals may benefit from treatment strategies that focus on improving speech efficiency by reducing word avoidance and increasing spontaneity in communication. Adults with fluency disorders have likely experienced years of treatment with varied outcomes. Luterman, D. M. (2006). https://doi.org/10.1016/j.jfludis.2013.01.001. https://doi.org/10.1542/peds.2007-1648, Boscolo, B., Ratner, N. B., & Rescorla, L. (2002). Guilford Press. Social anxiety disorder and stuttering: Current status and future directions. Retrieved month, day, year, from www.asha.org/practice-portal/clinical-topics/fluency-disorders/. https://doi.org/10.1016/j.jfludis.2014.01.001. Apply Now. Individuals who stutter are more likely to be self-aware about their disfluencies and communication, and they may exhibit more physical tension, secondary behaviors, and negative reactions to communication. https://doi.org/10.1016/j.jcomdis.2010.12.003. Randomised controlled trial of the Lidcombe programme of early stuttering intervention. Word-finding problems can also result in an increase in typical disfluencies that are similar to those observed in cluttering. Rocha, M., Yaruss, J. S., & Rato, J. R. (2019). See ASHAs Practice Portal pages on Bilingual Service Delivery and Collaborating With Interpreters, Transliterators, and Translators. American Journal of Speech-Language Pathology, 27(3S), 11801194. Thieme. School-based SLPs and IEP teams should resist pressure to minimize the impact of stuttering on educational achievement for the purpose of disqualifying students from speech-language pathology services. Although cluttering and stuttering can co-occur, there are some important distinctions between the two (see Scaler Scott, 2010). "Atypical" disfluencies include: sound repetitions ("s-s-s-so"); syllable repetitions ("be-be-be-be-because"); prolongations ("Aaaaaaaaaaaaand"); and Typical Disfluencies vs. Stuttering in Children. Direct treatment approaches can also target resilience and effort control in the child and family (Caughter & Crofts, 2018; Druker et al., 2019; Kraft et al., 2019). Determination of individual strengths and coping strategies. Helping adolescents who stutter focus on fluency. Recovery rates were estimated to be approximately 88%91% by Yairi and Ambrose (2013). Communication Disorders Quarterly, 6(1), 5059. Members were Gordon Blood, Eugene Cooper, Hugo Gregory, John Hanley, Charles Healey, Stephen Hood, Kenneth S. Louis, Theodore Peters, C.W. Genetic factors also may play a role in predicting the likelihood of persistence or recovery and, possibly, treatment outcomes (Frigerio-Domingues et al., 2019; Han et al., 2014). These may include stuttering modification (described above) in addition to awareness, desensitization, cognitive restructuring, self-disclosure, and support. In H. H. Gregory, J. H. Campbell, C. B. Gregory, & D. G. Hill (Eds. using fillers (e.g., like, um, uh, you know); avoiding sounds or words (e.g., substituting words, inserting unnecessary words, circumlocution); and. Temperament in adults who stutter and its association with stuttering frequency and quality-of-life impacts. They also can benefit from groups and intensive programs (Fry et al., 2014). Risk factors that may be associated with persistent stuttering include. These feelings may come from having a positive perception about the ability to face challenges (Boyle et al., 2019). A range of studies support a genetic predisposition for stuttering, but no definitive findings have been made regarding which transmission model, chromosomes, genes, or sex factors are involved in the expression of stuttering in the population at large (Kraft & Yairi, 2011, p. 34). These include when the individual who stutters. In fact, stuttering can affect all areas of academic competency, including academic learning, social-emotion functioning, and independent functioning (Ribbler, 2006, p. 15). See an article by ASHAs Ad Hoc Committee on Reading Fluency For School-Age Children Who Stutter (ASHA, 2014). (2017). Preus, A. Clinical utility of self-disclosure for adults who stutter: Apologetic versus informative statements. The prevalence rate of stuttering in African American children (25 years of age) was estimated to be 2.52%, but was not reported to not be significantly different from that reported for European American children in the same age group between 2- to 5-year-old African American children and European American children (Proctor et al., 2008). Parents of bilingual children easily can be trained to provide perceptual ratings of fluency in any language spoken by the child (Shenker, 2013). (2008). Contemporary Issues in Communication Science and Disorders, 31(Spring), 6979. Scientific Reports, 7(1), 118. The underlying relationship between stuttering and working memory is not fully understood but may be related to interruptions in sensorimotor timing for developmental stuttering and may involve both the basal ganglia and the prefrontal cortex (Bowers et al., 2018). However, these compensations may compound the negative experience of stuttering over time. Adjustments can include. Journal of Speech, Language, and Hearing Research, 61(5), 12381250. Hearne, A., Packman, A., Onslow, M., & Quine, S. (2008). Some of the most commonly prescribed typical or first-generation antipsychotics include: Haldol (haloperidol) Thorazine (chlorpromazine) Loxitane (loxapine) Moban (molindone) Mellaril (thioridazine) Serentil (mesoridazine) Navane (thiothixene) Trilafon (perphenazine) On the other hand, the following are atypical or second-generation antipsychotics: The goals of treatment may be (a) to eliminate, greatly reduce, or help the child manage their stuttering and (b) to help them not develop negative emotional reactions related to their stuttering (H. S. Arnold et al., 2011; Yaruss et al., 2006). Healey, E. C., Reid, R., & Donaher, J. The utility of stuttering support organization conventions for young people who stutter. Enhancing treatment for school-age children who stutter: II. Avoidance can lead to less talking and reduced linguistic complexity. ; American Psychiatric Association, 2013). Differentiating between typical disfluencies and stuttering (i.e., ambiguous and unambiguous moments of stuttering) is a critical piece of assessment, particularly for preschool children (see ASHAs resource on characteristics of typical disfluency and stuttering). Language, Speech, and Hearing Services in Schools, 49(1), 13. Journal of Fluency Disorders, 61, 105713. https://doi.org/10.1016/j.jfludis.2019.105713, Douglass, J. E., Schwab, M., & Alvarado, J. autism (see Scaler Scott, 2011, for a review), word-finding/language organization difficulties (Myers, 1992), and. For bilingual individuals, it is important for the clinician to consider the language or languages used during intervention. (2010). Treatment approaches are individualized based on the childs needs and family communication patterns. their disfluencies may be accompanied by physical tension and secondary behaviors. Language growth predicts stuttering persistence over and above family history and treatment experience: Response to Marcotte. See ASHAs resource on treatment goals for fluency disorders in the context of the WHO ICF framework. Cluttering: A synergistic framework. Stuttering: Its nature, diagnosis, and treatment. Clinicians need to be mindful of different beliefs and the stress imposed on the individual and family during treatment. Preliminary research suggests adults who clutter demonstrate differences in cortical and subcortical activity compared to controls (Ward et al., 2015). https://doi.org/10.1044/cicsd_31_S_69, Blood, G. W., & Blood, I. M. (2016). Overexpression of human NR2B receptor subunit in LMAN causes stuttering and song sequence changes in adult zebra finches. Adolescents and young adults who stutter were found to have more white matter connections in the right hemisphere as compared with normally fluent controls (Watkins et al., 2008). Journal of Speech, Language, and Hearing Research, 45(6), 10971105. International Journal of Speech-Language Pathology, 17(4), 367372.