Classification & external resources

ICD-10	F98.5
ICD-9	307.0
OMIM	184450 609261
MeSH	D013342

Stuttering, also known as stammering in the United Kingdom, is a speech disorder in which the flow of speech is disrupted by involuntary repetitions and prolongations of sounds, syllables, words or phrases, and involuntary silent pauses or blocks in which the stutterer is unable to produce sounds. 'Verbal non-fluency' is the accepted umbrella term for such speech impediments. The term stuttering is most commonly associated with involuntary sound repetition, but it also encompasses the abnormal hesitation or pausing before speech, referred to by stutterers as blocks, and the prolongation of certain sounds, usually vowels. Much of what constitutes "stuttering" cannot be noted by the listener; this includes such things as sound and word fears, situational fears, anxiety, tension, self-pity, stress, shame, and a feeling of "loss of control" during speech. The emotional state of the individual who stutters in response to the stuttering often constitutes the most difficult aspect of the disorder. The term "stuttering", as popularly used, covers a wide spectrum of severity: it may encompass individuals with barely perceptible impediments, for whom the disorder is largely cosmetic, as well as others with extremely severe symptoms, for whom the problem can effectively prevent most oral communication.

Stuttering is generally not a problem with the physical production of speech sounds or putting thoughts into words. Despite popular perceptions to the contrary, stuttering does not affect and has no bearing on intelligence . Apart from their speech impediment, people who stutter may well be 'normal' in the clinical sense of the term. Anxiety, low confidence, nervousness, and stress therefore do not cause stuttering per se, although they are very often the result of living with a highly stigmatized disability and, in turn, exacerbate the problem.

The disorder is also variable, which means that in certain situations, such as talking on the telephone, the stuttering might be more severe or less, depending on the anxiety level connected with that activity. In other situations, such as singing (as with country music star Mel Tillis or pop singer Gareth Gates) or speaking alone (or reading from a script, as with actor James Earl Jones), fluency improves. (It is thought that speech production in these situations, as opposed to normal spontaneous speech, may involve a different neurological function.) Some very mild stutterers, such as Bob Newhart, have used the disorder to their advantage, although more severe stutterers very often face serious hurdles in their social and professional lives. Although the exact etiology of stuttering is unknown, both genetics and neurophysiology are thought to contribute. Although there are many treatments and speech therapy techniques available that may help increase fluency in some stutterers, there is essentially no "cure" for the disorder at present.

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Classification

Developmental stuttering is stuttering that originates when a child is learning to speak and develops as the child matures into adulthood. Several other speech disorders resemble stuttering:

• Cluttering
• Parkinson's speech
• Essential tremor
• Spasmodic dysphonia
• Social anxiety

Onset and development

Stuttering is generally a developmental disorder beginning in early childhood and continuing into adulthood at least 20% of children of those affected.^[1]. In some cases stuttering may acquired in adulthood as the results of a head injury or other neurological event.^[1]

The mean onset of stuttering is 30 months, or two and a half years old.^[1] Stuttering rarely begins after age six.

65% of preschoolers who stutter spontaneously recover, in their first two years of stuttering.^[1][3] Only 18% of children who stutter five years recover spontaneously.^[4] The peak age of recovery is 3.5 years old. By age six, a child is unlikely to recover without speech therapy.

Among preschoolers, boys who stutter outnumber girls who stutter about two to one, or less.^[5][5] But more girls recover fluent speech, and more boys don't.^[6] By fifth grade the ratio is about four boys who stutter to one girl who stutters. This ratio remains into adulthood.^[7]

All children experience normal dysfluencies as they learn to talk, which they will outgrow. A current issue is whether stuttering develops progressively from normal childhood dysfluencies, or whether stuttering is something entirely different. Many parents are unsure whether their child's dysfluencies are normal, or whether he or she is beginning to stutter. As speech and language are difficult and complex skills to learn, almost all children have some difficulty in developing these skills. This results in normal dysfluencies that tend to be single-syllable, whole-word or phrase repetitions, interjections, brief pauses, or revisions. In the early years, a child will not usually exhibit visible tension, frustration or anxiety when speaking dysfluently and most will be unaware of the interruptions in their speech. With young stutterers, their dysfluency tends to be episodic, and periods of stuttering are followed by periods of relative fluency. This pattern remains through all stages of a stutterer's development, but as the stutter develops, the dysfluencies tend to develop more into repetitions and sound prolongations, often combined together (e.g., "Lllllets g-g-go there").

