Are you considering speech therapy?

If you as an adult or teen are considering speech therapy, the following tips may assist you:

1.   There can be no doubt that some people find stuttering therapy useful, either in the form of counselling, learning speech techniques, doing exercises provided by the therapist etc. Conversely, others complain that they have not been helped adequately. Often they say that they quickly achieve relative fluency when in the speech clinic, but are unable to maintain this fluency outside of the clinic.

2.   Therapy can be either one-to-one sessions with a therapist or group therapy, often in the form of a workshop or intensive course. While one-to-one sessions can be useful for clients who are hesitant to speak in a group setting, group therapy has the benefit of meeting other people who stutter, so providing opportunities for sharing problems and helpful experiences.

3. Much will depend on your expectations of therapy. Chronic stuttering is difficult to cure 100%. A more realistic expectation would be to aim at improved management of the disorder. Work toward clearly defined, practical goals such as speaking on the telephone, or making presentations before an audience, rather than a vague ideal of better speech.

4. Find a therapist who specialises in stuttering and has the professional qualification to back it up. Speech therapy encompasses many speech disorders, and stuttering is only one of them. These days, the field has broadened to such an extent that, in some countries such as the US, a student therapist can qualify as a speech pathologist / therapist without actually having followed a course in stuttering.

5.   Much will depend on the therapist and her knowledge and skills, as well as her view of stuttering. As in all professions, some professionals are better than others. Some will specialise in one particular approach or technique; others will be flexible in applying a treatment type according to the needs of the client. If you find that you are not making progress with a particular therapist, or a particular type of treatment, you should discuss this with her so that another treatment may be tried; or it may even be necessary to find another therapist.

  

6.   Try to improve your own knowledge on stuttering, as a preparation for therapy. Join a few Facebook groups for people who stutter; read some of the free online books on stuttering HERE.  Stuttering is to a large extent stress-related, so improve your knowledge of stress and how it can affect stuttering. Eg. the improvement often resulting from therapy within the clinic may be the result of reduced stress levels as you become comfortable with the therapist; outside of the clinic, however, all the usual stressors in your life may still be present, thereby impacting on fluency.

7.   If you are considering following an intensive group course from an organisation treating people who stutter, make sure that it is not a bogus money-making scheme – ask around on the internet. Ascertain if they offer long-term follow-up support and refresher events; don't trust them if they offer a quick cure. Ask if the first day of the course is free or if the fee is returnable should you decide midway that the course is not for you.

8.   Last but not least: Speech therapy seems to work best where there is a shared responsibility between client and therapist. Stuttering therapy is actually for 99% self-therapy; the therapist can only advise and guide, but it's the client who has the problem and who needs to do the real work. In other words: Become your own "therapist"! Wishing you all the best in your journey.

Is stuttering a manifestation of TMS?

              Join the "Stuttering as a mindbody disorder" Facebook group HERE.

Is stuttering a stand-alone speech defect, or part of a broader mindbody disorder known as TMS (tension myositis syndrome, aka The Mindbody Syndrome)?

TMS, which was first put on the map by the pioneering Dr John Sarno, MD, is not an officially recognised medical ailment even though some prominent doctors accept that it exists. Though TMS is usually associated with chronic pain such as lower-back pain, many other disorders such as ulcers, sinus problems, carpal tunnel syndrome, certain headaches / migraines, dry eyes, night muscle cramps, heartburn, eating disorders, "growing pains", chronic fatigue syndrome, various skin disorders, OCD, panic attacks etc. etc. may actually be camouflaged TMS - physical (and sometimes psychological) symptoms having an underlying subconscious base.

Spasmodic dysphonia, another speech disorder involving the vocal cords, may also be TMS-related; but stuttering is seldom thought of as perhaps being a form of TMS, in some cases at least, even though a comparison yields interesting results. Both TMS and stuttering are stress-related; and in both cases, muscle cramps / spasms or muscle “locking / freezing” play a major role (lower-back TMS: tension-related muscle cramps in the lower back causing pain. Stuttering: conditioned struggle reflexes in response to a tension-related “locking” of the vocal-cord muscles).

‘Knowledge therapy’

Dr Sarno regards repressed, unconscious psychological rage – or other repressed emotions such as fear, shame / guilt or sadness – as a major cause of TMS. According to him, TMS acts as a distraction, being a rather rough-and-ready defensive and survival technique from the more primitive parts of the brain; by creating pain or other disturbance through tension-induced hypoxia (lack of oxygen) via the autonomic nervous system (ANS), the conscious mind is distracted away from the inner conflict (which the primitive mind regards as more threatening than the actual external symptom). Other experts believe that TMS is the “inner child's” way of signalling its distress. TMS could therefore also be seen as rough “messages” from the subconscious, from the inner self, that all is not well and that corrective steps are needed.

