Preliminary Report on the Treatment of Stuttering, Stammering, and Lisping In a New York School
The Psychological Clinic Copyright, 1912, by Lightner Witmer, Editor. Vol. VI. No. 4. June 15, 1912. :Author: Michael Levine, A.M., Teacher in Public School 6J+, New York City.1
The first question is: what is tlie difference between stuttering and stammering, terms which are used interchangeably by the layman? According to modern physiology they both denote a disease of the mechanism involved in the production of speech, disturbances in the organs governing respiration, phonation, and articulation. While many authorities differentiate stuttering from stammering, others claim that fundamentally they describe one and the same condition. Writers who have accepted the view that stuttering and stammering are one disease, have made subdivisions based on the kind of cramps experienced by the patient while speaking. For the purposes of this discussion, however, it will be convenient to separate the two terms and to allot to each its peculiar symptoms.
Stuttering may be used to denote faulty speech as a result of respiratory disturbances, the defects being in the muscles of respiration, or in the larynx, or in both. Stammering, on the other hand, may be used to denote a disability of the muscles of articulation. These defects do not include disorders of speech associated with brain lesions, or the conditions described under such terms as Stammeln, Hornstummheit, or other speech abnormalities.
The possible physiological causes of stuttering are very complicated, but two at least may be distinguished. Stuttering is caused by highly intensified nervous impulses which pass not only to the nerves controlling laryngeal activity, but also to those governing other motor activities. In many instances these other activities at first offer relief, but finally become involuntary, so that the i Public School No. 64 Is under the supervision of Associate Superintendent Gustave Straubenmuller and District Superintendent John W. Davis, to both of whom the writer is Indebted for sympathetic co-operation, and also to Principal William E. Grady, whose suggestions and kind assistance made the work possible. patient is unable to speak without them. In many cases, however, these associated motor activities are involuntary from the beginning. This is self-explanatory when we remember that the laryngeal nerves are branches of the vagus. All the muscles except the thyro-cricoid, which innervated by the superior laryngeal, receive nerve filaments from the inferior laryngeal branch of the vagus, the fibres being derived from the accessory roots. This cranial nerve sends off branches which supply the heart and other internal organs. Moreover, the vagus has practically the same origin as the glosso-pharyngeal and the facial nerves. The glosso-pharyngeal supplies motor fibres to the muscles of the pharynx and the base of the tongue, and secretory fibres to the parotid gland. The facial motor branches supply the muscles of the face, scalp, and ear, while its secretory fibres supply the submaxillary and sublingual glands. It is not surprising, therefore, that in severe attacks of stuttering not only do the lips move, but also the head, the jaws, the eyes, the nostrils, the arms and the legs in a frantic endeavor to produce the desired sound. These are the external manifestations. There are concomitant internal manifestations such as palpitation of the heart, dull pain in the stomach, parched throat, and other depressing symptoms.
Stuttering may be due to some aberration of the superior laryngeal or recurrent fibres. The temporary paralysis of these fibres deprives the stutterer of the power to speak because this nerve controls the smaller muscles of the larynx which in turn control the size of the glottis. The sudden changes in the larynx destroy the rhythm of breathing which is of fundamental importance to normal speech.
As distinguished from stuttering, the term stammering may be used to denote defects of the speech organs employed in producing consonants. The patient repeats involuntarily the sound of a consonant several times before he can glide on to the next sound. As a rule the stammerer speaks very rapidly when he is not in difficulty. In all cases there seems to be a lack of proper respiratory control.
The views expressed by the leading German authorities (see bibliography, page 10G) show that at present there is no consensus of opinion as to the causes of stammering and stuttering. The best ciiterion of their theories would be the results of methods based upon them. \ ithout doubt many factors are involved in producing stuttering and stammering, and many causes are assigned, the most common of which are fear, imitation, injury to organs of articulation, and heredity. An investigation of thirtytwo cases showed the following causes. In the case of the four marked “unknown,” the parents simply stated that their children had suddenly developed the habit.
TABLE I. CAUSES OF STUTTERING AND STAMMERING. Imitation 7 Results of disease 8 Nervousness caused by fright 13 Unknown 4 32 The defects made their appearance between the ages of five and eight years, and in but one case did a pupil begin to stammer after he had attained the age of eight.