Usually by the age of six, a stutter is exacerbated when the child is excited, upset or under some type of pressure. Also around this age, a child will start to become aware of problems in his or her speech. After this age, stuttering includes repetitions, prolongations, and blocks. It also becomes more and more chronic, with longer periods of disfluency. Secondary motor behaviors (eye blinking, lip movements, etc.) may be used during moments of stuttering or frustration. Also, fear and avoidance of sounds, words, people, or speaking situations usually begin at this time, along with feelings of embarrassment and shame. By age 14 , the stutter is usually classified as an "Advanced stutter," characterized by frequent and noticeable interruptions, with poor eye contact and the use of various tricks to disguise the stuttering. Along with a mature stutter come advanced feelings of fear and increasingly frequent avoidance of unfavorable speaking situations. Around this time many become fully aware of their disorder and begin to identify themselves as "stutterers." With this may come deeper frustration, embarrassment and shame.

It is important to note that stuttering does not affect intelligence and that stutterers are sometimes wrongly perceived as being less intelligent than non-stutterers. This is mainly due to the fact that stutterers often resort to a practice called word substitution, where words that are difficult for a stutterer to speak are replaced with less-suitable words with one or two syllables that are easier to pronounce. This often leads to simple, short, and awkward sentences which give an impression of feeble mindedness. A stutterer may take longer to answer a question or respond, because it takes them longer to get a word out. They have to think about every word they are going to say and how they might modify that word so that a stuttering moment won't occur or won't be as intense. Stutterers often feel great frustration because they know what they want to say, but can not translate it into spoken language using the same words they are thinking of or the way they would like to. They may also feel that non-stutters do not have the patience to wait and listen for the prolonged time it could take them to complete what they want to say. Stuttering is a communicative disorder that affects speech; it is not a language disorder—although a person's use of language is often affected or limited by a stutter.^[8][9]

Characteristics

Core and secondary behaviors

Core stuttering behaviors include disordered breathing, phonation (vocal fold vibration), and articulation (lips, jaw, and tongue). Typically these muscles are overtensed, making speech difficult or impossible.

Secondary stuttering behaviors are unrelated to speech production. Such behaviors include physical movements such as eye-blinking or head jerks; avoidance of feared words, such as substitution of another word; interjected "starter" sounds and words, such as "um," "ah," "you know,"; and vocal abnormalities to prevent stuttering, such as speaking in a rapid monotone, or affecting an accent.

Fluency

Speech fluency consist of three variables: continuity, rate, and ease of speaking. Continuity refers to speech that flows without hesitation or stoppage. Rate refers the speed in which the words are spoken. For English-speaking adults, the mean overall speaking rate is 170 words per minute (w/m), substantially quicker than the approximately 120 w/m that stutterers produce.^[8] Ease of speaking refers to the amount of effort being expended to produce speech. Fluent speakers put very little muscular or physical effort into the act of speaking, while stutterers exert a relatively large amount of muscular effort to produce the same speech. In addition to the physical effort involved in producing speech, the mental effort is usually much greater in stutterers than non-stutterers.^[8]

Disfluency in speech, including repetitions and prolongations, is normal for all speakers, but stuttering is distinct from normal disfluency in that it occurs with greater frequency and severity—the disfluencies occur much more often and tend to last longer with more strain. The types of disfluencies are also markedly different: normal disfluencies tend to be a repetition of whole words or the interjection of hesitation markers like "um" and "er," while stuttering tends to be repetition and prolongation of sounds and syllables. The various behaviors that can disrupt the smooth flow of speech include repetition, prolongations, and pauses:^[10]

