Stuttering

Common stuttering behaviors are observable signs of speech disfluencies, for example: repeating sounds, syllables, words or phrases, silent blocks and prolongation of sounds. These differ from the normal disfluencies found in all speakers in that stuttering disfluencies may last longer, occur more frequently, and are produced with more effort and strain.[12] Stuttering disfluencies also vary in quality: common disfluencies tend to be repeated movements, fixed postures, or superfluous behaviors. Each of these three categories is composed of subgroups of stutters and disfluencies.[13]

• Repeated movements[13]
  • Syllable repetition—a single syllable word is repeated (for example: on—on—on a chair) or a part of a word which is still a full syllable such as "un—un—under the ..." and "o—o—open".
  • Incomplete syllable repetition—an incomplete syllable is repeated, such as a consonant without a vowel, for example, "c—c—c—cold".
  • Multi-syllable repetition—more than one syllable such as a whole word, or more than one word is repeated, such as "I know—I know—I know a lot of information."
• Fixed postures[13]
  • With audible airflow—prolongation of a sound occurs such as "mmmmmmmmmom".
  • Without audible airflow—such as a block of speech or a tense pause where nothing is said despite efforts.
• Superfluous behaviors[13]
  • Verbal—this includes an interjection such as an unnecessary uh or um as well as revisions, such as going back and correcting one's initial statements such as "I—My girlfriend ...", where the I has been corrected to the word my.
  • Nonverbal—these are visible or audible speech behaviors, such as lip smacking, throat clearing, head thrusting, etc., usually representing an effort to break through or circumvent a block or stuttering loop.

The severity of a stutter is often not constant even for people who severely stutter. Stutterers commonly report dramatically increased fluency when talking in unison with another speaker, copying another's speech, whispering, singing, and acting or when talking to pets, young children, or themselves.[14] Other situations, such as public speaking and speaking on the telephone, are often greatly feared, and increased stuttering is reported.[15]

Stuttering could have a significant negative cognitive and affective impact on the person who stutters. It has been described in terms of the analogy to an iceberg, with the immediately visible and audible symptoms of stuttering above the waterline and a broader set of symptoms such as negative emotions hidden below the surface.[16] Feelings of embarrassment, shame, frustration, fear, anger, and guilt are frequent in people who stutter,[17] and may actually increase tension and effort, leading to increased stuttering.[18] With time, continued exposure to difficult speaking experiences may crystallize into a negative self-concept and self-image. Many perceive stutterers as less intelligent due to their disfluency; however, as a group, individuals who stutter tend to be of above average intelligence.[19] People who stutter may project their attitudes onto others, believing that the others think them nervous or stupid. Such negative feelings and attitudes may need to be a major focus of a treatment program.[18]

Many people who stutter report a high emotional cost, including jobs or promotions not received, as well as relationships broken or not pursued.[20]

Linguistic tasks can invoke speech disfluency. People who stutter may experience varying disfluency.[21] Tasks that trigger disfluency usually require a controlled-language processing, which involves linguistic planning. In stuttering, it is seen that many individuals do not demonstrate disfluencies when it comes to tasks that allow for automatic processing without substantial planning. For example, singing "Happy Birthday" or other relatively common, repeated linguistic discourses, could be fluid in people who stutter. Tasks like this reduce semantic, syntactic, and prosodic planning, whereas spontaneous, "controlled" speech or reading aloud requires thoughts to transform into linguistic material and thereafter syntax and prosody. Some researchers hypothesize that controlled-language activated circuitry consistently does not function properly in people who stutter, whereas people who do not stutter only sometimes display disfluent speech and abnormal circuitry.[21]

Stuttering can co-occur with other learning disorders. These associated disabilities include:

• Attention deficit hyperactivity disorder (ADHD): A disorder characterized by problems sustaining attention, hyperactivity, or acting impulsively.[22] The prevalence of ADHD in school-aged children who stutter is around 4-50%.[23][24][25][26]
• Dyslexia: A disorder involving difficulties with reading and spelling.[27] The prevalence rate of childhood stuttering in dyslexia is around 30-40%, while in adults the prevalence of dyslexia in adults who stutter is around 30-50%.[28][29][30]
• autism spectrum disorder[31]
• intellectual disability[32]
• language or learning disability[33]
• seizure disorders[31]
• social anxiety disorder[34]
• speech sound disorders[35]
• other developmental disorders[31]

