Stuttering

What is Stuttering ?

"Mind Simulation" Approach in the Treatment of Stuttering:

Simulation The definition we have for simulation is that it is a version of certain real objects or work situations that attempt to represent some behavioral aspects of a physical or abstract system through the behavior of other systems, mostly applied in natural and human systems. This method, like a mirror, simulates reality. For example, a person working alongside a flight instructor or a driving instructor observes their way of driving.
In mind simulation, the element of "seeing" is highly influential, and when a person sees, a significant amount of information is transmitted through the eyes and processed by the individual. The driver's assistant or the pilot's assistant gradually learns the driving and piloting techniques in their own mind, in addition to the training they receive, and records and registers the observed events like a mirror.

Definition of Mind Simulation:

The knowledge of mind simulation is a means of accessing information about the human mind. Mind simulation means simulating the mind and converting it into material and physical information and observing it. With this innovative knowledge, it is possible to access information about the mind and quickly bring about most changes in the mind. The knowledge of mind simulation is a combination of various sciences, including social sciences, philosophy of mind, artificial intelligence, computer science, and psychology. Mind simulation is a reenactment or reconstruction of an object or a real situation, mimicking reality like a mirror.

Stuttering is a subset of communication disorders, which itself is divided into five categories according to the DSM-5 definition. In the second chapter of the book "Complete and Sustainable Treatment of Stuttering" by Dr. Mohammad Ehsan Taghizadeh, one of these disorders is mentioned, which is called "expressive or developmental stuttering." Some speech specialists refer to it as "stuttering" at a stage where it has more pathological and pathological aspects. Individuals who stutter have one or two of these disorders. Stuttering typically exhibits several of the following symptoms:
1. Sound or syllable repetition, also known as speech disfluency, which is the primary and most important characteristic of stuttering, especially in children.
2. Speech hesitations or tonal disfluency, including audible or silent pauses that mainly occur on voiced sounds.
3. Sound prolongation, where they elongate words, letters, or syllables.
4. Choppy or fragmented speech.
5. Avoidance of specific words and word substitutions.
6. Tense physical speech with facial, head, and shoulder muscle tension and twitches.
Other symptoms of stuttering include stress, anxiety, and weak eye contact.

Definition of stuttering from the author's perspective:

In general, stuttering is the result of a disruption in the functioning and performance of speech-related cognitive processes and rhythmic disturbances in speech-related cognition. It also involves spasms of the vocal cords affecting the person's speech, including blocking (on sounds), dragging (sounds), repetition (sounds, syllables, and words), and respiratory disturbances (inhaling and exhaling). In other words, stuttering is an involuntary act aimed at releasing spasms of the vocal cords and during which the individual experiences difficulties in their speech.

Description and Definition of Stuttering:

Social behavior forms the basis of an individual's life. One of the most influential and effective tools for expressing human thoughts and one of the most important elements for establishing human and social relationships is language. In fact, language is a superior and common form of social behavior. On the other hand, speech is one of the tangible and audible manifestations of language, which holds significant importance in facilitating interpersonal communication. Speech and language can separately or together be affected by various factors and impair the primary communication pathway of an individual. One of the most important speech disorders is speech fluency disorder or stuttering. Stuttering is a complex disorder, and understanding its nature and characteristics provides a more comprehensive view of this disorder through a nonlinear perspective.

What is the root cause of stuttering?

The primary root causes of stuttering are primarily linked to real fears, fears in dreams, and then observational learning. Approximately 10% of children develop stuttering by observing and imitating the speech of individuals with stuttering. These fears and observational learning disrupt the rhythmic functioning of speech cognition, leading to a decrease in speech skills and the manifestation of stuttering. These fears and learning affect the functioning of speech in the mind, not the brain and body of the individual.

What is meant by contagiousness of stuttering?