• Repetition occurs when a unit of speech, such as a phrase, word, or syllable, is superfluously repeated. (Examples of repetition for a phrase would be, "I want.. I want.. to go.. I want to go to the store," or, "I want to go to the - I want to go to the store." A word repetition would often resemble, "I want to-to-to go to the store," and a syllable or sound repetition being, "I wa-wa-want to go to the store," or, "I w-w-want to g-go to the store.") Repetition occurs in the speech of both stutterers and non-stutterers, but non-stutterers are less likely to repeat shorter units of speech, mainly repeating phrases and sometimes words but rarely syllables. Non-stutterers will also, in the majority of cases, repeat the unit once or twice as opposed to the 6 or so times common from stutterers.
• Prolongations are one of the least typical behavior exhibited by stutterers. Prolongations normally happen with child stutterers and with the sounds /θ/, /ʃ/, /v/, and any other fricative consonant or vowel. With stutterers, prolonging a sound sometimes leads to a pitch and volume increase.
• Pauses are also a common source of disfluency in both stutterers and non-stutterers. Most pauses can be divided into two categories: filled pauses and unfilled pauses.
• Unfilled pauses are extraneous portions of silence in the ongoing stream of speech. These pauses differ from the pauses that punctuate normal speech, where they reflect common sentence structure or are used to add a particular rhythm or cadence to speech. Unfilled pauses by stutterers are usually unintentional and may cause the larynx to close, restricting the flow of air necessary for speech. Stutterers refer to this as "blocking".
• Filled pauses are interjections typical in normal speech like "um", "uh", "er", and so on. In speech these serve as a kind of place-holder—a way a speaker lets listeners know that he or she still has the floor and is not finished speaking. In addition to being used as a way of preempting interruption, they are also used by stutterers as a way of easing into fluency or deflecting embarrassment when they cannot speak fluently.

Avoidance behavior

When stuttering, stutterers will often use nonsense syllables or less-appropriate (but easier to say) words to ease into the flow of speech. Stutterers also may use various personal tricks to overcome stuttering or blocks at the beginning of a sentence, after which their fluency can resume. Finger-tapping or head-scratching are two common examples of tricks, which are usually idiosyncratic and may look unusual to the listener. In addition to word substitution or the use of filled pauses, stutterers may also use starter devices to help them ease into fluency. A common practice is the timing of words with a rhythmic movement or other event. For instance, stutterers might snap their fingers as a starter device at the beginning of speech. These devices usually do work, but only for a short amount of time. Often a person who stutters will do something at some point to avoid, postpone, or disguise a stutter and, by coincidence, will not stutter. The stutterer then makes a cause-effect connection between that new behavior and the release of the stuttering, and the behavior becomes a habit.^[10]

As stutterers often resort to word substitution in order to avoid stuttering, some develop an entire vocabulary of easy-to-pronounce words in order to maintain fluent speech—sometimes so well that no one, not even their spouses or friends, know that they have a stutter. Stutterers who successfully use this method are called "covert stutterers" or "closet stutterers". While they do not actually stutter in speech they nevertheless suffer greatly from their speech disorder. The extra effort it takes to scan ahead for feared words or sounds is stressful, and the replacement word is usually not as adequate a choice as the stutterer originally intended. Some stutterers have even changed their own given name because it contains a difficult-to-pronounce sound and frequently leads to embarrassing situations.

Although this behavior may appear unusual or unreasoned to a fluent speaker, to a stutterer it comes as second nature: due to the embarrassment and fear associated with speaking, many stutterers will wish to hide their stutter from listeners. This is the prime reason for avoidance.

Severity

When the behaviors of a stutter are infrequent, brief, and are not accompanied by substantial avoidance behavior, the stutter is usually classified as a mild or a non-chronic stutter. Non-chronic stuttering is often called "situational stuttering" because the afflicted person generally has difficulty speaking only in isolated situations—usually during public speaking or other stressful activities—and outside of these situations the person generally does not stutter. When the behaviors are frequent, long in duration, or when there are visible signs of struggle and avoidance behavior, the stutter is classified as a severe or chronic stutter. Unlike mild or situational stuttering, chronic stuttering is present in most situations, but can be either exacerbated or eased depending on different conditions (see Positive conditions). Severe stutters often, but not always, are accompanied by strong feelings and emotions in reaction to the problem such as anxiety, shame, fear, self-hatred, etc. This is usually less present in mild stutterers and serves as another criteria by which to define stutters as mild or severe. Another way of discerning between the two severities is by percentage of disfluency per 100 words. When a speaker experiences disfluencies at a rate around 10%, they usually have a mild stutter, while 15% or more is usually indicative of a severe stutter.^[9] In addition to the disfluency, many people who stutter display secondary motor behaviors. Observers often notice muscles tensing up, facial and neck tics, excessive eye blinking, and lip and tongue tremors. In extreme cases entire body movements may accompany stuttering. Most common with stutterers is the inability to maintain eye contact with the listener, which in many cultures may hamper the growth of personal or professional relationships.