Perfectionists apparently are highly susceptible to TMS. Perfectionism and "goodism" (the tendency to be as ethical and moral as possible; actually also a form of perfectionism) are particularly enraging to the subconscious "id" (the primitive inner animal / child-like part of the brain).  

Treatment for TMS consists of soothing the inner child, doing certain self-help exercises and, in severe cases, counselling; some people are cured simply by reading a book on TMS, thereby bringing to consciousness the psychological underlay of their physical symptoms, and becoming aware of long-hidden emotions that manifest themselves as ailments.

All this will sound pretty crazy if you share the mindset of modern Western medicine with its strict mind-body division. Don't get me wrong - Western medical science has reached fantastic heights in the past century and should be respected for that; but it suffers from a blind spot when it comes to the grey area between mind and body. Western medicine's epic breakthroughs in the modern age, thanks to its focus on the material body, has seduced it to disregard the more hazy area of mindbody health.

 I must admit that I would not have written this article five years ago. I'm not really into unconventional medicine; but some years ago I had the misfortune of suddenly experiencing excruciating lower-back pain. I won't bore people with the details, but after following the usual conventional route of MRI scans and an epidural injection, without much success, I basically solved my back problem by reading a few TMS books and following their advice. So in my experience, TMS is real. Since then I suspect that some of my other, mainly stomach-related, previous ailments were actually TMS-related. I'm even wondering whether my lifelong stuttering, though mild these days, is part of TMS and whether TMS treatment will have an effect on it. 

A vicious circle

TMS is, of course, radically different from current mainstream views on stuttering. Current mainstream thinking regards developmental stuttering as a neurological disorder, with the cause or causes not being psychological in nature. I have no doubt that stuttering has a genetic and neurological component, and that some kids are predisposed to begin to stutter. But does this exclude the possibility of unconscious psychological factors in the period when children begin to talk?

Let's consider the onset of stuttering, usually between the age of 3 and 5. For some predisposed kids, overt stress seems to be the trigger; for instance, some children begin to stutter after a traumatic incident such as a car accident, or after having been bitten by a dog, or after a parental divorce. Here the stress trigger seems clear.

In most cases, however, the stress is not so obvious. It could be argued that the actual learning of language also involves stress triggers: the child needs to master complex grammar, new meanings and difficult pronunciations, all of which could overstress a still immature speech system.    

But perhaps a psychological stress trigger is also possible? Consider, for instance, the following scenario: a child, perhaps rather sensitive by nature, wants to please his parents (as most kids want), but soon learns that anger (fighting / resisting), a normal response to ordinary day-to-day irritations and part of the fight / flight / freeze reaction, is frowned upon. He quickly adapts to this by repressing his "fight" response and instead initiates the "freeze" response (if "flight" is not an option); in other words, he does nothing and keeps quiet (perhaps starting on the road to a degree of introversion - but that's another story which I won't go into here). Repressing the fight response, however, merely relegates his anger to his subconscious, so that unconscious rage begins to build up. The same may happen with other emotions that the child may regard as socially inappropriate, such as sadness, fear and anxiety. And built-up unconscious emotions, so Dr Sarno has taught us, can generate tension and seek a physical outlet.

In this particular, genetically predisposed individual the outlet is the vocal cords that “lock” or “freeze”  - as per the pioneering work of Dr Martin Schwartz, who was instrumental in identifying the role of the vocal cords that freeze when overstressed. Apparently some people are genetically and neurologically predisposed to direct their tension to their vocal cords, just as others direct their tension to other body parts. And so the stress response of freezing becomes a physical “freeze” of the vocal-cord muscles; and the child begins to stutter - the actual sound or word repetitions are simply conditioned reflexes in response to the vocal-cord freeze. The stuttering, in turn, will increase the unconscious inner rage and stress, so that a vicious circle is created, established and strengthened over the years.

The TMS argument can be taken even further. TMS experts would argue that mindbody issues are often symbolic; that the mindbody often chooses a particular body part to symbolically communicate its message. In his book The Great Pain Deception, Steven Ozanich says, in discussing spasmodic dysphonia, that the vocal cords are common targets of tension since the voice is a mechanism of expressing self. In the same way, TMS-related shoulder pain may indicate that the subconscious mind feels that it is "carrying the world on its shoulders". 

A major question would be the following: if stuttering is a type of TMS, is that TMS still active in adulthood; or did the TMS only occur in early childhood, so resulting in stuttering and creating the conditioned responses, after which the TMS itself receded so that the conditioned stuttering remained as a leftover, continuing into adulthood? In the case of this last-mentioned scenario, TMS treatment will obviously not have any effect.