If the question is whether stuttering is contagious like the common cold virus, the answer is negative. If the question refers to the imitation of observational learning and speech assimilation from individuals with stuttering, which can act as a factor in stuttering, then the answer is positive. Some translated books state that imitation is not a factor in stuttering. However, this issue does not align with our scientific, clinical, and empirical experiences. As mentioned before, approximately 10% of individuals develop stuttering as a result of observational learning. It is not the case that everyone who sees a person with stuttering will develop stuttering. If the imitation and observation become mental representation and are repeated over time, the individual may develop

Reasons for stuttering:

Dr. Mohammad Ehsan Taghizadeh's theory considers stuttering as a mental problem rooted in the triangle of fear (real and imaginary), observational learning (imitation of another person's stuttering), and incorrect speech habits. Therefore, according to our theory, contrary to what is commonly believed, stuttering is not a genetic or hereditary issue, but rather it is influenced by one of the three aforementioned factors in the process of speech, leading to a lack of coordination between the brain, mind, and body. The uneven distribution of speech energy disrupts the rhythm of speech in the mind and results in stuttering. Through our studies on the mind, its processes, and its content, we have discovered that a part of the root cause of stuttering can be traced back to real and imaginary fears. In certain situations, children develop this problem after watching horror movies, witnessing real-life scary scenes, or experiencing traumatic events. For example, a mother may have confined a child in a dark room as a punishment, and after that, the child developed a stuttering problem. Alternatively, a child may develop this issue after escaping from a dog attack. These are some of the examples we have encountered in our studies. Some instances of stuttering can be attributed to imaginary fears, where a child wakes up from a nightmare after seeing a scene from a horror movie and experiences stuttering with screams and cries. Another cause of stuttering is observational learning. According to our theory of the language of the mind, one of the causes of stuttering is environmental factors associated with observational learning. Observation can influence mirror neurons. In some cases, stuttering has been developed in our clients through observational learning and imitation. Some individuals claim that they imitated classmates or colleagues who had a stutter, and after a while, they couldn't speak normally anymore. After studying these cases, we realized that the problem lies in the rhythm of the mind's speech, which, once created and altered, is not easily correctable. A healthy individual, by observing someone with stuttering and imitating it, has altered their own speech rhythm. This phenomenon, which involves changing mirror neurons and creating new synapses and neural connections, is not easily changeable, and the individual cannot easily return to their original state. Therefore, learning, incorrect speech habits, and fear are the main roots of stuttering. Some may ask, can stress, mild anxiety, low selfconfidence, and similar factors be the causes? We say no! These are exacerbating factors of stuttering, not the underlying causes. The main causes are the three mentioned factors: fear, incorrect speech habits, and observational learning. Individuals with stuttering have deviated from the correct path of speech and need to be taught the proper way of speaking, transforming education into a paradigm of learning and turning learning into a skill. It is worth mentioning that the threefold causes are related to psychological, mental, and environmental factors, not stuttering resulting from cognitive, genetic, neurological, syndromic, anatomical, and physiological disorder

Stages of stuttering:

Children who experience stuttering usually go through various stages from the onset of stuttering until the final stage:
1. Accepted stuttering:
In this stage, the child becomes aware that they repeat certain letters and words unnaturally, but they are not concerned about their speaking condition, and it doesn't cause them distress. They don't make any effort to overcome it.
2. Stuttering pushed back:
It refers to the stuttering that the child reacts to. As the child grows older and their range of conversations widens, they show noticeable surprise and sometimes frustration regarding their speech disorders due to specific behaviors and pressures that are often noticed by others around the child. The child understands these reactions, which naturally lead to more uncertainty
3. Complicated and severe stuttering:
As involuntary movements and accompanying behaviors become apparent in stuttering, the severity of stuttering increases, and the child becomes sensitive and anxious about all situations, words, and sounds. In these circumstances, the stuttering itself becomes more complex and severe day by day.

Is stuttering hereditary?

No, according to the theory and clinical and research experiences of Dr. Mohammad Ehsan Taghizadeh, stuttering is not hereditary. Rather, it occurs through observational learning and fears because children's speech patterns are not yet established. They observe someone who stutters, which could be a family member like a mother, father, or someone in society, and as a result, they change their own speech patterns.