It is worth noting that the severity of a stutter is not constant and that stutterers often go through weeks or months of substantially increased or decreased fluency. Stutterers universally report having "good days" and "bad days" and report dramatically increased or decreased fluency in specific situations. Below is an overview of the circumstances that harm and help the fluency of most stutterers:

Positive conditions

Subtle changes in mood or attitude often greatly increase or decrease fluency, with many stutterers developing tricks or methods to achieve temporary fluency. Stutterers commonly report dramatically increased fluency when singing, whispering or starting speech from a whisper, speaking extremely slowly, speaking in chorus, speaking without hearing their own voice (e.g., speaking over loud music), speaking with a metronome or other rhythm, speaking with an artificial accent or voice, speaking in a foreign dialect, or when speaking while hearing their own voice with a delay or pitch change. Stutterers also display increased fluency when speaking to nonjudgmental listeners, such as pets, children, or speech pathologists. It is perhaps most interesting to note that most stutterers experience extraordinary levels of fluency when talking to themselves. A rare few even experience increased fluency when they exclusively "have the floor" (public speaking or teaching), when they are intoxicated, or when they are explicitly trying to stutter. There is no universally accepted explanation for these phenomena. Non-stutterers often interpret such instances of fluency as evidence that a stutterer can in fact speak "normally", which may partly explain the popular belief that stuttering is a transient nervous condition. Nevertheless, the appearance of fluency in certain situations in no way indicates that a stutterer can consciously produce similar fluency at other times, or that the disorder is any less "real".

Negative conditions

All speech is more difficult when under pressure. Commonly, social pressures, like speaking to a group, speaking to strangers, speaking on the telephone, or speaking to authority figures, will irritate and make worse a stutter. Also, time pressure often exacerbates a stutter. Pressure to speak quickly when answering or conversing is usually very difficult for a stutterer, particularly on the telephone where stutterers do not have body language to aid themselves. This usually leaves dead silence in the place of nonverbal communication, which will indicate to the listener that the stutterer is not there or the line has been disconnected. Other time pressures will also worsen a stutter, such as saying one's own name, which must be done without hesitation to avoid the appearance that one does not know his or her own name, repeating something just said, or speaking when somebody is waiting for a response. By 16 years of age, a person who stammers will have had a great deal of experience of stammering and, for many, these experiences have been quite negative. The threat of being teased, bullied or not accepted takes a tremendous toll on the stutterer's everyday life. A person dealing with this may often feel like he or she has limited opportunities and options since today speaking out in public is almost a necessity, especially when one wants to be successful in one's career.

Causes

No single, exclusive cause of stuttering is known. A variety of hypotheses and theories suggest multiple factors contributing to stuttering.

Neurology of adult stuttering

Brain scans of adult stutterers have found several neurological abnormalities:

• During speech adult stutterers have more activity in their right hemispheres, which is associated with emotions, than in their left hemispheres, which is associated with speech. Non-stutterers have more left-hemisphere activity during speech. It is unknown whether this abnormal hemispheric dominance results from something wrong with stutterers' left-hemisphere speech areas, with right-hemisphere area unsuited for speech taking over speech tasks; or whether the unusual right-hemisphere activity is related to fears, anxieties, or other emotions stutterers associate with speech.
• During speech, adult stutterers have central auditory processing underactivity. One study suggested that stutterers may have an inability to integrate auditory and somatic processing, i.e., comparing how they hear their voices and how they feel their muscles moving.^[11]
• A brain scan study examined the planum temporale (PT), an anatomical feature in the auditory temporal brain region. Typically people have a larger PT on the left side of their brains, and a smaller PT the right side (leftward asymmetry). A brain scan study found that stutterers' right PT is larger than their left PT (rightward asymmetry).^[12]
• Adult stutterers have overactivity in the left caudate nucleus speech motor control area. Because stuttering is primarily overtense, overstimulated respiration, vocal folds, and articulation (lips, jaw, and tongue) muscles, it should be no surprise that the brain area that controls these muscles is overactive.

No brain scan studies have been done of stuttering children. It is unknown whether stuttering children have neurological abnormalities.

The first brain imaging studies in stuttering were done on two subjects using SPECT scanning before and after the administration of haloperidol. The researchers found that the subjects with stuttering had less blood flow in the Broca's and Wernicke's area and associated this with dysfluency. They found that haloperidol not only reduced stuttering but reversed this functional abnormality. Numerous PET and functional MRI studies have presented data that is in agreement with this first study.