Though neuroimaging studies have not yet found specific neural correlates, there is much evidence that the brains of adults who stutter differ from the brains of adults who do not stutter. Several neuroimaging studies have emerged to identify areas associated with stuttering. In general, during stuttering, cerebral activities change dramatically in comparison to silent rest or fluent speech between people who stutter and people who do not. There is evidence that people who stutter activate motor programs before the articulatory or linguistic processing is initiated. Brain imaging studies have primarily been focused on adults. However, the neurological abnormalities found in adults does not determine whether childhood stuttering caused these abnormalities or whether the abnormalities cause stuttering.[46]

Studies utilizing positron emission tomography (PET) have found during tasks that invoke disfluent speech, people who stutter show hypoactivity in cortical areas associated with language processing, such as Broca's area, but hyperactivity in areas associated with motor function.[21] One such study that evaluated the stutter period found that there was overactivation in the cerebrum and cerebellum, and relative deactivation of the left hemisphere auditory areas and frontal temporal regions.[52]

Functional magnetic resonance imaging (fMRI) has found abnormal activation in the right frontal operculum (RFO), which is an area associated with time-estimation tasks, occasionally incorporated in complex speech.[21]

Researchers have explored temporal cortical activations by utilizing magnetoencephalography (MEG). In single-word-recognition tasks, people who did not stutter showed cortical activation first in occipital areas, then in left inferior-frontal regions such as Broca's area, and finally, in motor and premotor cortices. The stutterers also first had cortical activation in the occipital areas but the left inferior-frontal regions were activated only after the motor and premotor cortices were activated.[21][52]

During speech production, people who stutter show overactivity in the anterior insula, cerebellum and bilateral midbrain. They show underactivity in the ventral premotor, Rolandic opercular and sensorimotor cortex bilaterally and Heschl's gyrus in the left hemisphere.[46] Additionally, speech production yields underactivity in cortical motor and premotor areas.[46]

Much evidence from neuroimaging techniques has supported the theory that the right hemisphere of people who stutter interferes with left-hemisphere speech production.

In 2008, it was shown that adults who stutter have anatomical differences in gyri within the perisylvian cortex, in frontotemporal areas. A large amount of white matter is found in the right hemisphere of the brain, including the region of the superior temporal gyrus. This was discovered using voxel-based morphometry. On the other hand, lesser amounts of white matter are found in the left inferior arcuate fasciculus connecting the temporal and frontal areas in stuttering adults.[53]

As of 2011 it was known that the corpus callosum, which transfers information between the left and right cerebral hemispheres. rostrum, and the anterior mid-body sections were larger in adults who stutter as compared to normally fluent adults. This difference was thought to be due to unusual functions of brain organization in stuttering adults or a result of how the stuttering adults performed language-relevant tasks. Furthermore, previous research had found that adults who stutter show cerebral hemispheres that contain uncommon brain proportions and allocations of gray and white matter tissue.[54] There is less coordination between the speech motor and planning regions in the brain's left hemisphere of men and women who stutter, when compared to a non-stuttering control group.[55] Anatomical connectivity of the speech motor and planning regions is less vigorous in adults who stutter, especially women. Men who stutter seem to have more right-sided motor connectivity. On the other hand, stuttering women have less connectivity with the right motor regions.[55]

In non-stuttering, normal speech, PET scans have shown that both hemispheres are active but that the left hemisphere may be more active. By contrast, people who stutter yield more activity on the right hemisphere, suggesting that it might be interfering with left-hemisphere speech production. Another comparison of scans anterior forebrain regions are disproportionately active in stuttering subjects, while post-rolandic regions are relatively inactive.[56]

Bilateral increases and unusual right-left asymmetry has been found in the planum temporale when comparing people who stutter and people who do not.[52] These studies have also found that there are anatomical differences in the Rolandic operculum and arcuate fasciculus.[4]

In 2019, Denis Drayna suggested that brain imaging studies of people who stutter do not tell if the differences in the brain anatomy caused stuttering or if they are the effect of stuttering;In the mouse model for stuttering created by Drayna and team, they noticed significant similarities between the vocalizations in mice (carrying GNPTAB mutation) and human stuttering.[57]

