My examination of patients led me to conclude that the force distinction was erroneous; type III and IV stutterers, for example, never struggle openly but are clearly advanced forms of the disorder. I therefore developed, in its place, three diagnostic questions which have been shown to yield far more useful information. The first question is, "When you speak, do you sometimes look ahead for difficult words and try to substitute one word for another?" The second, "Can you usually tell when you are going to stutter just before it happens?" And the third, "Do you stutter when you talk to yourself out loud alone?"

A primary stutterer will answer no to all three. Indeed, for the very young child, the questions may not make sense, and this lack of understanding is a positive sign that the child has no anticipatory stress. Children who respond this way will invariably show repetitions or hesitations only at the beginnings of sentences. The behaviors may, however, be forceful.

The Secondary Stutterer will usually say yes to the first two questions and no to the last. If the last question is also responded to with a yes, it is a indication that the overall stress level is high. The Secondary Stutterer usually exhibits strong struggle behaviors which can occur anywhere in the sentence.

Using the severity of the struggle as the major distinction between Primary and Secondary Stuttering is, as I have indicated, invalid. For example, twenty percent of patients are hidden or "closet" stutterers. They never stutter but rather look ahead for difficult sounds, words and situations and avoid them. No one knows they stutter - their overt struggle symptoms are less than mild; they are non-existent.

So the distinction between Primary and Secondary Stuttering cannot be the magnitude of the struggle behavior but has to be the presence or absence of anticipatory stress. Does the patient see the sounds, words or fearful speaking situations approaching? For most children under seven, the answer is no, and they are Primary, for most over ten, the answer is yes, and they are Secondary. And during the three-year interval between, there exists a period of Transitional Stuttering.

During Transitional Stuttering the child may report fear of speaking in certain situations while at the same time have no knowledge of the words or sounds with which he will have difficulty. Also during this period some children will report that they can see some of the feared words coming but that others are a surprise. The average eight year old will understand the following line of questioning, "Sometimes you have trouble with your speech, don't you? When you have trouble, do you know what words you are going to have trouble with - can you see the hard words coming?" The child may respond, "Sometimes." This is followed with the question, "You mean sometimes you can tell and sometimes it's a surprise - is that right?" Usually the child will say yes and the next question is, "Is it mostly a surprise or mostly you can tell?"

If the child says it's mostly a surprise we can be fairly certain he is at the beginning of the transitional period. But if he reports that mostly he can tell, we must then view him as an adult stutterer and treat him accordingly.

While it is generally correct to say that most children under the age of seven are Primary Stutterers and those over the age of ten are Secondary, it is clear there are many exceptions to this rule. I have seen precocious five year olds with well established sound, word and situation fears coupled with strong struggle behaviors and word substitutions. And I have also seen teenagers with no word or sound anticipations and only minor effortless repetitions at the beginnings of sentences.

Another reason for focusing on the presence or absence of anticipatory stress is that it directly relates to the expected outcome of therapy. A child with no word or sound fears is unaware of his difficulty and thus is not in much pain. Self-motivation to do anything about the problem is low and prognosis for recovery is guarded.

The Secondary Stutterer, on the other hand, lives in continuous anticipatory dread of feared words and sounds, and is in considerable emotional pain. Thus motivation to improve is great.

I attempted to treat several children who were clearly either Primary or Beginning Transitional Stutterers. In each instance, the child learned the techniques for stopping stuttering and upon returning home began practicing with a parent. In each instance, the technique produced complete fluency, but there was no motivation to follow through with the prescribed exercises.

The parents found themselves badgering the child and an initial willingness disintegrated into continuous bickering. They would call to express frustration and I would respond by altering the mix of exercises. But this, too, soon lost its power to sustain interest.

We would then use a reward system in which the child would be given a gold star for a correct sequence of performances. At a later time these could be redeemed for a prize. The reward system worked well for some but for others it, too, failed to sustain.

It became clear that it was unlikely that direct therapy with a primary stutterer would always be successful. Later in this book I will present a series of indirect approaches that have proven successful with a large number of Primary Stutterers.

My case records show several examples of children worked with unsuccessfully as Primary Stutterers who demonstrated a successful outcome five years later after they had become Secondary. In a sense it is very much like pneumonia. You may not be able to treat them when they have a cold, but you can when they have pneumonia.