PRIMARY VERSUS SECONDARY STUTTERING
Our consideration of the speech symptoms of stuttering would be incomplete
without noting the difference between the beginning and advanced forms
of the disorder. They have been labeled Primary versus Secondary Stuttering,
and have traditionally been defined in terms of the forcefulness and location
of the struggles. The Primary Stutterer is said to show effortless repetitions
only at the beginnings of sentences, and the Secondary Stutterer struggles
forcefully anywhere in the sentence.
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
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.
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