In 2021, researchers investigated the brain tissue from the mice mutants and reported a significant decrease in the number and density of astrocytes in their corpus callosum.[58] Astrocyte is a star-shaped cell in the brain that supports the nerve cells by supplying oxygen and nutrients, and taking away the waste. The corpus callosum enables the communication between the left and right hemispheres of the brain.[59] As of 2020 follow-up experiments with the GNPTAB mutation introduced to brain cell types showed that the vocalization defects in mice were specific to the loss of astrocytes,[60] and mice did not show stuttering-like vocalization defects when the mutation was engineered to other brain cell types.[61]

Recent studies have found that adults who stutter have elevated levels of the neurotransmitter dopamine, and have thus found dopamine antagonists that reduce stuttering (see anti-stuttering medication below).[52] Overactivity of the midbrain has been found at the level of the substantia nigra extended to the red nucleus and subthalamic nucleus, which all contribute to the production of dopamine.[46] However, increased dopamine does not imply increased excitatory function since dopamine's effect can be both excitatory or inhibitory depending upon which dopamine receptors (labelled D1–D5) have been stimulated.

Preschool aged children often have difficulties with speech concerning motor planning and execution; this often manifests as disfluencies related to speech development (referred to as normal dysfluency or "other disfluencies").[68] This type of disfluency is a normal part of speech development and temporarily present in preschool aged children who are learning to speak.[68] These normal disfluencies can present as interjections ("Um"), multisyllable repetitions ("I want I want to do that"), or revised or abandoned utterances ("I want—hey what's that?").[68] Normal disfluency should be ruled out before diagnosing stuttering.[69]

Developmental stuttering (also known as childhood onset fluency disorder) is stuttering that originates when a child is learning to speak and may persist as the child matures into adulthood. Stuttering that persists after the age of seven is classified as persistent stuttering.[68]

Other much less common causes of stuttering include neurogenic stuttering (stuttering that occurs secondary to brain damage, such as after a stroke) and psychogenic stuttering (stuttering related to a psychological condition).[68]

Stuttering is typically a developmental disorder beginning in early childhood and continuing into adulthood in at least 20% of affected children.[36][70] The mean onset of stuttering is 30 months.[71] Although there is variability, early stuttering behaviours usually consist of word or syllable repetitions, while secondary behaviours such as tension, avoidance or escape behaviours are absent.[72] Most young children are unaware of the interruptions in their speech.[72] With young stutterers, disfluency may be episodic, and periods of stuttering are followed by periods of relatively decreased disfluency.[73]

Though the rate of early recovery is very high,[36] with time a young person who stutters may transition from easy, relaxed repetition to more tense and effortful stuttering, including blocks and prolongations.[72] Some propose that parental reactions may affect the development of a chronic stutter. Recommendations to "slow down", "take a breath", "say it again", etc., may increase the child's anxiety and fear, leading to more difficulties with speaking and, in the "cycle of stuttering," to yet more fear, anxiety and expectation of stuttering.[74] With time secondary stuttering, including escape behaviours such as eye blinking and lip movements, may be used, as well as fear and avoidance of sounds, words, people, or speaking situations. Eventually, many become fully aware of their disorder and begin to identify themselves as stutterers. With this may come deeper frustration, embarrassment and shame.[75] Other, rarer patterns of stuttering development have been described, including sudden onset with the child being unable to speak, despite attempts to do so.[76] The child usually is unable to utter the first sound of a sentence, and shows high levels of awareness and frustration. Another variety also begins suddenly with frequent word and phrase repetition, and does not include the development of secondary stuttering behaviours.[76]

Some stuttering is also believed to be caused by neurophysiology. Neurogenic stuttering is a type of fluency disorder in which a person has difficulty in producing speech in a normal, smooth fashion. Individuals with fluency disorders may have speech that sounds fragmented or halting, with frequent interruptions and difficulty producing words without effort or struggle. Neurogenic stuttering typically appears following some sort of injury or disease to the central nervous system. Injuries to the brain and spinal cord, including cortex, subcortex, cerebellum, and even the neural pathway regions.[4]

In rare cases, stuttering may be acquired in adulthood as the result of a neurological event such as a head injury, tumour, stroke, or drug use. The stuttering has different characteristics from its developmental equivalent: it tends to be limited to part-word or sound repetitions, and is associated with a relative lack of anxiety and secondary stuttering behaviors. Techniques such as altered auditory feedback (see below), which may promote decreasing disfluency in those with the developmental condition, are not effective with the acquired type.[36][70][77]