Stuttering due to psychological pressure (fear, jealousy, insecurity):

The psychological strength and resistance of a person have a threshold beyond which excessive pressure can cause distress and vulnerability in individuals. One of the physiological reactions to psychological pressure is increased muscle tension, which can lead to increased spasms and constriction of the vocal cords. It is easy to observe vocal cord spasms and constriction in individuals who have experienced fear and tension. In young children, jealousy and feelings of insecurity can also evoke similar reactions.

Stuttering due to imitation: (Source: "The Secret of Stuttering")

During the fourth stage of speech development, which can be referred to as the imitation stage, a child imitates speech patterns recorded in their primary auditory and phonetic centers, similar to a sound recording and playback device. Therefore, if a child in this stage interacts with a person who stutters and adopts their speech patterns as a model, they will develop similar speech patterns, which initially become a temporary pattern for the child. It is temporary because it is not yet firmly established and can still change. If the child surpasses this stage and enters the sixth stage of speech development while maintaining this speech pattern, stuttering becomes established and permanent. The undeniable fact is that the type and manner of stuttering in a child who has acquired it through imitation is very similar to the speech of the person they imitated. This similarity can only be explained by imitation.

Stuttering due to unknown factors:

Stuttering can be attributed to the following factors:
Severe physical punishment by one of the parents or close relatives
Frightening the child by the father, mother, or close relatives
Eliciting feelings of jealousy in the child due to the birth of a sibling or comparing them to other children
Parental embarrassment in expressing an event Hidden factors from the parents' perspective:
The child's exposure to individuals with stuttering at kindergarten, neighbors, and gatherings
Fears triggered by darkness (when they wake up at night) or by observing conflicts and scary movies.

Presence of multiple individuals with stuttering in a family and relatives:

It is sometimes observed that multiple individuals in a family or relatives have stuttering. Many researchers attribute the cause to genetic factors without any evidence, but the reasons for the occurrence of multiple individuals with stuttering in a family or relatives can be as follows:
1. It is natural considering the prevalence: Given the prevalence of 3%, it is natural to have multiple individuals with stuttering in some relatives. Even if we assume the prevalence of stuttering is 1%, it is still normal to have two or three individuals with stuttering in some relatives.
2. Coincidental factors: Sometimes the factors that cause stuttering (psychological pressure and imitation) occur coincidentally in a family, leading to multiple children developing stuttering. Just as some families may not have any individuals with stuttering.
3. Imitation factor: It has been observed that stuttering can also be transmitted through imitation. Therefore, one of the reasons for the presence of multiple individuals with stuttering in a family or relatives can be attributed to children imitating other individuals.

Diagnosing stuttering in children and adults:

The diagnosis scale for stuttering includes:
Sound repetition
Syllable repetition
Prolongation of voiceless sounds
Prolongation of voiced sounds
Fragmented words (such as pauses within a word)
Audible or silent pauses (pauses within speech)
Audible or silent gaps (completed or incomplete pauses in speech)
Circumlocution (substituting words to avoid difficult words)
Repetition of monosyllabic words like "me, me, me"
Pronouncing words with tension
Articulating words with pressure
Fear of speaking in public
Stress and anxiety while speaking
Difficulty establishing eye contact, looking up, down, and sideways
Opening the mouth while speaking
Puckering lips while speaking
Breath-holding while speaking
Difficulty in reading aloud
Audible breathing, making sounds like wheezing, clicking, and popping
Speaking with jaw movements
Protrusion of the tongue while speaking
Pressing lips together
Muscle tension in the jaw
Nodding or shaking the head during speech
Hand and arm movements while speaking
Hand movements towards the face while speaking
Excessive body movements
Leg movements, tapping the foot, oscillating leg movements
Hitting the thigh with the hand
Avoidance of speaking and being unclear in speech
Frequent coughing (not due to a cold) during speaking.

What are The consequences of stuttering ?