Major implications for treatment

If the stuttering of some people is indeed a type of TMS, it has major implications for treatment. For instance, if unconscious rage is identified as a driver of stuttering in an individual, he could perhaps be helped by focusing on assertiveness. Assertiveness could be seen as a “civilized”, subdued and socially acceptable form of anger, thereby tapping into, channeling and discharging the unconscious rage. (For a short summary of assertiveness as a tool in improving fluency, check out THIS CHAPTER of my free online book, Coping with Stuttering. And for an excellent TED talk on how a few assertive body positions will actually change your body chemistry to make you more relaxed and assertive, click here.)

A major part of TMS treatment is to convince the client's conscious as well as subconscious mind that the problem is fundamentally psychological and NOT structural (after, of course, having excluded the possibility that there is indeed a serious structural defect or injury). This convincing is necessary so that the subconscious mind - the level at which the problem arises - will stop trying to distract you by means of the symptoms. If the subconscious mind becomes aware that its distraction tricks no longer work, it stops its mischief.  I know, it sounds unbelievable - but it works. The proof of the pudding lies in the eating. So many people are benefiting from TMS treatment that it needs to be taken seriously.

Applied to stuttering, it would mean that you have to be convinced, and have to convince your subconscious, that unconscious emotions drive your stuttering. 

A complicating factor, of course, is that stuttering is usually developmental, with onset before school-going age, which means that the years or decades of stuttering and its conditioned components - the force of habit - will need to be taken into account. In TMS, conditioning and learning play a major role, and one can expect that the power of conditioning will be a formidable obstacle for those who want to tackle their stuttering through TMS treatment. However, the TMS treatment may stop the stutter from being fed by the subconscious source, ultimately leading to it withering away.  

Finding your own way

All this is of course speculation; even if it has merit it may be extremely difficult to convince both speech experts and people who stutter, as there is a lot of resistance to the seemingly very alternative and way-out TMS concept ... most people prefer to listen to conventional, officially accepted medical advice. Also, many people hate the idea of having to deal with "mental" issues that still carry the stigma of perhaps being "crazy", and may be unwilling to face their inner demons, preferring physical treatments that are socially acceptable and easier to handle.

Most speech professionals, again, will say that the psychological approach to stuttering has long since been discarded, and that the focus these days is on neurology and brain scanning. They will be quick to tell you that Freud, the father of modern psychology and of psychoanalysis, did not succeed in treating people who stuttered (even though we have come a long way since Freud, with our knowledge of psychology and stress having expanded enormously since then).

So once again it is up to the individual with an open mind to try and find his own way, and experiment with this, or any other, approach which makes sense. Fortunately a small but growing number of doctors are embracing the TMS concept and treating patients accordingly.   

If you're interested in TMS, check out the TMS Wiki site HERE where you will also find a growing list of disorders that may actually be types of TMS. For an excellent introduction to TMS, read Dr John Sarno's Healing Back Pain: The Mind-Body Connection . And for a very comprehensive book on TMS in its many manifestations, have a look at Steven Ozanich's The Great Pain Deception: Faulty Medical Advice Is Making Us Worse. It may radically change the way you view health. And isn't stuttering a part of health? Or else read any of the other books by Dr Sarno, for instance The Divided Mind: The Epidemic Of Mindbody Disorders.  Also consider joining the Facebook group on TMS.

For those who stutter and wish to experiment with this approach, I would suggest that you (1) work on adopting an assertive manner just before speaking, as mentioned above; and (2) carefully read one or more of the TMS books, such as The Great Pain Deception mentioned above, substituting the word "pain" with "stuttering". In other words, read the books as if it were all about stuttering instead of chronic pain. If the stuttering of some people is indeed a type of TMS, the chronic laryngeal blocks may just be the subconscious mind's way of distracting you away from unconscious emotions. Try to re-read these books as often as possible so that the concepts sink in deep into your subconscious, where the real healing occurs; (3) keep a daily journal of your experiences with and feelings about your speech - journalling is a highly successful tool used by TMS sufferers (4) follow a TMS treatment course, again doing the exercises as if it were about stuttering. A free online course can be found at the TMS Wiki ; or do the exercises in the book Unlearn Your Pain, by Dr Howard Schubiner , a medical doctor and TMS practitioner; or any other TMS workbook; (5) join the Facebook group "Stuttering as a mindbody disorder" HERE:  

Feel free to provide feedback in the comments section below if you are experimenting or have experimented with TMS treatment for stuttering. PS Don't be upset when things get worse before they get better! This is typical in TMS treatment, as the subconscious tries to maintain the status quo when it notes that things are changing. TMS treatment is a journey; so be sure to join the TMS Facebook support group mentioned above.