Psychogenic stuttering may also arise after a traumatic experience such as a death, the breakup of a relationship or as the psychological reaction to physical trauma. Its symptoms tend to be homogeneous: the stuttering is of sudden onset and associated with a significant event, it is constant and uninfluenced by different speaking situations, and there is little awareness or concern shown by the speaker.[78]

Other disorders with symptoms resembling stuttering, or associated disorders include autism, cluttering, Parkinson's disease, essential tremor, palilalia, spasmodic dysphonia, selective mutism, and social anxiety.

Fluency shaping therapy, also known as "speak more fluently", "prolonged speech", or "connected speech", trains people who stutter to speak less disfluently by controlling their breathing, phonation, and articulation (lips, jaw, and tongue). It is based on operant conditioning techniques.[84]

People who stutter are trained to reduce their speaking rate by stretching vowels and consonants, and using other disfluency-reducing techniques such as continuous airflow and soft speech contacts. The result is very slow, monotonic, but fluent speech, used only in the speech clinic. After the person who stutters masters these skills, the speaking rate and intonation are increased gradually. This more normal-sounding, fluent speech is then transferred to daily life outside the speech clinic, though lack of speech naturalness at the end of treatment remains a frequent criticism. Fluency shaping approaches are often taught in intensive group therapy programs, which may take two to three weeks to complete.

The goal of stuttering modification therapy is not to eliminate stuttering but to modify it so that stuttering is easier and less effortful.[85] The rationale is that, since fear and anxiety cause increased stuttering, using easier stuttering and with less fear and avoidance, stuttering will decrease. The most widely known approach was published by Charles Van Riper in 1973 and is also known as block modification therapy.[86] However, depending on the patient, speech therapy may be ineffective.[87]

Altered auditory feedback, so that people who stutter hear their voice differently, has been used for over 50 years in the treatment of stuttering.[88] Altered auditory feedback effect can be produced by speaking in chorus with another person, by blocking out the voice of the person who stutters while they are talking (masking), by delaying slightly the voice of the person who stutters (delayed auditory feedback) or by altering the frequency of the feedback (frequency altered feedback). Studies of these techniques have had mixed results, with some people who stutter showing substantial reductions in stuttering, while others improved only slightly or not at all.[88] In a 2006 review of the efficacy of stuttering treatments, none of the studies on altered auditory feedback met the criteria for experimental quality, such as the presence of control groups.[89]

Stuttering treatment using mobile application

There are specialized mobile applications and PC programs for stutter treatment. The goal pursued by the applications of this kind is speech cycle restoration: I say, I hear, I build a phrase, I say, and so on, using various methods of stutter correction.[90]

The user interacts with the application through altered auditory feedback: they say something into the headset's microphone and listen to their own voice in the headphones processed by a certain method.[90]

The following stutter correction methods are typically used in applications:

• MAF (masking auditory feedback). It is basically masking by white noise or sinus noises of the user's own speech. Scientists believe that people who stutter can speak more smoothly when they do not hear their own speech. This method is considered old-fashioned and ineffective.[91][92][93]
• DAF (delayed auditory feedback). This method involves sending the user's voice from a microphone to headphones with a delay of fractions of a second. The goal of this method is to teach people who stutter to prolong vowels and reduce their speech rate. After speech correction with long delays, the application is adjusted at shorter delays which increase the speech rate until it becomes normal.[94][95]
• FAF (frequency-shifted auditory feedback). This method involves shifting the user's voice tone frequency that they are listening to compared to their own voice. The shift range can be different: from several semitones to half an octave.[96][97][98]
• Using metronomes and tempo correctors. Rhythmic metronome strikes are used in this method. The effectiveness of the method is related to the fact that rhythm has positive effect on someone who stutters, especially when pronouncing slowly.[99]
• Using visual feedback. This method determines the user's speech parameters (for instance, speech tempo) and their representation on screen as visual information. The principal goal of the method is allowing the user to effectively manage their voice through achieving the defined targeted parameters. It is supposed that the user sees visual representation of both current and targeted parameters (such as speech tempo) on the screen while pronouncing.[100][101]

Although no medication is FDA approved for stuttering, several studies have shown certain medications to have beneficial effects on reducing the severity of stuttering symptoms. Although different classes of medications have been investigated, those with dopamine blocking activity have been shown in numerous trials to have positive effects on stuttering. These medications are FDA approved in the United States and hold similar approval in most countries for other conditions and their safety profiles are well established in these disorders.