The consequences of stuttering are likely to create several problems for individuals, including:
•Impairment in speech (mental and cognitive)
• Hindrance to the development of individual talents (mental and cognitive)
• Decreased self-confidence (mental and cognitive)
•Increased stress and anxiety in individuals (emotional and affective)
•Impact on social relationships (social)
•Increased mental turmoil (mental and cognitive)
• Heightened feelings of hopelessness and despair (emotional and affective)
•Problems in marital relationships (social and lifestyle)
•Influence on job positions (social and lifestyle)
•Challenge to academic success (social and lifestyle)
• Disruption in family relationships and the family system (social and lifestyle)
• Impaired ability to speak confidently in groups (behavioral and function)
• Weakening of individual creativity and innovation (cognitive and cognitive)
• Diminishing feelings of joy and happiness (emotional and affective)
• Weakening of emotional control (emotional and affective)
• Impact on anger management (emotional and affective)
• Social isolation (social and lifestyle)
•Increase in pessimism (mental, cognitive, and social)
•Decrease in positive thinking (mental and cognitive)
•Decrease in coping skills (behavioral and function)
•Marital conflicts (social and lifestyle)
•Decrease in emotional self-regulation (emotional and affective)
•Decrease in resilience (behavioral and function)
•Decrease in mental well-being (mental and cognitive)
•Decreases willingness to volunteer in life situations (behavioral and function)
•Decrease in psychological and social functioning (mental and social)
•Decrease in self-efficacy (cognitive and behavioral)
•Decrease in motivation (emotional)
•Decrease in motivation for progress (emotional and motivational)
•Decrease in self-control (behavioral and function)
•Decrease in self-esteem (mental and cognitive)
•Decrease in social intimacy (social and lifestyle) (Taqizadeh, 1397)

When should you consult a specialist for the treatment of stuttering?

1- When people don't understand your child's speech.
2- When your child has difficulty articulating words that are in their mind.
3- When your child stutters and struggles to speak.
4- When the person has difficulty with social interaction and direct communication, learning games, etc.
5- When hearing impairment or deafness leads to stuttering.
6- Swallowing disorders.
7- Speech delay in children.
8- Difficulty in speech comprehension.
9- Articulatory phonetic problems.
10- Difficulty in fluent and coherent expression.

The complete treatment approach for stuttering:

What we have referred to as complete or definitive treatment entails a comprehensive and clinical approach. Modern methods commonly used today include Stroboscopy, fluency shaping techniques, medication prescribed by psychiatrists and neurologists, magnet therapy, laser therapy, jaw, throat, and laryngeal surgery, speech therapy techniques, avoiding cold and acidic foods, and even methods like swallowing canary eggs! However, patients have not obtained satisfactory results from any of these methods, and we do not utilize them. Our treatment approach is based on the methods of Dr. Taghizadeh, incorporating psychological techniques, mental simulation through cognitive exercises, and speech techniques.

Description and definition of stuttering:

Social behavior constitutes the foundation of every individual's life. Language is one of the most effective and powerful tools for expressing human thoughts and is among the essential elements for establishing human and social relationships. Essentially, language is a superior and shared form of social behavior. On the other hand, speech is a tangible and audible manifestation of language, which holds great significance in facilitating communication between individuals. Speech and language can separately or together be affected to varying degrees due to various reasons, disrupting the primary communication pathway of humans. One of the most significant and common speech disorders is fluency disorder or stuttering. Stuttering is a complex disorder, and understanding its nature provides a more comprehensive view of this disorder through the lens of complexity and its non-linear characteristics. Stuttering is defined as a speech fluency disorder that begins in childhood (developmental stuttering) or as a disturbance in natural fluency and inappropriate timing patterns of speech in relation to the patient's age and language skills, which persists continuously and is accompanied by recurrent and prominent occurrences of one or more of the following: sound and syllable repetitions, prolongations of voiced and voiceless sounds, broken words, silent or voiced pauses, blocks, excessive physical tension during word articulation, and complete repetition of singlesyllable words. Stuttering is a speech disorder that affects normal fluency and temporal patterns of speech, causing difficulties for an individual in acquiring ageappropriate language skills. This disfluency persists over time and is characterized by frequent repetitions or prolongations of sounds and syllables, as well as other forms of speech disfluency, including broken words, silent or voiced pauses, blocks, excessive physical tension during word articulation, and complete repetition of single-syllable words. Stuttering interferes with the individual's educational, occupational, and social communication as its severity varies from one situation to another, often exacerbated in situations involving pressure and excitement. Stuttering is typically not observed during reading aloud, singing, or speaking to pets and inanimate objects. It manifests as repetitions in a tonic or locked state, as well as prolonged speech and vocal strain in which the individual involuntarily struggles to express words or parts of words. Individuals with stuttering may exhibit eye movements, head and neck jerks, and overall non-fluent speech. They may have incomprehensible speech, experience locking, pulling, and repetition of a word or parts of words. Stuttering is a speech disorder that causes speech fragmentation and lack of fluency. It displays various signs, including repetition of parts of words or whole words, locking or getting stuck on specific sounds, especially /a/, /o/, /e/, /s/, /kh/, etc., and in some cases, individuals may feel excessive tightness in the throat and chest. Stuttering can be described as an inability to express words or sentences smoothly and fluently to the listener or listeners, in other words, a type of incomplete expression where the individual experiences word repetitions accompanied by pauses and sometimes locking of the jaw, along with muscle tension in the facial area. Individuals with stuttering experience disruptions in the flow of their speech, which lead to inappropriate emotional, cognitive, and behavioral reactions. Over time, individuals may develop various emotions such as frustration, hopelessness, and fear, which, along with initial signs of speech difficulties, result in reduced social participation in various social situations. Stuttering specialists have long stated that stuttering goes beyond speech interruptions, and perhaps the most famous metaphorical description is the iceberg analogy. According to this analogy, stuttering is like a floating iceberg with a visible part and a hidden part. The visible part represents the portion of the iceberg above the water surface, which comprises only ten percent of the entire iceberg. This visible part of
stuttering can be divided into two dimensions:
•Muscular spasms concurrent with speech production
•Behaviors related to overt struggle and attempts to release or avoid control
over spasms. Stuttering spasms are essentially either tonic or clonic in nature.
The remaining ninety percent is below the water and cannot be observed from above. This part includes hidden avoidance behaviors and, in general, encompasses emotions and feelings that arise in individuals due to stuttering.
The hidden components include the following:
•Tightening of the mechanism of the velopharyngeal muscles
•Irregular breathing patterns
•Negative emotions, feelings, and perceptions: Individuals with stuttering often feel embarrassed due to their inability to speak fluently and encounter difficulties in communicating with others. They frequently experience feelings of emptiness and worthlessness as they are unable to achieve their desires due to stuttering, leading to feelings of guilt. They also feel discomfort due to the lack of fluency in their speech and the impatience of listeners.
•Fear of specific speech situations: Most individuals with stuttering fear particular speech situations such as using the telephone, ordering food at a restaurant, asking for directions from a passerby, etc. Stuttering typically occurs more frequently when individuals with stuttering speak to authoritative figures such as police officers, parents, teachers, or their superiors. Individuals with stuttering usually do not exhibit stuttering when speaking alone, talking to themselves, or when having conversations with domestic animals. Interestingly, they stutter less when conversing with their spouses, possibly because spouses are considered somewhat familiar.
•Avoidance strategies: When individuals with stuttering feel stuck on certain words, they may resort to using alternative words with similar meanings. Often, these replacement words are less appropriate for the context, reinforcing the perception that they are incapable of effective communication. Sometimes, individuals with stuttering may say something entirely different from what they intended to convey.
•Withdrawal: Another method of escaping the grip of stuttering is avoidance of speaking. You may recall a moment when you had to listen to someone with speech difficulties and incomprehensible speech; this situation is likely one of the most frustrating for individuals with stuttering to endure.
•Avoidance of eye contact
•Tendency to stand still
• Speaking softly
Resistance to change: It is natural that most individuals with stuttering do not desire to stutter in everyday real-life situations. However, resistance to change is part of human nature and instinct. Each individual with stuttering knows that if they speak fluently, they are expected to speak more and become more sociable. However, their subconscious mind may believe that they are incapable of doing so, and therefore, their subconscious mind resists this change.