Lisping is a relatively minor speech defect, usually due to absence of front teeth, an unusual protrusion of the lower jaw, to carelessness, and in many cases to a lack of knowledge concerning the position of the tongue and the shape of the mouth necessary to the production of various sounds. Assuming the truth of these fundamental considerations, yet remembering that our inferences are based on the limited material supplied by a single city school, let us inquire: (1) What is the percentage of stutterers, of stammerers, and of lispers in the school ? (2) What effect does school life have on the production of speech defects ?
(3) What specific remedial measures may be adopted? The figures given in Table II are very conservative, in that they represent only the pupils who are sent to the speech class because their speech is so poor as to handicap their progress. It is probable that a thorough examination of all the pupils in the school would largely increase these figures.
TABLE II. Per cent of Per cent of Per cent of bchool Enrolment defective stammerers and lispers or speakers stutterers “babytalkers” 2997 3.0 1.8 1.2 Investigations conducted abroad, in German and Belgium (see bibliography, page 106), show approximately similar results. As an index of general conditions the figures correspond to those given in table II, and while it may seem premature to generalize, yet it seems as if a thorough investigation of the problem in our city schools would reveal an even higher percentage of speech defectives here than abroad. In addition to ascertaining the number of speech defective in the schools, an interesting problem would be to find the distribution of such pupils in the grades, with a view to drawing .conclusions as to the influence of school conditions in producing speech defects. A careful study of the problem of distribution and school influence by Eouma in Belgium showed that the proportion of lispers diminishes from the first to the sixth school year, while the proportion of stutterers and stammerers increases in the same period. His figures also show a gradual increase in the number of stuttering and stammering boys from the first to the fourth grades, as in the following table:
TABLE III. First year 8 per cent Second year 1.3 ” ” Third year 2.0 ” ” Fourth year 2.4 ” ” Fifth year 1.8 ” ” Sixth year 2.3 ” “
Table IV shows the distribution of children with speech defects in Public School No. G4, New York City, (see page 97). In this table the number of stammerers, stutterers and lispers in each grade represents the number sent to the speech class by the grade teachers. Owing to duties imposed upon them by their parents, many of the children could not attend either the morning or afternoon sessions. As the table shows, only sixteen of the thirty-seven lispers attended the speech class.
A study of table IV will show that lisping is greatest in the early school years, and that it has a tendency to become less as we approach the third and fourth years. On the other hand the percentage of stammerers and stutterers increases rapidly. Few if any are found in the early grades, but the number increases until we have as many as 4 per cent in the eighth year of the elementary course. These results are substantially in accord with the findings of Rouma. Apparently the school is increasing rather than decreasing the number of speech defects. It is true that, as Rouma has remarked, indifference and neglect on the part of parents, are factors contributing to the acquisition of habits of faulty
TABLE IV.?DISTRIBUTION OF DEFECTIVE SPEAKERS IN PUBLIC SCHOOL NO. 64 Kgn 1A IB 2A 2E-2B 3A 3E-3B 4A 4E-4B 5A 5E-5B 6A 6E-6B 7A 7B 8A 8B Totals 75 204 145 174 188 187 184 190 252 237 253 243 189 155 127 95 99 2997 STUTTERER8 AND Stammerers 55 0.7 1.1 1.5 0.5 3.2 1.0 2.3 1.2 2.3 3.7 3.1 1.2 4.2 3.0 1.5 So a-S 11 32 Lispers and } Total Defect”Babytalkebs” ive Speakers o o 11 37 1.3 1.9 2.7 1.1 1.0 1.0 0.5 1.5 1.6 0.7 0.8 0.5 1.2 2.3 2.1 1.0 1.2 ? rt e5 ll5 II 0 0 0 0 2 2 0 1 3 4 0 0 0 0 3 0 1 16 1 4 5 4 5 3 6 3 10 7 8 11 7 4 3 7 4 92 1.3 1.9 3.4 1.1 2.6 1.5 3.2 1.5 3.9 2.9 3.1 4.5 3.7 2.5 2.3 6.3 4.0 3.0
speech by children, nevertheless, modern pedagogical methods probably produce many stutterers and stammerers. Devices such as perception cards, rapid oral arithmetic, rapid interrogation, compulsory answering irrespective of the pupil’s readiness and willingness, and those school activities in general which require intense mental effort combined with immediate oral response, frequently tend to transform a nervous tendency into a disease. There are, of course, still other factors within the control of the school. For example, a number of children who have been under instruction in, the speech class have relapsed into their former manner of speech shortly after promotion into a new class. Investigation has proved that various influences snch as nagging, over-pressure, sarcasm, and mimicry of classmates, all tend to disturb the pupil and hinder him from living up to the standards set for him in the speech class.