The best studied medication in stuttering is olanzapine, whose effectiveness as of 2004[102] had been established in replicated trials. Olanzapine acts as a dopamine antagonist to D2 receptors in the mesolimbic pathway, and works similarly on serotonin 5HT2A receptors in the frontal cortex.[103] At doses between 2.5 and 5 mg, olanzapine has been shown to be more effective than placebo at reducing stuttering symptoms, and may serve as a first-line pharmacological treatment for stuttering based on the preponderance of its efficacy data.[104] However, other medications are generally better tolerated with less weight gain and less risk of metabolic effects than olanzapine.

As of 2000, Risperidone[105] and haloperidol had also shown effectiveness in the treatment of stuttering. However, haloperidol in particular often result in poor long-term compliance due to concerning side effects such as movement disorders and prolactin elevation, which can also occur with risperidone.[104] Other dopamine active medications reported to positively treat stuttering include aripiprazole, asenapine, lurasidone, which tend to be better tolerated than olanzapine with less weight gain. All these medications as well as olanzapine can carry the potential risk of a long-term movement disorder known as tardive dyskinesia.

The investigational compound, ecopipam, is unique from other dopamine antagonists in that it acts on D1 receptors instead of D2, owing little, if any risk, of movement disorders. A 2019 open label study of ecopipam in adults demonstrated significantly improved stuttering symptoms with no reports of parkinsonian-like movement disorders or tardive dyskinesia which can be seen with D2 antagonists.[106] In addition, ecopipam had no reported weight gain, but instead has been reported to lead to weight loss.[106] In a preliminary study, it was well tolerated in subjects, effectively reduced stuttering severity, and was even associated in a short-term study with improved quality of life in persons who stutter.[106] Further research is still warranted, but this novel mechanism is showing promise in the pharmacologic treatment of stuttering.

With existing behavioral and prosthetic treatments providing limited relief and pharmacologic treatments in need of FDA approval for widespread use, support groups and the self-help movement continue to gain popularity and support from professionals and from people who stutter. Self-help groups provide people who stutter a shared forum within which they can access resources and support from others facing the same challenges of stuttering.[80] One of the basic tenets behind the self-help movement is that since a cure does not exist, quality of life can be improved by not thinking about the stammer for prolonged periods. Psychoanalysis has claimed success in the treatment of stuttering.[107] Hypnotherapy has also been explored as a management alternative.[108][109][110] Support groups further focus on the fact that stuttering is not a physical impediment but a psychological one.[111]

Cognitive behavior therapy has been used to treat stuttering.[112] Also sociological approaches has been explored regarding how social groups maintain stuttering through social norms.[113]

Several treatment initiatives, for example the McGuire programme[114] and the Starfish Project, advocate diaphragmatic breathing (or costal breathing) as a means by which stuttering can be controlled.

Cross-cultural studies of stuttering prevalence were very active in early and mid-20th century, particularly under the influence of the works of Wendell Johnson, who claimed that the onset of stuttering was connected to the cultural expectations and the pressure put on young children by anxious parents. Johnson claimed there were cultures where stuttering, and even the word "stutterer", were absent (for example, among some tribes of American Indians). Later studies found that this claim was not supported by the facts, so the influence of cultural factors in stuttering research declined. It is generally accepted by contemporary scholars that stuttering is present in every culture and in every race, although the attitude towards the actual prevalence differs. Some believe stuttering occurs in all cultures and races[37] at similar rates,[70] about 1% of general population (and is about 5% among young children) all around the world. A US-based study indicated that there were no racial or ethnic differences in the incidence of stuttering in preschool children.[124][119] At the same time, there are cross-cultural studies indicating that the difference between cultures may exist. For example, summarizing prevalence studies, E. Cooper and C. Cooper conclude: "On the basis of the data currently available, it appears the prevalence of fluency disorders varies among the cultures of the world, with some indications that the prevalence of fluency disorders labeled as stuttering is higher among black populations than white or Asian populations" (Cooper & Cooper, 1993:197). In his "Stuttering and its Treatment: Eleven lectures" Mark Onslow remarked that "one recent study with many participants (N=119,367)[128] convincingly reported more stuttering among African Americans than other Americans. Why this could be the case is challenging to explain ..."[129]