Update January 2017: According to new research, there are indications of reduced blood flow to the brain's speech centres during stuttering. This could strengthen the argument that stuttering is a type of TMS. Keep in mind that, according to the TMS experts, TMS symptoms are physiologically effected by a reduced oxygen supply to the affected area. It could be that the central nervous system reduces the blood flow to the speech centres, thereby reducing the oxygen supply to those areas, so messing up these centres and resulting in the dyscoordination of the vocal cords and the resultant vocal-cord freezing that in turn results in stuttering. Check out this research article. 

'Tightening' of vocal cords results in stuttering, says AIS

Emily Blunt, the beautiful UK actress who is also a board member of the American Institute for Stuttering (AIS). The AIS has come out in support of the concept that stuttering results from a tightening or closure of the vocal cords.

Good news for people who stutter is that the American Institute for Stuttering (AIS), a leading organisation in New York offering treatment for this disorder, has joined those who believe that stuttering results from a tightening of the vocal cords.

The role of the vocal cords in stuttering has for decades been a hotly debated issue among speech experts. Though speech therapists generally accept that the vocal cords can behave unnaturally during stuttering, the traditional view has been that word and sound repetitions, prolongations and unnatural vocal-cord behaviour are all primary manifestations of this mysterious disorder.

In contrast there has been, for many decades, a dissenting line of experts who insist that an unnatural tightening, "locking" or "freezing" of the vocal cords, apparently caused by excessive tension on the cords, triggers the speech repetitions and other struggle behaviours. In other words, the internal vocal-cord spasm happens first and leads to the other, more visible symptoms. 

Fundamental implications

"It appears as if there is a timing problem in the communication of signals from the brain to the speech mechanism. This 'glitch' results in a tightening or closure of the vocal cords. Because of this tightening in the throat, breathing and mouth movements become forced and laboured," according to the AIS's current website.

The view that vocal-cord spasms result in stuttering has fundamental implications for stuttering treatment, as it implies that the focus of treatment should be on the vocal cords, instead of attempting to deal with the stuttering itself. If the vocal cords can be made to behave, the stutter is aborted as it depends on the cord spasm occurring. 

This blog has consistently argued for years that stuttering is a conditioned reflex, resulting from a tension-related "locking" of the vocal cords. Traditional treatment aimed at the stuttering itself is misplaced as it does not address the true problem, namely the erratic, abnormal behaviour of over-tensed vocal cords. The vocal-cord muscles seem to behave this way because, when overstressed, the fine vocal-cord muscle coordination necessary for normal speech breaks down.

Reflexive attempt

A vocal-cord tightening (or "block" as it is called by people who stutter) can easily be reproduced artificially, according to the AIS website. "Take in a breath of air, keeping your mouth open, and hold your breath. Then let little puffs of air out. Feel the sensation in your throat. You just closed your vocal cords on purpose. If you stutter, this feeling will be all too familiar. Now, do that again. Hold your breath with your mouth open, don't let any air out at all and try to speak.

"If you don't stutter you have just created the physical sensation of what we call blocking. You know what you want to say, but imagine trying to speak and nothing comes out. Those who stutter, experience this all the time. It's as if they are choking when trying to speak.

"In a reflexive attempt to help the person speak, the mouth muscles (articulators) then kick into 'overdrive' to compensate for the vocal cords that aren't 'working'. This is the aspect of stuttering that most people see."

The AIS's view of stuttering shows that this approach to stuttering is gaining ground within therapy circles. Hopefully other speech professionals will follow their example. This is a major step toward improved and more realistic stuttering therapy.              

Helpful website for improving your life skills

I believe that good life skills, such as avoiding perfectionism, building self-image, being your own best friend etc. are a crucial part of stuttering management.

These skills tend to reduce inner stresses, thereby lowering base-level tension which plays such an important part in stuttering. Unfortunately we often forget to apply these useful concepts in our day-to-day life, and it really helps to be reminded of them regularly.

For the past few months I have been a subscriber of a very useful site that sends out regular messages with good, common-sense advice for maintaining a positive and less stressful outlook on life and life's challenges. It's called The Positivity Blog. The regular emailed messages are free, though paid courses are also available if you want to go more deeply into any of the particular topics.

I have found that the regular messages help me stay on track and on top of things. If you're interested, feel free to check out The Positivity Blog by clicking HERE. 

       

Dr Martin Schwartz's Training Course for People who Stutter now available for free!