Volumetric MRI studies have found that portions of the Broca's and Wernicke's areas are smaller in people who stutter and this correlates well with the hypometabolism in these two brain regions. New forms of structural MRI have found that there is a disconnection in white matter fiber tracts in the left hemisphere and greater numbers of white matter fiber tracts in the right hemisphere.

Stress-related changes

In certain situations, such as talking on the telephone, stuttering might increase, or it might decrease, depending on the anxiety level connected with that activity.

Under stress, people's voices change. They tense their speech-production muscles, increasing their vocal pitch. They try to talk faster. They repeat words or phrases. They add interjections, also known as "filler words", such as "uh." These are normal dysfluencies. A study found that under stress, non-stutterers went from 0% to 4% dysfluencies, for the simple task of saying colors. Stutterers went from 1% to 9%.^[13]

Stuttering reduces stress 10%, as measured by systolic blood pressure.^[14] Stuttering appears to reduce stress temporarily, but then cause stress, creating a cyclical pattern in which the stutterer stutters on the first syllable of the first word, then says the rest of the word and several more words fluently, then stutters again, then says a few more words fluently, and so on.

One study found that developmental stuttering and Tourette syndrome may be pathogenetically related.^[15] Tics are exacerbated by stress, and when the affected person tries harder to control the undesired movement, the conditions can become more pronounced.

Epidemiology

Stuttering affects males two to five times more often than females.^[16][1][5] The lifetime prevalence, or the proportion of individuals expected to stutter at one time in their lives, is about 5%.^[18] Most stuttering begins in early childhood and according studies suggest 2.5% of children under the age of 5 stutter.^[18][18] Due to high rate (approximately 65-75%) rates of early recovery,^[16][19] the overall prevalence of stuttering is generally considered to be approximately 1%.^[20][1]

The stuttering occurs at similar rates in different countries around the world.^[1] A US-based study indicated that there were no racial or ethnic differences in the incidence of stuttering in preschool children.^[18][18]

Adult treatments

A wide variety of stuttering treatments are available. No single treatment is effective for every stutterer. This suggests that stuttering doesn't have a single cause, but rather is the result of several interacting factors. If so, then combining several stuttering treatments may be more effective than relying on a single treatment. Many speech-language pathologists favor such an integrated approach to stuttering, and tailor therapy to each individuals' needs.

Fluency shaping therapy

Fluency shaping therapy trains stutterers to speak fluently by relaxing their breathing, vocal folds, and articulation (lips, jaw, and tongue).

Stutterers are usually trained to breathe with their diaphragms, gently increase vocal fold tension at the beginning of words (gentle onsets), slow their speaking rate by stretching vowels, and reduce articulatory pressure. The result is slow, monotonic, but fluent speech. This abnormal-sounding speech is used only in the speech clinic. After the stutterer masters these target speech behaviors, speaking rate and prosody (emotional intonation) are increased, until the stutterer sounds normal. This normal-sounding, fluent speech is then transferred to daily life outside the speech clinic.

Stuttering modification therapy

The goal of stuttering modification therapy is not to eliminate stuttering. Instead, the goals are to modify moments of stuttering so that stuttering is less severe and reduce the fear of stuttering, while eliminating avoidance behaviors associated with this fear. Unlike fluency shaping therapy, stuttering modification therapy assumes that adult stutterers will never be able to speak fluently, so the goal is to be an effective communicator despite stuttering.

Stuttering modification therapy has four stages:

• In the first stage, called identification, the stutterer and clinician identify the core behaviors, secondary behaviors, and feelings and attitudes that characterize the stuttering.
• In the second stage, called desensitization, the stutterer tells others about stuttering, freezes core behaviors, and intentionally stutters ("voluntary stuttering").
• In the third stage, called modification, the stutterer learns "easy stuttering." This is done by "cancellations" (stopping in a dysfluency, pausing a few moments, and saying the word again); "pull-outs," or pulling out of a dysfluency into fluent speech; and "preparatory sets," or looking ahead for words one may stutter on, and using "easy stuttering" on those words.
• In the fourth stage, called stabilization, the stutterer prepares practice assignments, makes preparatory sets and pull-outs automatic, and changes their self-concept from being a person who stutters to being a person who speaks fluently most of the time but who occasionally stutters mildly.