Different regions of the world are researched very unevenly. The largest number of studies has been conducted in European countries and in North America, where the experts agree on the mean estimate to be about 1% of the general population (Bloodtein, 1995. A Handbook on Stuttering). African populations, particularly from West Africa, might have the highest stuttering prevalence in the world—reaching in some populations 5%, 6% and even over 9%.[130] Many regions of the world are not researched sufficiently, and for some major regions there are no prevalence studies at all (for example, in China). Some claim the reason for this might be a lower incidence in the general population in China.[131]

Bilingualism is the ability to speak two languages. Many bilingual people have been exposed to more than one language since birth and throughout childhood. Since language and culture are relatively fluid factors in a person's understanding and production of language, bilingualism may be a feature that impacts speech fluency. There are several ways during which stuttering may be noticed in bilingual children including the following.

• The child is mixing vocabulary (code mixing) from both languages in one sentence. This is a normal process that helps the child increase their skills in the weaker language, but may trigger a temporary increase in disfluency.[140]
• The child is having difficulty finding the correct word to express ideas resulting in an increase in normal speech disfluency.[140]
• The child is having difficulty using grammatically complex sentences in one or both languages as compared to other children of the same age. Also, the child may make grammatical mistakes. Developing proficiency in both languages may be gradual, so development may be uneven between the two languages.[140]
• Adding a second or third language between the ages of three and five years of age may cause stuttering to increase (become more severe). However, this may be the case only when: (1) the child's first language is not strong or the child is experiencing difficulties in their first language, (2) One language is used more than the other or, (3) the child resists speaking the additional language.

Stuttering may present differently depending on the languages the individual uses. For example, morphological and other linguistic differences between languages may make presentation of disfluency appear to be more or less of a problem depending on the individual case.[141]

Much research is being conducted to look at the prevalence of stuttering in bilingual populations and the differences between languages. For instance, one study concluded that bilingual children who spoke English and another language had an increased risk of stuttering and a lower chance of recovery from stuttering than monolingual speakers and speakers who spoke solely a language other than English.[142] Another study, though methodologically weak, showed relatively indistinguishable percentages of monolingual and bilingual people who stutter.[143] Due to so much conflicting data, the relationship between bilingualism and stuttering has been called enigmatic,[144] which can demonstrate the intricacies of the topic and encourages more research to be conducted in order to sway the belief of impact the relationship between bilingualism and stuttering has.

Self-help and advocacy organisations for people who stammer have reportedly been in existence since the 1920s. In 1921, a Philadelphia-based attorney who stammered, J Stanley Smith established the Kingsley Club. [156] Designed to support people with a stammer in the Philadelphia area the club took inspiration for its name from Charles Kingsley. Kingsley, a nineteenth century English social reformer and author of Westward Ho! and The Water Babies had a stammer himself. He has also acknowledged his own stammer and wrote about it, including his thoughts on the origins of stammering and thoughts on a ‘cure’. In his Irrationale of Speech or Hints to Stammerers published in Fraser’s Magazine for Town and Country in 1859 under the pen name Minute Philosopher he recounted his experience with stammering as well as offering advice to others with a stammer.[157] Kingsley identifies with the loneliness and despair of the person who stammers and the desire for a cure. Believing a cure was possible, he praised the teachings of Dr. James Hunt who outlined his approach to Stammering in Stammering and Stuttering, their nature and treatment. Notwithstanding Kingsley's praise for Hunt's treatment for stammering he was keen to emphasise that achieving fluency rested on an individual's responsibility to adopt a lifestyle consisting of a good diet, a moral attitude which he believed would support the learning of the art of speaking.  

Whilst Kingsley himself did not appear to recommend self-help or advocacy groups for people who stammer the Kingsley Club promoted a positive mental attitude to support its members in becoming confident speakers, in a similar way discussed by Charles Kingsley in Irrationale of Speech.

The Kingsley Club may be considered a forerunner of The Stuttering Foundation in the US, which was established in 1947 by Malclom Fraser.[158] Between 1925 and 1927, Fraser was private secretary to J Stanley Smith. Fraser, who also had a stammer, helped run the Kingsley Club and went on to be the founder of The Stuttering Foundation.