Dr Martin Schwartz has been so generous as to make his 2008 DVD-based Self-therapy Course for People who Stutter available to the general public for free, and it gives me great pleasure to present the course here on my blog. Much thanks to Dr Schwartz for this great gesture.

The course consists of three videos plus a manual and a workbook. Note that Dr Schwartz also highly recommends that you acquire the MotivAider, an electronic appliance that will remind you to use your speech technique. 

Video 1, titled The Understanding, explains why people stutter. What we see and hear as "stuttering", is merely struggle behaviour resulting from the vocal cords that have "locked" due to excessive tension on the cords. Here is video 1: (If you have a mobile phone or tablet, or have problems in viewing the video, watch it on YouTube HERE )

But what can we do about this vocal-cord lock? Video 2 is all about treating the cord lock, not the stutter itself. When we reduce the tension on the vocal cords, we lower the possibility that they will lock (and cause a stutter). In video 2, the Slowed First Syllable technique is explained - the first of various techniques to reduce pre-speech tension on the vocal cords. Herewith video 2: (View it HERE on YouTube if you have a mobile appliance or are unable to open the video.)  

In the third video, Dr Schwartz discusses another powerful technique to reduce vocal-cord tension: the Passive Airflow Technique: (View it HERE on YouTube if you have a mobile appliance or are otherwise unable to open the video.)

The really excellent manual will be found HERE.  It should be downloaded for study as it contains a lot of important information for people who stutter. And click here for the workbook which should also be downloaded, as it contains various "homework" exercises to which Dr Schwartz refers to in the videos.  

Do read and study the manual carefully! An understanding of stuttering is actually part of the treatment - knowing how stuttering occurs makes it easier to deal with it. 

Note that though this is basically a self-help programme, it is strongly recommended that you get a "monitor" - a therapist / friend / spouse / significant other / parent etc. to assist you with the various exercises. Better still, try to combine this with joining a stuttering support group in your area, and do the exercises as part of their meetings. 

I attended two Schwartz workshops in the 1980s, joined the support group which was formed afterwards, and have been helped much by them. It's not a miracle cure though and will require time, work and dedication - but I believe this is the best available. If you intend to do the course, I wish you well! For any questions, join the Passive Airflow Facebook group which you will find here. 

New free e-book on thiamin (vitamin B1) for stuttering now available

Dr Martin F Schwartz's new e-book, The Thiamin Protocol, is now available as a free PDF download. This book, only 92 pages long, can be downloaded HERE.

The book contains the latest information on the thiamin (vitamin B1) and magnesium treatment protocol for people who stutter. According to Dr Schwartz's original trial study, of which you can read more HERE, about 1/3 of adult males who stutter can be helped significantly by following the protocol.

If you have previously tried these supplements without any effect, do read this book as you may have omitted or done something which compromised your fluency. For instance, some foods and drinks, as well as some medicines, contain anti-B1 factors such as caffeine, sugars and sweetened beverages. It makes no sense to take B1 pills if, at the same time, your diet neutralises the B1 in your body. So it's important to follow a pro-B1 diet during the 3-week test period.

This book is not only valuable because of the thiamin treatment, but also as it clearly sets out Dr Schwartz's view of how and why people stutter. Chapter 5, titled "The trigger for stuttering", explains how a stress-related dyscoordination of the vocal cords within the larynx results in vocal-cord "locking". The speech repetitions and prolongations which we hear as "stuttering" are merely learned struggle behaviours in an effort to speak in spite of the vocal cords that intermittently lock to a greater or lesser extent. 

This dyscoordination, in turn, could be due to a deficiency of the GABA neurotransmitter in the brain. Vitamin B1 is required for the proper functioning of GABA, so this may be why thiamin improves fluency in some people.

The thinking man or woman's speech therapist

Finally, for those who do not benefit from the thiamin protocol, the author gives an overview of his "Intent Therapy". Intent Therapy resembles the "slow onset" approach, but also requires a "mental comma" after the first word (if a monosyllabic word), with the rest of the sentence spoken as an afterthought. Intent Therapy is actually part of his Passive Airflow Technique, but is presented here as a simplified stand-alone approach.

"The important thing is not to have the rest of the sentence in your mind before you say the first word," he writes. You must intend to say just one word, and then shift your intent and say the rest of the sentence. The purpose is to reduce pre-speech tension on the vocal cords, which would otherwise result in stuttering. This technique, if done correctly, sounds quite natural but, as with all fluency techniques, needs to be practised a lot.