Types of stuttering:

Developmental stuttering (borderline, initial, intermediate, advanced), neurological, and psychologic

Developmental stuttering (DS):

The usual age of onset for developmental stuttering is between 2 and 5 years, and in some cases, it starts during school years, possibly due to neurophysiological abnormalities (abnormalities in the left hemisphere) that worsen with a more challenging environment.Its speech characteristics include whole-word repetition, repetition of a portion of a word, prolongation, and blocking, with a frequency of more than three syllables of stuttering.
Secondary behaviors are also observed.
This type of stuttering is divided into four categories: borderline stuttering (1.5 to 6 years old), initial stuttering (2 to 8 years old), intermediate stuttering (6 to 13 years old), and advanced stuttering (14 years old and above).
Developmental stuttering (DS) is an inappropriate term for the level of language development.
It is the most common form of stuttering. Existing evidence indicates that the disorder disrupts fluent speech mastery. Up to 90% of children with stuttering in their childhood (CWS) naturally improve over time.
It is said that adults who have not improved during childhood have DS, estimated to be less than 1% of the population.
Acquired forms appear to be secondary, although they have fewer emotional or brain damage, but the exact estimate is unknown. Men are four times more likely to have DS and are more likely to persist in men compared to women. Late onset, longer duration of stuttering, family history of persistence, and lower language and nonverbal skills are other predictors of stuttering's stability.
Early diagnosis in children as an initial intervention yields the best results.
Family physicians or pediatric specialists are often the first caregivers to provide healthcare for CWS. For adults with stuttering, medical knowledge about causes, treatments, symptoms, and appropriate referrals can ensure proper management in this population. Nonetheless, greater and more accurate understanding of physicians will require collaboration with speech pathologists and psychologists and proper management.
For adults with stuttering, medical knowledge about the causes, treatments, symptoms, and appropriate referrals can ensure proper management in this population. However, it requires a greater and more accurate understanding of physicians, which is why it demands collaboration with speech pathologists, psychologists, and proper management. Stuttering is a common speech disorder that usually resolves in early adolescence. Persistence is rare and is associated with psychiatric issues and social consequences. More research is needed regarding medication treatments, and early intervention in children who stutter (CWS) is crucial. Approximately 1% of children and adolescents, 2% of women, and 8% of men experience stuttering, and a smaller percentage suffer from stuttering severity.Persistent speech disorders often create communication and social participation problems throughout a person's life. Considering the fact that stuttering is common (in its developmental and neurogenic forms), it is associated with structural and functional changes in the brain.
Guidelines recommend referring to stuttering as "Primary Non-Syndromic Neurogenic Stuttering." The estimated heritability for the disorder ranges from 70% to over 80%. There is strong evidence for indirect treatments. For children aged 6 to 12, there is no comprehensive evidence of effectiveness for any treatment, while for adolescents and adults, there is good evidence with large effect sizes for speech restructuring techniques such as fluency shaping. There is weak evidence with moderate effect sizes for stuttering modification techniques, and weak evidence for combining speech restructuring and stuttering modification. There is no support for the effectiveness of medication, rhythmic speech, or breathing regulation as sole primary treatments or for the use of hypnosis and combined or unspecified stuttering treatments.
This guideline classifies speech disorders into stuttering and cluttering and distinguishes between primary (non-syndromic neurogenic) and acquired (neurogenic and psychogenic) disorders. The term "primary" describes a neurogenic speech disorder that occurs in childhood due to genetic factors, while "secondary" refers to the psychological, motor, and emotional reactions to these speech disturbances.
"Neurogenic syndrome" indicates a type of stuttering that can occur, for example, in trisomy 21 (Down syndrome).
The term "neurogenic stuttering" can occur at any age following brain injury. Congenital stuttering, which is rare, usually occurs after puberty as a result of a psychological impairment based on a psychiatric disorder.

