Stammering can undermine someone's confidence and self-esteem, as Andrew Iles knows all too well. Here he draws on his experiences and takes a look at stammering

Think back to autumn 2001, and Pop Idol, the reality TV programme in search of a UK pop star, was in full swing. Gareth Gates was one of the finalists and he was speechless--literally. As each week went by, more and more viewers watched Gareth as he tried to speak, but he could not--the words just would not come out.

The public became endeared to him because of his speech difficulties. They could not quite understand how he could sing so fluently, but found speaking so impossible. And so Gareth became somewhat of a national figurehead for personal courage, "Just look at how brave that boy is, entering that competition with his problems." But I used to cringe; I could not bear to watch. As someone who stammers, I find stammering utterly embarrassing because it makes me realise how others see me.

The incidence of stammering is startlingly high. The British Stammering Association (BSA) suggests that as many as 1% of the adult population in the United Kingdom stammers.¹ The problem affects men between three to four times more than women. For children, the numbers are even higher with as many as 5% of under fives and 1.2% of school aged children living with the problem.¹

Marylin Monroe

To stammer or to stutter

Stammering describes a range of speech difficulties. It is characterised by stoppages and disruptions in fluency, which interrupt the smooth flow and timing of speech. These stoppages may take the form of repetitions of sounds, syllables or words, or of prolongations of sounds so that words seem to be stretched out, and can involve silent blocking of the airflow of speech when no sound is heard.² Stuttering means exactly the same as stammering, and is favoured in the United States. Some people avoid and substitute words to such an extent that people do not realise that they have a stammer. This is called covert stammering.

Why people stammer

The cause of stammering is complicated and not fully understood--there is no one accepted model. Genetics are thought to be relevant in some cases.³ People with a family history of stammering seem more likely to develop a stammer themselves. And brain imaging studies have shown differences in the brain activity of people who stammer compared with those who speak fluently.^4,5

The severity of someone's stammer is not constant--a stammer often becomes worse in times of increased anxiety. Examples of such situations include speaking on the telephone and attending job interviews. Someone who stammers may become more anxious when there is an expectation for them to speak. For this reason some children who stammer find it difficult to answer their name when a class register is being called. Physical factors such as excitement, illness, fatigue, and sadness can make speaking for someone who stammers even harder. There is also a tendency for people who stammer to become stuck on the words in a sentence, which carry the most meaning. The psychological stress of being unable to express themselves clearly makes the problem worse.¹

MOK YUI MOK/PA

Gareth Gates

A communication problem

Stammering is more than a speech difficulty--it is a serious communication problem. Stammering can undermine confidence and self esteem and interfere with their interpersonal relationships, education, and career. The problem is often endured without adequate support from specialised services. When I was 7, after just two sessions with a speech and language therapist, I was discharged from the clinic. My mother was told that I would grow out of it, and that I stammered because my brain worked too fast for my mouth. This is of course a myth, as is the idea that people who stammer are less intelligent. But many children do not even make it to clinic, as awareness of specialised speech services is so poor.

Speech and language therapy is most effective in children under 5 before psychological issues of anxiety and self consciousness arise.⁶ Evidence shows that when treatment is given before this age, the child is able to learn to speak fluently again with no evidence of recurrence.⁷ Treatment for older children and adults is more complex and aims to manage the problem rather than provide a cure.

It was not until my second year at medical school that I tackled the problem of my speech again. Frustrated with my problem and my earlier experiences, I arranged to attend private classes to help overcome my stammer. Despite the abundance of advertisements for coaching by former stammerers, I opted to see an elocution teacher with a strong interest in speech fluency problems. The weekly lessons have been helpful, and although I am constantly aware of having to work around my stammer, I now feel more confident speaking.

An approach to speech therapy

There is a consistent thread that runs through everyone's problem--breathing. People who stammer snatch a breath and take a run at the sentence as fast as they can. Often the first task facing someone who stammers is to learn how to breathe properly--a technique known as intercostal-diaphragmatic breathing. This has a calming effect, but more importantly it gives them time to speak slowly and support the voice. Support comes from the abdominal muscles and lower ribs, and not the throat and chest.

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Bruce Willis

Secondly, people who stammer often speak with their mouth almost shut. Teaching people to speak with their mouths open wider gives them better control. This makes their muscles become more relaxed thereby improving vocal resonance and giving the speech a more confident quality.

The third most important rule for people who stammer is to speak slowly. People who stammer are so terrified of their speech becoming stuck that they rush their speech, which creates even more problems. In short, people who stammer need to speak slowly, open their mouth, and breathe.

Singing without stammering

A curiosity surrounding stammering is how someone who stammers can sing so perfectly. The answer is that when someone sings they take in deep breaths, thus supporting their voice. They also open their mouths wide, and take time to sing the words--the basis of the treatment that I receive. But more than that, performing means taking on a role. A person who is recovering from a stammer is also playing a part. They are performing the role of someone who speaks fluently.

Communicating with patients

I chose to resolve my speaking difficulties for many reasons, but one of the most important of these was to improve my communication with patients. I felt as if I should do everything I could to make my speech as clear and understandable as possible. Communicating with patients is such an important aspect of medicine that hiding from my problem would have been a disservice on my part.

A profile of Aidan Halligan, the chief medical officer for England,⁸ showed how successfully people have overcome the challenges that a stammer can present. International celebrities who have had stammers include the film actors Bruce Willis and Sam Neill, US singer-songwriter Carly Simon, and Marylin Monroe.

Stammering should not prevent someone progressing in life but it does put obstacles in their way. Many successful people have stammered at some point in their life.

Andrew Iles Clegg scholar, BMJ

Email: ailes@bmj.com

Helen Love elocution, speech, and drama teacher, The Cardiff Academy of Speech and Drama
Email: hlove@fish.co.uk

1. British Stammering Association, www.stammering.org (accessed 13 Oct 2003).
2. Enderby P. Stammering: what the research is telling us. London, British Stammering Association, 1996.
3. Amrose N, Cox N, Yairi E. The genetic basis of persistence and recovery in stuttering. J Speech Hear Res 1997;40:567-80.
4. Foundas AL, Bollich AM, Corey DM, Hurley M, Heilman KM. Anomalous anatomy of speech-language areas in adults with persistent developmental stuttering. Neurology 2001;57:207-15.
5. Sommer M, Koch MA, Paulus W, Weiller C, and Buchel C. Disconnection of speech-relevent brain areas in persistent developmental stuttering. Lancet 2002;360;380-3.
6. Starkweather CW, Gottwald SR, Halfond MM. Stuttering prevention: a clinical method. New Jersey: Prentice Hall, 1990.
7. Attanasio JS, Onslow M, Packman A, Onslow M. Representativeness reasoning and the search for the origins of stuttering: a return to basic observations. J Fluency Disord 2003;23:265-77.
8. MacDonald R. The charm of the Irish. BMJ 2003;327(suppl):S94.

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