Dr Schwartz's books have consistently re-defined stuttering and its treatment, beginning with the highly controversial Stuttering Solved (1976) up to Stutter No More (1991), and The Thiamin Protocol is no exception. He is the thinking man or woman's speech therapist and so is not everybody's cup of tea, but I love his work. 

Do read this latest book, try the protocol if you haven't yet done so, and study Chapter 5 for a very plausible explanation of stuttering. And for a fuller picture of the author's thinking about stuttering also read Stutter No More, a 65-page free PDF - focused on his Airflow approach - which can be downloaded HERE. Dr Schwartz is to be commended for making these important books available for free to the stuttering community. Hopefully other authors will follow his example.      

Stammering in young children - the wisdom of Ann Irwin

Though this blog is mainly about developmental chronic stuttering in adults and teens, I did write a chapter on stuttering children in my free online book Coping with Stuttering. I based that chapter to a large extent on Ann Irwin's very useful book Stammering in young children - a practical self-help programme for parents (1988), which was well known and received at the time but seems to have been somewhat forgotten.

Ann's book made a great deal of sense to me at the time - also because she is acutely aware of the huge impact of stress on stuttering - and I thought it a good idea to revive her thinking on the subject, particularly as the issue of how to best deal with stuttering children up to the age of about seven has always been particularly controversial.

This controversy is partially due to the fact that most children (about 3/4 of kids) anyway outgrow the disorder, with or without treatment. The question inevitably arises whether, in order to maximise the chances of outgrowing it, it is best to either treat the child as soon as possible, or rather not at all in the hope that they will outgrow it. The controversy rages to this day, but Ann Irwin is firmly on the side of those who feel that direct intervention could do more harm than good. In my book I summarised her ideas, and I reprint that section here:

Book summary

       

"In the book Stammering in young children – a practical self-help programme for parents (1988, Thorsons), Ann Irwin describes a systematic preventative programme developed to temporarily reduce the child’s speech-related tension levels and in the process put an end to their stuttering. The programme is suitable for children up to the age of seven. While the programme is in effect, the child is temporarily as it were protected from exposure to all kinds of speech-related stress. If he has been completely fluent for a period of nine months, the parents may assume that he is cured and return to a normal routine. This protection programme should be introduced gradually – too many changes can confuse children and make them insecure.

"The extent to which children’s base-level tension varies was mentioned before – they may not stutter for months due to low base-level tension. If a child does not stutter for several months, parents may draw the wrong conclusion and consider him cured. The fact is that he may only be experiencing a period of temporary fluency due to low stress levels. For this reason Ann Irwin uses a nine-month period of fluency as the criterion for determining if the child has in fact outgrown his stuttering.

Strategies

"Her programme includes the following strategies:

* Parents should identify the factors that improve or weaken their child’s speech. The next step would be to develop strategies to control the negative aspects and enhance the positive ones.

Parents may, for example, find that Johnny’s speech deteriorates when he is excited. The appropriate strategy would then be not to emphasise exciting events such as Christmas – do not ask him what present he wants six weeks in advance, but rather one week before the event. Also avoid exciting games, tickling, et cet. If, however, parents notice that Johnny’s speech improves when he plays with his brother, they should encourage it, e.g. by buying a game they can play together.

* If he is by nature a hurried and active child who speaks too fast, try to calm him down in general without pointing out that he must speak slower. One way of doing this is to play a game in which the child is given a small financial reward if he walks to school instead of running.

Reduce direct questions

* Reduce the number of direct questions that you ask the child. Direct questions have to be answered and place the child under a great deal of speaking pressure. Bear in mind that your aim is to make Johnny enjoy speaking – and since you want to encourage him to associate speech with pleasure, avoid unpleasant questions. Also, many direct questions can be asked in an indirect way, e.g. instead of asking: ‘Do you want to play with these toys?’ you could say: ‘I put these toys on the table in case you want to play with them.’ If a question cannot be avoided, try to ask questions that require a simple yes or no instead of a long explanation. A good idea is to inform outsiders, especially teachers, of what you are doing. 

* Parents should reduce their speech demands and eliminate sentences starting with ‘say’ and ‘tell’, e.g.: ‘Say hello to Uncle Pete’, ‘Say goodbye’, ‘Say please’, ‘Tell Granny that story’, ‘Tell Dad what happened today’. Other speech demands include: `Johnny, come and talk to Granddad on the phone’ or ‘I saw you pull the cat’s tail. You have to tell me why you did it and promise that you will never do it again.’ Requests to repeat a word or sentence also constitute speech demands.

* Avoid interrupting the child. It only causes frustration and self-doubt and will force him to increase his tempo so that he can have his say before he is interrupted again. However, parents must allow the child to interrupt them. This is to prevent the type of self-consciousness and speech consciousness that would make him hesitate before saying something. He should not be thinking: Is it okay if I say something now?