Anti-stuttering devices

Altered auditory feedback, so that stutterers hears their voice differently, has been used for over 50 years in the treatment of stuttering.^[23] Altered auditory feedback effect can be produced by speaking in chorus with another person, by providing blocking out the stutterer's voice while talking (masking), by delaying the stutterer's voice slightly (delayed auditory feedback) and/or by altering the frequency of the feedback (frequency altered feedback). Studies of these techniques have had mixed results, with some stutterers showing substantial reductions in stuttering, while others improved only slightly or not at all.^[23] In a 2006 review of the efficacy of stuttering treatments, none of the studies on altered auditory feedback met the criteria for experimental quality, including the absence of control groups.^[24]

Anti-stuttering medications

The effectiveness of pharmacological agents, such as anti-convulsants, anti-depressants, antipsychotic and antihypertensive medications, and dopamine antagonists in the treatment of stuttering has been evaluated in studies involving both adults and children.^[25] A comprehensive review of pharmacological treatments of stuttering in 2006 concluded that few of the drug trials were methodologically sound.^[25] Of those that were, only one, not unflawed study,^[26] showed a reduction in stuttering to less than 5%. In addition, potentially serious side effects of pharmacological treatments were noted.^[25]

Stuttering and society

For centuries stuttering has featured prominently in both popular culture and in society at large. Because of the unusual-sounding speech that is produced, as well as the behaviors and attitudes that accompany a stutter, stuttering has been a subject of scientific interest, curiosity, discrimination, and ridicule. Stuttering was, and essentially still is, a riddle with a long history of interest and speculation into its causes and cures. Stutterers can be traced back centuries to the likes of Demosthenes, Aesop, and Aristotle—some interpret a passage of the Bible to indicate Moses also to have been a stutterer.^[27] Misinformation and superstition have influenced society's perceptions of the causes and remedies of a stutter, as well as the intelligence and perceived disposition of people afflicted with the disorder.

Partly due to a perceived lack of intelligence because of his stutter, the man who became the Roman Emperor Claudius was initially shunned from the public eye and excluded from public office. His infirmity is also thought to have saved him from the fate of many other Roman nobles during the purges of Tiberius and Caligula. Isaac Newton, the English scientist who developed the law of gravity, also had a stutter. Other famous Englishmen who stammered were King George VI and Prime Minister Winston Churchill, who led the UK through World War II. Although George VI went through years of speech therapy for his stammer, Churchill thought that his own very mild stutter added an interesting element to his voice: "Sometimes a slight and not unpleasing stammer or impediment has been of some assistance in securing the attention of the audience…"^[28]

Ancient views of stuttering

For centuries "cures" such as consistently drinking water from a snail shell for the rest of one's life, "hitting a stutterer in the face when the weather is cloudy", strengthening the tongue as a muscle, and various herbal remedies were used.^[29] Similarly, in the past people have subscribed to theories about the causes of stuttering which today are considered odd. Proposed causes of stuttering have included tickling an infant too much, eating improperly during breastfeeding, allowing an infant to look in the mirror, cutting a child's hair before the child spoke his or her first words, having too small a tongue, or the "work of the devil."^[29]

Roman physicians attributed stuttering to an imbalance of the four bodily humors: yellow bile, blood, black bile, and phlegm. Humoral manipulation continued to be a dominant treatment for stuttering until the eighteenth century. Italian pathologist Giovanni Morgagni attributed stuttering to deviations in the hyoid bone, a conclusion he came to via autopsy. Later in the century, surgical intervention, via resection of a triangular wedge from the posterior tongue to prevent spasms of the tongue, was also tried.

Blessed Notker of St. Gall (ca. 840–912), called Balbulus (“The Stutterer”) and described by his biographer as being "delicate of body but not of mind, stuttering of tongue but not of intellect, pushing boldly forward in things Divine," was invoked against stammering.

Discrimination and awareness

In addition to personal feelings of shame or anxiety, discrimination is a significant problem for stutterers. The majority of stutterers experience or have experienced bullying, harassment, or ridicule to some degree during their school years from both peers and teachers who do not understand the condition.^[30] It can be especially difficult for stutterers to form friendships or romantic relationships, both because stutterers may avoid social exposure and because non-stutterers may find the disorder unattractive. The stigma of stuttering carries over into the workplace, often resulting in severe employment discrimination against stutterers. Consequently, stuttering has been legally classified as a disability in many parts of the world, affording stutterers the same protection from wrongful discrimination as for people with other disabilities. The UK Disability Discrimination Act 1995 and the Americans with Disabilities Act of 1990 both expressly protect stutterers from wrongful dismissal or discrimination.^[31][32]

The U.S. Congress passed a resolution in May 1988 designating the second week of May as Stuttering Awareness Week, while International Stuttering Awareness Day (ISAD), is held internationally on October 22. In September 2005, ISAD was recognised and supported by over 30 Members of the European Parliament (MEPS) at a reception given by the European League of Stuttering Associations.

