Introduction to the Issue “Stuttering: Beyond Disfluencies”

I am honored to bring together this issue of Topics in Language Disorders focusing on developmental stuttering without specific focus on disfluent speech productions. For decades, much of the research in this field has centered on counting and characterizing observable disfluencies in the speech of people who stutter. We now have a more comprehensive understanding of the nature of stuttering that extends beyond speech productions alone (e.g., ^{Bloodstein et al., 2021}). Developmental stuttering arises from complex interactions between a vulnerable speech motor system, where the neural networks that regulate speech motor control produce unstable speech signals, and a set of child factors, including cognitive, language, emotional, and environmental characteristics (^{Smith & Weber, 2017}). Understanding these complex factors, and the interactions between them, is critical for understanding the nature of stuttering. Several of the articles in this issue focus on factors beyond speech production that contribute to stuttering.

Along similar lines, for decades, clinicians and researchers have acknowledged that it is critical for stuttering treatment to extend beyond a focus on stuttered events. Despite this knowledge, much of stuttering treatment in practice continues to focus on “reducing the number of disfluencies.” Several articles in this issue address why it is critical to focus on other factors in stuttering treatment and provide examples of how to target other communication goals. Together, this set of articles highlights important factors underlying stuttering and positive treatment outcomes for people who stutter, without focusing on speech disfluencies.

The first article in this issue focuses on relationships between language and stuttering across the life span (^{Brundage & Bernstein Ratner, 2022}). The authors begin by reviewing evidence of the influence of language features, including phonetic factors, word frequency, and syntactic structure, on the presence of stuttered events. They then review a long-disputed topic: Do individuals who stutter exhibit language differences compared with individuals who do not stutter? The high rate of concomitance of phonological disorders and the relationships between linguistic factors and stuttered events indicate the importance for including a comprehensive language evaluation of children who stutter in clinical assessments. The authors go on to discuss how language skills may influence persistence in or recovery from stuttering in children. The authors then review the recent and growing literature on stuttering in children who are bilingual and conclude with a discussion of the interface between language and speech motor factors in stuttering. Together, this comprehensive review highlights the multifaceted relationship between language and stuttering and the importance of additional research in this area as well as the need to include language as part of a comprehensive assessment plan in stuttering.

The next article, by ^{Usler (2022)}, provides a theoretical account that aims to explain the development and variability of stuttering. Usler proposes that stuttering develops in association with heightened cognitive conflict and control for speech production. Inconsistencies between decision-making, motivations, and/or expectations—action-based cognitions—and difficulty resolving those conflicts interfere with goal-directed actions. The challenges that occur in monitoring and regulating cognitive conflict associated with language and speech production result in disfluent speech. Stuttered events influence a child's awareness of and feelings about their speech, increasing cognitive conflict associated with speech and eventually resulting in persistence in stuttering. Usler discusses factors that influence the variability of stuttering, the development of stuttering, the sense of loss of control reported by individuals who stutter, and the nature of disfluent events. He concludes with a discussion of treatment effectiveness in stuttering as well as why the majority of children show recovery from stuttering while it persists in others. He concludes with specific future research directions that will explicitly test this theory. This theory provides connections between cognitive control and many factors associated with stuttering and presents concrete directions to advance understanding of the nature of stuttering.

A study by ^{Lescht et al. (2022)} directly tests one aspect of language in children who stutter—novel word learning. Using a well-studied paradigm, they taught children, aged 3–8 years, a set of novel nonword–object pairs, with nonwords ranging from two to four syllables. Following the training session, novel word recognition was assessed using a looking-while-listening task, where children looked at the labeled object, as well as immediate and delayed (1 hr) novel word recognition and production tasks. There were no differences in novel word recognition on any of the measures, indicating that, in this paradigm, where novel nonword learning was supported with repeated presentations of the word along with a labeled object, children who stutter and children who do not stutter exhibited similar novel word recognition abilities. These findings indicate that declarative learning processes for novel nonwords may be intact in children who stutter.

Expanding on their recent line of research, ^{Tichenor and colleagues (2022)} review their revised framework for stuttering based on the World Health Organization International Classification of Functioning, Disability, and Health (WHO-ICF; ^{Tichenor & Yaruss, 2019; World Health Organization, 2001}). They then detail multiple aspects of personal context, or individual reactions to stuttering that individuals experience. They discuss affective responses, including feelings of fear, anger, embarrassment, or guilt, behavioral responses, such as disfluent speech or avoidance, and cognitive reactions to stuttering—the thoughts a person has about their speech. They then review findings regarding the moment of stuttering and how speakers often report stuttered events that are not observed by the listener. In other words, the listener hears fluent speech but the person who stutters experiences a stuttered event. They discuss limitations of using only overt stuttering behaviors as criteria for research and clinical practice. Finally, they discuss treatment implications of the ICF model and of speakers' experiences of the moment of stuttering, providing specific suggestions and examples. Incorporating this more holistic view of stuttering has the potential to result in more comprehensive treatment of people who stutter that addresses aspects of stuttering beyond speech disfluencies.

In the final article in this issue, ^{Byrd et al. (2022)} evaluated a treatment approach for adults who stutter that focuses on communication competencies without any goals or evaluation of speech fluency or stuttered events. The treatment program focuses on both affective and cognitive aspects of stuttering (outlined in ^{Tichenor et al., 2022}) by targeting speaking confidently, communicating effectively, and advocating meaningfully with the aim of improving quality of life. The 12-week program combined weekly group and individual sessions that targeted specific aspects of each individual's life. After treatment, adults who stutter reported improved quality of life, as measured by the Overall Assessment of Speakers Experience of Stuttering (OASES; ^{Yaruss & Quesal, 2016}), and listeners rated adults who stutter as having greater communicative competence. Interestingly, changes in communicative competencies were not predicted by stuttering frequency prior to treatment. This preliminary study suggests that communicative, cognitive, and affective aspects of stuttering can be improved by stuttering treatment without focusing on modifying or eliminating stuttered events in adults who stutter. This study lays the foundation for future research that extends this important work to further expand and refine treatment to best serve quality-of-life outcomes in people who stutter.

Although the hallmark of stuttering is speech disfluencies, focusing on stuttering beyond disfluent speech serves to advance understanding of the disorder, specifically factors that contribute to the emergence of and persistence in stuttering, and treatment approaches that serve to support people who stutter in saying what they want, when they want, and how they want. Together, these articles focusing on stuttering beyond disfluencies offer perspectives that continue to advance our field in service and support of people who stutter.

—Amanda Hampton Wray, PhD, CCC-SLP
Issue Editor