Pay attention

* Pay attention to him when he speaks, so that he finds speaking an enjoyable and rewarding experience. Be a good listener. If you look bored, you will undermine his self-confidence. In real life, however, it is sometimes difficult to respond to your child with good listening – if giving him your undivided attention is difficult at a given moment, you should say something like: ‘I’m feeding the baby, so it’s difficult for me to listen to you right now. Give me thirty minutes and then you can tell me everything you want to.’ Bear in mind that children are often talking to themselves rather than to you – one should learn to distinguish between the different types of conversations children indulge in.

* Try to protect the child from competing for an opportunity to talk. It often happens – especially in families – that the stuttering child is deprived of an opportunity to speak his mind due to a lack of pauses in the conversation. This can make him speech-conscious. Give each child a turn to speak.

* Do not correct the child if his pronunciation or grammar is incorrect. If you make him aware of his language, he will also become aware of his stutter.

* Relax all discipline, criticism and punishment.

"Keep in mind that all these dos and don'ts are temporary. If the child remains fluent for nine months, you may resume the normal routine. The normal routine should be introduced gradually and in a step by step manner. If this process results in renewed stuttering, apply the relevant protective measure until the stuttering disappears.

If the stuttering persists

"If the stuttering persists in spite of the above guidelines, Ann Irwin has the following additional advice:

* Parents should not expect too much of their child. Avoid parental perfectionism.

* Is there something in the child’s life of which he is excessively afraid? Watch out for scary movies – try to reduce his fears and other negative emotions. If he fears something and wants to talk about it, he may stutter badly – it may then be better to express those fears on his behalf. Loneliness and sorrow also increase stress. Children have been known to recover after receiving a present such as a pet, or after going fishing with their father.

* A warm and loving home atmosphere allowing conversation, emotional outbursts and spontaneity will be of benefit. Comments such as: ‘Don’t ask so many questions’, ‘Don’t talk so much’ and too much discipline, criticism and punishment can be harmful. However, too little discipline or inconsistent discipline can lead to insecurity, resulting in ‘the stress of uncertainty’ and stuttering. Find the golden mean. Discipline should be fair.

Relapses

"After months of fluency a child may resume his stuttering due to a sudden frightening experience or stressful event, such as changing schools or going on a special holiday. This is unfortunate, but under normal circumstances the child’s fluency should return after a few weeks or months provided that he receives adequate protection against stress. However if he has a traumatic experience during this recovery period, the stuttering may increase in severity and last longer before improving. A third traumatic experience during this period may lead to chronic stuttering. One reason for this is that the child is growing up – and it is more difficult to treat older children. It is even possible that a single traumatic event, such as a car accident, may induce enough stress to cause continued stuttering due to high base-level tension."

The above summary can actually be condensed further in a single sentence: Try to keep the child's "speech tension" below his "stuttering threshold", in order to increase the chances that he will outgrow it. For more information on "speech tension", "base-level tension" and "stuttering threshold", read this chapter of my book. Also check out the remainder of the chapter on stuttering children here. You may also want to try the thiamine protocol. If you have a child who stutters, I wish you the very best of luck!

Those on B1 MUST take magnesium

If you are taking thiamine (vitamin B1) for stuttering on a long-term basis, you should definitely also take magnesium pills, says Dr Martin F Schwartz, a stuttering expert from New York.

Dr Schwartz, who is writing a book on the use of thiamine and magnesium as a treatment for about 1/3 of people who stutter, has cautioned that just taking thiamine on its own can in the long run result in a magnesium deficiency.

"There is a distinct possibility that a magnesium deficiency of significant proportions might occur after some months if a person only uses thiamine to address their stuttering," says Dr Schwartz. "I am assuming here that the thiamine is working for an individual and they see no need to take magnesium. But this would be wrong.

"The reason is that increased levels of thiamine require increased amounts of magnesium to convert thiamine to its usable form. This increased demand for magnesium, occasioned by the increased presence of thiamine, but in the absence of sufficient magnesium, causes the body to withdraw magnesium from other parts of the body. This is not desirable.

"So, to prevent this, I would always suggest that a person using 300 mg of thiamine daily should also always use the RDA (recommended daily allowance) for magnesium - just as a precaution."

For more information on this approach to stuttering, read this FAQ.

Fake it till you make it

In this excellent TED video, social psychologist Amy Cuddy explains how a few simple body positions can change body chemistry and make us not only more assertive, but more relaxed. How does this relate to stuttering?