Even though public awareness of stuttering has improved markedly over the years, misconceptions are still common, usually reinforced by inaccurate media portrayals of stuttering and through popular misconception. A 2002 study focusing on college-age students conducted by the University of Minnesota Duluth found that a large majority viewed the cause of stuttering as either nervousness or low self-confidence, and many recommended simply "slowing down" as the best course of action for recovery.^[33] While these misconceptions are damaging and may actually worsen the symptoms of stuttering, groups and organizations are making significant progress towards a greater public awareness.

See also

• List of stutterers
• The Monster Study
• Dyslexia
• Speech processing
• Stuttering Foundation of America
• Basal ganglia

Notes

References

• Alm, Per A. (2004). "Stuttering and the basal ganglia circuits: a critical review of possible relations". Journal of communication disorders 37 (4): 325-69. PMID 15159193. 
• Alm, Per A. (2005). On the Causal Mechanisms of Stuttering. Doctoral dissertation, Dept. of Clinical Neuroscience, Lund University, Sweden.
• Compton, D. G. (1993). Stammering : its nature, history, causes and cures. Hodder & Stoughton. ISBN 0-340-56274-9. 
• Conture, Edward G. (1990). Stuttering. Prentice Hall. ISBN 0-13-853631-7. 
• Fraser, Jane (2005). If Your Child Stutters: A Guide for Parents. Stuttering Foundation of America. ISBN 0-933388-44-6. 

External links

• The Stuttering Foundation of America
• Stuttering at the Open Directory Project
• Stuttering at the Open Directory Project (Organizations)

•  • [ e] WHO ICD-10 Mental and behavioural disorders (, )
Neurological/symptomatic	Dementia (Alzheimer's disease, Multi-infarct dementia, Pick's disease, Creutzfeldt-Jakob disease, Huntington's disease, Parkinson's disease, AIDS dementia complex) - Delirium - Post-concussion syndrome
Psychoactive substance	Intoxication (Drunkenness) - Physical dependence (Alcohol dependence, Opioid dependency) - Withdrawal (Benzodiazepine withdrawal, Delirium tremens) - Amnesic (Korsakoff's syndrome)
Psychotic disorder	Schizophrenia (Disorganized schizophrenia) - Schizotypal personality disorder - Delusional disorder - Folie deux - Schizoaffective disorder
Mood (affective)	Mania - Bipolar disorder - Clinical depression - Cyclothymia - Dysthymia
Neurotic, stress-related and somatoform	Agoraphobia - Anxiety disorder - Panic disorder - Generalized anxiety disorder - Social Anxiety Disorder - OCD - Acute stress reaction - PTSD - Adjustment disorder - Conversion disorder (Ganser syndrome) - Somatoform disorder - Somatization disorder - Neurasthenia
Physiological/physical behavioural	Eating disorder (Anorexia nervosa, Bulimia nervosa) - Sleep disorder (Dyssomnia, Insomnia, Hypersomnia, Parasomnia, Night terror, Nightmare) - Sexual dysfunction (Erectile dysfunction, Premature ejaculation, Vaginismus, Dyspareunia, Hypersexuality) - Postpartum depression
Adult personality and behaviour	Personality disorder - Passive-aggressive behavior - Kleptomania - Trichotillomania - Voyeurism - Factitious disorder - Munchausen syndrome
Mental retardation	Mental retardation
Psychological development (developmental disorder)	Specific: speech and language (Expressive language disorder, Aphasia, Expressive aphasia, Receptive aphasia, Landau-Kleffner syndrome, Lisp) - scholastic skills (Dyslexia, Dysgraphia, Gerstmann syndrome) - motor function (Developmental Dyspraxia) Pervasive: Autism - Rett syndrome - Asperger syndrome
Behavioural and emotional, childhood and adolescence onset	ADHD - Conduct disorder - Oppositional defiant disorder - Separation anxiety disorder - Selective mutism - Reactive attachment disorder - Tic disorder - Tourette syndrome - speech (Stuttering, Cluttering)