The pertinent question still remains, Avhat specific remedial measures can be adopted to assist the child with defective speech.
The first problem is one of organization. There are various possible modes of grouping such pupils:
Isolation and segregation of speech defectives in a special class, the session of which shall last from 9 a. m. to 3 p. m.
Compulsory attendance of speech defectives in the room of a regular teacher, preferably a departmental teacher, who having been relieved of official class work, can give within the limits of the school session, instruction for an hour or more daily to pupils who report to his room.
Attendance, compulsory or optional, of speech defectives before the regular session (8 to 8:30 a. m.) or after the regular session (3 to 3:30 p. m.) for instruction by a regular or a special teacher.
Looking at the problem in terms of a school district, rather than one particular school, attendance compulsory or optional at a centrally located school, conforming to any of the foregoing schemes.
Without going into the relative merits of these various plans, it may be remarked that it is inadvisable to isolate the defectives as suggested in (1). We may well apply to such pupils the statement of Dr flames Kerr Love with reference to the deaf. Instead of stuttering, stammering or lisping being a reason for sending a child to a special class, it is a good reason for keeping him out of it. Grouping him with others like himself would make him more conscious of his condition and this consciousness would become the basis of timidity. Moreover, it is obvious that normal pupils can set a better standard of speech than can any group of speech defectives. In connection with (2) it may be noted that a special class takes the pupil away from his regular lessons and retardation may result, not only directly from speech defects, but indirectly from absence during periods of instruction in sequential subjects. Conclusions like the above led to the organization in Public School To. 64 of a class which met for two short periods daily, one in the morning prior to the opening session (8 to 8: 30 a. m.), the other at the close of the session (3 to 3: 30 p. m.). The grade teachers were urged to co-operate bv attending a session of the speech class to note the method of instructing the pupils, and by making the pupils conform to certain standards in the daily recitation. The speech defectives were told to consult with their regulai class teachers and to indicate their willingness and readiness to recite orally by raising the hand. When reciting, the pupils are supposed to stand erect, to take deep breaths, to talk very slowly, and to try to vary the pitch. The teachers were requested to encourage the pupils to live up to these requirements. To compel speech defectives to recite in response to questions sharply put when they are not ready with an answer, frequently throws them iuto such a nervous state that in their attempt to answer, they will relapse into their former habits and nullify the results of special instruction.
Three forms of exercises were employed in the morning and afternoon speech classes.
1. An exercise to build up the weakened respiratory system. For this purpose, use was made of the “Two-minute drill” as given in the city schools. This drill, when properly done, becomes a “minute-and-a-half drill,” and consists of deep breathing, armstretching, and forward bending at hips to touch tips of fingers to toes, knee-bending with thumbs locked behind back. Abdominal breathing was taught and a conscious use of this mode of breathing was encouraged. 2. A second exercise for the purpose of recapitulating the steps taken by a young child in acquiring speech. This exercise was based on Wundt’s Development of Speech in Children (Entwicklung der Kindersprache). Inarticulate sounds (Schreilaute) gradually lead to the development of articulate sounds, and these in turn lead to the word in the sentence. 3. Ear training. This enables the pupil to hear his own voice and to make an effort to change the tone of his speaking voice from a low monotonous pitch to the modulated speech of a normal child. Inasmuch as speech defectives tend to crowd their speech and use a faster tempo than normal, a metronome was employed to give the pupil a standard by which to measure the gait of his speech.