Types of developmental stuttering

Borderline stuttering

Children with borderline stuttering often exhibit a higher degree of dysfluency compared to typically developing children (more than 7 dysfluencies per 100 words). Children with borderline stuttering tend to have a tendency to repeat a part of a word more than once, use single-syllable word substitutions, Employ syllable repetitions, revisions, and interjections. The underlying processes of borderline stuttering may be due to abnormalities in speech and language processing. These impairments may interact with the demands of speech and language growth. Pressure resulting from fast speech rates, highly complex language, competitive speaking situations, and certain psychosocial conflicts contribute to increased normal dysfluency and likely play a role in the development of borderline stuttering.
Since children with borderline stuttering have limited awareness of their stuttering, they do not typically exhibit negative emotions or frustration during instances of dysfluency. Even if they repeat a sound or syllable 5 or 6 times, children with borderline stuttering continue speaking without any apparent reaction. These children only pause their speech and express slight surprise when they are unable to articulate a syllable after several repetitions. They may say, "I can't say this word," but generally, they are unaware of their dysfluencies.
The characteristics of borderline stuttering can be summarized as follows:
1- More than 7 dysfluencies per 100 words.
2- Often, repetitions of more than 2 segments.
3- More instances of repetitions and prolongations compared to revisions and incomplete phrases.
4- Dysfluencies are typically loose, relaxed, and comfortable.
5- Rarely exhibit reactions to their speech dysfluencies.

Initial stuttering

Initial stuttering, also known as developmental stuttering, is characterized by periods of increased stuttering that may last for several months, while periods of fluency may only last a few days. As these symptoms occur more frequently, tension increases and the struggle becomes more apparent.
Classical conditioning and environmental factors contribute to the increased frequency of stuttering behaviors. The patterns of stuttering become more complex in children, and the signs extend to more situations. It should be noted that some children may exhibit initial stuttering without going through the borderline stuttering phase. These children are aware of their stuttering because they have stuttered repeatedly. The most common response of these children is frustration. Consequently, a child may interrupt their speech during stuttering and say, "Why can't I say this word?"
Although the child is aware of the "difficulty" in their speech, they do not perceive themselves as completely incapable speakers and do not harbor strongly negative emotions towards themselves or their stuttering. According to Van Riper and Bella Dustin, the episodic nature of stuttering prevents the child from experiencing intense negative emotions towards themselves.

Characteristics of initial stuttering:

1. Signs of muscular tension and hurry are evident in stuttering, with rapid, irregular, and disorganized repetitions.
2. Increased sub vocalization may be observed at the end of repetitions or prolongations.
3. Postural adjustments are observed, sometimes when the child is momentarily unable to initiate a word, resulting in muscular tension.
4. Escape behaviors occasionally appear in individuals with stuttering, including blinking, head movements, and neck movements.
5. Awareness of difficulty and feelings of frustration are apparent, but there is not a strong negative emotion towards oneself as a speaker.

Moderate Stuttering:

An individual with moderate level of stuttering, between the ages of 3-13, has two important characteristics that distinguish them from children with initial stuttering. Firstly, they begin to fear their stuttering, unlike initial stutters who are usually unsuccessful, discouraged, anxious, or distressed. Secondly, they react to their fears of stuttering by avoiding it, something that individuals with initial stuttering never do. These new symptoms gradually appear as the stuttering person experiences negative encounters with their stuttering. For example, they get stuck and feel helpless, and listeners respond to this state with discomfort or mockery, which happens intermittently and increases their fear. Although individuals with moderate stuttering still experience repetitions and prolongations, the main and most noticeable behaviors are blocks. The blocks in children with moderate stuttering grow in intensity with increased tension, starting from the initial stuttering stage.
A child in the moderate stuttering phase typically experiences stuttering by interrupting airflow, sound production, movement, or a combination of them, and then making efforts to regain their speech. Their stuttering no longer surprises them greatly. Instead, by considering their sound and behavior in specific situations, they can anticipate their stuttering.