Although the Kingsley Club sought to support people who stammer to become confident speakers it also appears to have exercised judgement on the level of fluency of its members. In 1938, reported that the club had expelled four of its members who were heard speaking ‘too well’ on the radio; this would suggest that the club did not necessarily celebrate the demonstration of fluent speech by its members.

Other support groups for people who stammer began to emerge in the first half of the twentieth century. In 1935 a Stammerer’s Club was established in Melbourne, Australia by a Mr H Collin of Thornbury.[159] At the time of its formation it had 68 members. The club was formed in response to the tragic case of a man from Sydney who “sought relief from the effects of stammering in suicide”. As well as providing self-help this club adopted an advocacy role with the intention of appealing to the Government to provide special education and to fund research into the causes of stammering (Bermuda Reporter). This newspaper article also reports that the club objected to the title of Stammerer’s Club with the founding members committed to finding a more ‘optimistic title’; this may reflect negative  connotations associated with the term stammerer’ which align with contemporary debates about identity-first or person-first use of language in relation to disability.

The Queensland Stammerer’s Club outlined three aims:

1. To stimulate interest and research in stammering for its cure and alleviation.
2. To obtain particulars of the most modern methods of treatment used overseas and to organise adult and children's classes at which this treatment may be given.  
3. To provide opportunities for friendly intercourse between stammerers and to further their interests in every possible way.[160]

As with the Kingsley Club, the Stammerer’s Club is reported to have exercised judgement on the level of fluency of its members. However, in this case fluency appears to have been the only desirable outcome as according to an article in the Nottingham Post of 1935 the club banned its members from stammering.

Other clubs for people who stammer developed across Australia over the next few years. In 1936 The Bulletin, reported that the Stammerer’s Club of New South Wales had commenced  ‘a postal course of instruction’ for country members.[161] Readers were invited to contact the Honorary Secretary, Mr L. J. Hullick in Sydney for further details. Hullick is reported to have been keen for people who stammer to establish other self-help clubs across Australia. This instruction course promoted by the Stammerer’s Club appears to have been an early form of a group supporting its members remotely via postal services. 

The Stuttering Pride flag symbolises the waves of stuttering pride rippling through the community.

Stuttering pride (or stuttering advocacy) is a social movement repositioning stuttering as a valuable and respectable way of speaking. The movement seeks to counter the societal narratives in which temporal and societal expectations dictate how communication takes place.[162] In this sense, the stuttering pride movement challenges the pervasive societal narrative of stuttering as a defect and instead positions stuttering as a valuable and respectable way of speaking in its own right. The movement encourages stutterers to take pride in their unique speech patterns and in what stuttering can tell us about the world. It also advocates for societal adjustments to allow stutterers equal access to education and employment opportunities.[162]

Stuttering pride has drawn ideas and inspiration from disability rights, in particular the development of the social model of disability and the neurodiversity paradigm.[163] For instance, the neurodiversity movement has led some in the stuttering community to advocate for what can be gained from the experience of stuttering.[164][162] Thus, stuttering pride activists advocate for celebration and respect of stuttered speech.

In terms of stuttering therapies, some stuttering pride activists have suggested therapy approaches that focus on fluent speech as the goal can be unhelpful and damaging to those who stammer.[165] Other activists suggest "it is important that a social or cultural model does not entirely exclude medicine or speech therapy”, but is used “to ask critical questions about how some of the assumptions of a curative model of speech might injure dysfluent individuals".[166]

Stammering pride foregrounds an emerging stammering culture. Crucially, stuttering culture highlights the power of creative writers, artists, and musicians to subvert concepts of 'normative' speech through the power of expressive and generative dysfluency.[167] Stuttering pride activists propose stuttering as a form of vocal and linguistic diversity that enriches our language, ideas, and art forms.[168] For instance, the cultural enrichment of stuttering is apparent in musical elements that take the shape of the physical nature of stuttering, including turntablism and scratching. Stuttering has been integral to many popular songs, such as My Generation by The Who, Changes by David Bowie and Ride on Time by Black Box. Parallel forms of creativity inspired by stuttering can also be seen in repeated motifs featured in fine art or graphic design.[168]