In the first exercise, the effort is made not only to strengthen the weakened respiratory and circulatory system, but to impress upon the pupil the fact that proper breathing is a means of overcoming his difficulty. The child is placed on his back and told to inhale and to feel the movement of the belly wall during inhalation and exhalation. In a stutterer, during these respiratory movements, a marked quivering of the diaphragm may be felt. The pupil can not control his breath in exhalation, nor can he in any way check the quivering of the diaphragm. Moreover, the breath ing is usually very shallow. The pupil is made to realize these defects, and at once puts forth a conscious effort to take deeper breaths and to control the exhalation. Constant practice of abdominal breathing causes the spasmodic contractions of the diaphragm to disappear and enables the pupil to control his breathing. The following exercises for strengthening the diaphragm are used. The pupil is told to inhale deeply and then to exhale slowly with the tongue, teeth and lips in the position for pronouncing the consonants / or v. At the beginning of the work, the length of time the child can sustain a tone is usually very short, but he is encouraged to hold a definite tone until perfect control of the diaphragm and larynx is obtained. To a moderate degree, relaxation of the muscles of the larynx is obtained through suggestions as to the poise of the head, absence of collar pressure, front or back, the necessity of talking “up,” etc. After telling the pupil that he should have a sense of ease in the throat, breathing exercises are begun. Inhalation is performed very slowly, and exhalation assumes the sound of ah. Inaudible at first, the sound becomes louder and louder in successive drills until finally it is normal. The second exercise is then begun. Expiration takes the form of a vowel or a series of vowels, for the defective never falters on a vowel but always on a consonant. The vowels are sung and sustained at a definite pitch. In the early stages of the work, the duration of this sound varies from five to ten seconds, but after a few days’ practice, it reaches thirty to fifty seconds. That is to say, during one exhalation, the vocal cords, the glottis and the diaphragm, can be so regulated as to allow the continuation of one sound for half a minute or longer. The exercise is repeated with each vowel in turn. Later the vowels are combined with single consonants, as ha, be, bi, bo, bu, and the series is gone through with one breath. Drills on the more difficult consonants follow, special attention being given to the peculiar difficulties of the individual children. To some g gives the most trouble, to others b, p, 1c, v, etc. Frequently, the initial consonant of the pupil’s name is the most difficult. The most difficult consonant, whatever it may be, is combined with a vowel and a method is devised by which the pupil eventually succeeds in producing it easily. This sound is then combined with another consonant and both are prefixed to vowels, as pra, pre, pri, pro, pru. The third exercise is intended to develop a keen sense of pitch and rhythm. The pupils find little difficulty in repeating the syllables mentioned, especially in a sing-song manner. The introduction of melody in speaking serves the very good purpose of developing a new habit; it produces a change of tone. To break the pupils of the habit of speaking in a low-pitched monotone, all the vowels and syllables were at first recited in a sing-song. This led to the fourth development, namely slower, rhythmic speech. The slower utterance was taught through the use of a metronome and through simple rhymes or jingles. Varied intonation was secured through imitation and by the use of charts containing sentences underscored with colored lines suggesting the proper variations of pitch. For example, in the following sentences the intonation is a rising or a falling one, according to the thought expressed in the sentence, and the pupil is taught to indicate the change in tone by raising or lowering the hand.
The flag was raised. I walked down the steps. I jump up and down.
Further sentences expressing everyday occurrences were put on charts and colored chalk used in marking the vowels, each vowel being marked with a different color.
Inasmuch as the vowels are easiest for the pupil to sound, this device seems to encourage him and enable him to master the consonants more easily. In cases where the first word in a sentence begins with a consonant, and difficulty is encountered in sounding it, the pupil is taught to introduce a vowel before the consonant. For example, in the sentence, “Prince George became King of England,” if the initial consonant prevents the pupil from getting a start, he is instructed to read the sentence as though it were “A Prince George,” etc. Having once got under way through the help of such a device, the child encounters no further difficulty provided the respiratory activities are normal. He then practices the initial sound in this connection until he can repeat the sentence with ease. Merely suggesting that the pupil can say a word often enables him to do so; he becomes confident, and finds himself trying to verify his growing belief in his ability.
Drills in reading the vowels in a sentence are also very helpful. A rhyme is written on a chart and all the vowels are marked in their characteristic colors. The pupil then reads the vowels slowly in a sing-song manner according to one of the five types of melodies shown in Fig. 1. The consonants are then slipped in and the pupils read the entire sentence in a musical tone. The selection and presentation of reading material is of great importance, and should come as a final step in the treatment.
The pupils are taught to be self-critical of their speech. Inappropriate movements, a dull monotonous tone, lack of breath, careless pronunciation or enunciation,?all these faults arouse immediate criticism. Through experience the pupil learns (1) to inhale until the belly wall is well extended; (2) to speak slowly and in rhythm; (3) to use a melody; (4) to pay close attention to vowels; (5) to introduce a vowel when in straits.