Characteristics of Moderate Stuttering:

1. The most common behaviors are blocks. The individual may also exhibit repetitions or prolongations.
2. Stutters use avoidance behaviors to escape from blocks.
3. It appears that the person anticipates blocks and often employs avoidance behaviors before feared words. They also anticipate challenging situations and sometimes avoid them.
4. Pre-stuttering fear, struggle during stuttering, and embarrassment after stuttering are characteristics of this level of stuttering.

Advanced Stuttering:

Advanced stuttering is the highest level of developmental stuttering, which primarily emphasizes the age of the individual with stuttering rather than differences in the pattern of stuttering or its underlying processes. This advanced level is seen in adolescents and adults, but it's important to note that not all individuals with stuttering progress to this stage. These individuals feel that their stuttering and speech are beyond their control (external locus of control) because they are unable to prevent its occurrence. The negative emotions of people who stutter become distorted by the mental image they have of their listeners. Even if the listeners do not react negatively to their speech, individuals who stutter believe that their silence also elicits negative emotions. These experiences ultimately lead to feelings of hopelessness, anger, and frustration in people who stutter. After years of stuttering and experiencing unpleasant emotions, individuals who stutter perceive stuttering as a significant part of their personality. They despise this aspect of their identity and attribute all their problems to their stuttering. For individuals whose stuttering has become part of their identity, treatment is almost impossible. They believe that treatment requires erasing their existential nature, viewing it as something like "reopening old wounds." If these individuals enter a treatment program and experience failure, their negative emotions towards themselves and their stuttering multiply, and they may even lose the self-confidence they had prior to seeking treatment.

Advanced Stuttering Characteristics:

1. The most common behaviors in advanced stuttering are longer durations of primary behaviors, often involving intense tension in the lips, tongue, or jaw. They also require repetitions and prolongations.
2. Stuttering may increase in some individuals during the application of extensive avoidance behaviors.
3. Complex patterns of avoidance and escape behaviors exist in individuals with stuttering. It may become so rapid and habitual that the person may not even realize what they are doing.
4. Sensitivity, frustration, and intense shame are prominent. Negative emotions about oneself as a person become overwhelming when experiencing stuttering. This self-perception can be pervasive.

Neurological Stuttering:

The typical onset age for neurological stuttering occurs after childhood, following a neurological event such as a stroke, head injury, tumor, processing disorders, drug toxicity, dialysis-induced dementia, epilepsy, or thalamic stimulation. The speech characteristics of neurological stuttering may include the following: stuttering to some degree in content and functional words, lack of stuttering restriction to initial syllables, absence of secondary behaviors, and limited adaptation in reading sequential text.

Psychological Stuttering:

The typical onset age for psychological stuttering occurs after childhood, following traumatic psychological events such as prolonged stress, physiological conflicts, psychological shocks, emotional conflicts, or emotional arousal that appear to interfere with speech production. One characteristic of psychological stuttering is that stuttering persists or increases when the individual speaks under stressful conditions. The person may exhibit unusual secondary behaviors.

Clonic or Convulsive Stuttering:

It refers to the seizure-like repetition of a syllable or phoneme before a word or phrase is uttered or continues. For example, "aaa give me water" or "mama grandma went." The cause of this stuttering is considered to be a neuromuscular physiological disorder that occurs at the nerve-muscle junction, and since it has a familial aspect, it is often assumed to have a genetic cause. However, some researchers consider this neuromuscular physiological disorder at the synapse-to-muscle site to be a metabolic and psychological issue. Occasionally, individuals may exhibit both forms of stuttering, namely clonic stuttering and convulsive stuttering.

Tonic or Constrictive Stuttering:

It refers to a condition in which the articulatory muscles remain immobile for a few seconds to a minute, causing a blockage in speech or what is commonly referred to as "getting tongue-tied." When the constriction is released, speech bursts out rapidly and explosively. This type of stuttering is entirely psychological in nature.
Pure or Repetitive Stuttering: It is a type of repetition that does not fit the clonic pattern, and it can be called pure or repetitive stuttering. For example, when a child is asked, "What is your name?" and they respond, "B-b-b Hussein."