The application of these exercises was fraught with difficulty. The oral rendition of any selection from the reader seemed to undo all that had been laboriously accomplished. The pupils still lacked power and confidence, and the sight of a reader or any other book made them revert to their old habits. This may have been due to the association of a reader with the unsympathetic audience in the classroom. For a long time it was hard to develop a type of recitation other than that of question and answer, which would serve for the application of principles already taught; but the imitative instincts of the children suggested a plan which was followed with excellent results. They originated games which were nothing less than a dramatization of familiar occupations.
One game that proved very effective was called “grocery.” The pupils first told what could be bought in a grocery store, and then chose a grocer, several clerks, errand boys, and so on. Although it usually required an entire period for the mere organization of the game, it was worth while because it aroused a deep interest in the work. The pupils talked freely and seemed to forget their difficulties. The next two or thrtee periods were spent in buying at the imaginary shop, the grocer, his clerks, and the purchasers taking their respective positions, and conducting the transactions in a realistic manner. This type of play became very popular with the children. The transition from this to the dramatization of reading material would not be too difficult.
The course of work briefly outlined above tended to make the stutterers and stammerers optimistic. Each felt that through his own efforts he had ceased to be a legitimate object for the gibes of his classmates. Even if he had not been entirely cured, at least he felt more confident of his ability to improve, and the attempt had been made to imbue him with the idea that if he faithfully followed up the work he was bound to succeed.
Lispers include that group of defective speakers who are unable to give certain letters their proper sounds. This inability may be due to the persistence of a habit formed in childhood of dropping the final syllable or of substituting sounds for those required in a word. The latter form of speech is often called “baby-talk” or more properly “infantile stammer”. It may be due to malformation or late development of the teeth, and in the case of many foreign pupils, to a lack of knowledge as to the position of various parts of the articulatory apparatus for the production of certain sounds. Figure 2 shows the position of the tongue, teeth and lips to form such difficult sounds as r, tli, I, s, v and wh. Investigation disclosed the fact that the most difficult sounds were the six just mentioned, and w, z, d and t. The s and 2 are especially difficult for children who lack the incisor or canine teeth, and they frequently substitute th for s or z. The I, r, t, d, wh and w are usually mispronounced because of inability to place the tongue, teeth and lips in the proper position.
In correcting such defects the work is individual. Each pupil is studied thoroughly and his difficulties understood. In cases where nothing could be done because of the condition of the teeth, the children were advised to consult a dentist and then return to the class. The pupil who lisps the I, is brought before a mirror and shown how to place his tongue in order to sound the letter. He then repeats numerous words containing I, and practice in reading from a book follows. To make the sound of s, the pupil is told to close his teeth and to touch them lightly with his tongue. After he masters the position he is told to blow his breath between his teeth. The letter r is sinned against chiefly by our foreigners and “baby-talkers”. It is especially difficult for Russian Jewish children. The tongue plays an important part in the production of the r sound, being placed opposite the middle of the hard palate and vibrated while its outer edges rub against the hard palate. This sound, like the I, is taught with the aid of a mirror, and also by imitation of another pupil who practices at the same time. Wh is not a difficult sound, except for the foreigner. The pupil is told to protrude his lips in the form of a funnel and to blow out his breath as if trying to cool a spoonful of hot liquid. V, which is sometimes interchanged with w, is made by placing the upper teeth on the lower lip and blowing the breath between the lip and the teeth. Tli, a sound incorrectly given by many, is made by placing the tip of the tongue between the upper and lower teeth and quickly withdrawing the tongue while allowing the breath to escape between the teeth. The sound may also be made by opening the teeth and forming a slip between the upper teeth and the tongue, but the former method was used because it proved to be easier. T is made by placing the tongue on the upper teeth, d by placing it on the hard palate near the teeth. The mouth, of course, is open and the breath is forced out while the tongue is rapidly moved downward.
Only two pupils found trouble in forming the cli and sh sounds, which as they gave them, were thick and resembled the escape of steam. On close examination it was found that the mouth was drawn to one side and the sound emitted through an aperture made by the lips and teeth. The defect was overcome by making the pupil control the motion of his lips and close the teeth as much as possible when producing th’e sounds.
Further study of speech defectives is urgently needed. Physiological investigation should be made of pupils who are not cured in a reasonable time, because of conditions obviously other than weak mentality. Pedagogical investigation should discover a method for the successful treatment of theste peculiar cases. Statistics should be collected for the purpose of determining the character of the speech of pupils in city schools, so that the investigator of speech defects may give his attention to those groups which most need his assistance.
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