Well, I believe that both stress management and assertiveness training can improve fluency for a person who stutters. In my free online book Coping With Stuttering I wrote chapters on stress management as well as on assertiveness, and Amy's TED video complements these subjects.

So sit back, relax and find out how some body positions can increase testosterone (the dominance hormone) and decrease cortisol (the stress hormone). Click here to watch the video. Enjoy!   

These medicines interact with magnesium

Magnesium assists with the absorption of thiamine (vitamin B1) in the body, but can have side effects when taken with certain medicines. The following detailed description of undesirable side effects for magnesium with certain medications has been compiled by an expert. Always first consult your doctor before taking any supplement! 

Antibiotics (aminoglycoside antibiotics)

Some antibiotics can affect the muscles. These antibiotics are called aminoglycosides. Magnesium can also affect the muscles. Taking these antibiotics and getting a magnesium shot might cause muscle problems.
Some aminoglycoside antibiotics include amikacin (Amikin), gentamicin (Garamycin), kanamycin (Kantrex), streptomycin, tobramycin (Nebcin) and others.

Antibiotics (quinolone antibiotics)

Magnesium might decrease how much antibiotic the body absorbs. Taking magnesium along with some antibiotics might decrease the effectiveness of some antibiotics. To avoid this interaction, take these antibiotics at least 2 hours before, or 4 to 6 hours after, magnesium supplements.
Some of these antibiotics that might interact with magnesium include ciprofloxacin (Cipro), enoxacin (Penetrex), norfloxacin (Chibroxin, Noroxin), sparfloxacin (Zagam), trovafloxacin (Trovan) and grepafloxacin (Raxar).

Antibiotics (tetracycline antibiotics)

Magnesium can attach to tetracyclines in the stomach. This decreases the amount of tetracyclines that the body can absorb. Taking magnesium along with tetracyclines might decrease the effectiveness of tetracyclines. To avoid this interaction, take calcium 2 hours before or 4 hours after taking tetracyclines.
Some tetracyclines include demeclocycline (Declomycin), minocycline (Minocin) and tetracycline (Achromycin).

Bisphosphonates

Magnesium can decrease how much bisphosphate the body absorbs. Taking magnesium along with bisphosphates can decrease the effectiveness of bisphosphate. To avoid this interaction, take bisphosphonate at least two hours before magnesium or later in the day.
Some bisphosphonates include alendronate (Fosamax), etidronate (Didronel), risedronate (Actonel), tiludronate (Skelid) and others.

Medications for high blood pressure (calcium channel blockers)

Magnesium might decrease blood pressure. Taking magnesium with medication for high blood pressure might cause your blood pressure to go too low.
Some medications for high blood pressure include nifedipine (Adalat, Procardia), verapamil (Calan, Isoptin, Verelan), diltiazem (Cardizem), isradipine (DynaCirc), felodipine (Plendil), amlodipine (Norvasc, Lomanor, Calbloc) and others.

Muscle relaxants

Magnesium seems to help relax muscles. Taking magnesium along with muscle relaxants can increase the risk of side effects of muscle relaxants.
Some muscle relaxants include carisoprodol (Soma), pipecuronium (Arduan), orphenadrine (Banflex, Disipal), cyclobenzaprine, gallamine (Flaxedil), atracurium (Tracrium), pancuronium (Pavulon), succinylcholine (Anectine) and others.

“Water pills” (potassium-sparing diuretics)

Some "water pills" can increase magnesium levels in the body. Taking some water pills along with magnesium might cause an excess of magnesium in the body.
Some water pills that increase magnesium in the body include amiloride (Midamor), spironolactone (Aldactone) and triamterene (Dyrenium).

These factors reduce your thiamine levels

Those who find that thiamine (vitamin B1) reduces their stuttering may be interested in the following list, mailed to me by an expert, of factors that reduce thiamine levels in the body.

If you find that more thiamine improves your fluency, it makes sense to try and avoid depleting the thiamine in your body where possible - though of course this should be weighed up against the positive effects these factors may have on other aspects of health.

For more information on thiamine/magnesium and their possible impact, if any, on stuttering, read this FAQ. Health Warning: Never take any food supplement without first consulting your medical practitioner. 

 Here is an exhaustive list of substances and other factors that can affect thiamine utilisation negatively:

Thiamine deficiency can occur when excess vitamin B1 is used up by the body. This can be caused by:

• Pregnancy
• Hyperthyroidism
• Lactation
• Fever - severe infection/sepsis
• Increased physical exercise; and
• Refeeding syndrome (a metabolic complication that occurs when nutritional support is given to severely malnourished patients).

Inadequate thiamine intake can also occur via diets consisting mainly of the following:

• Food containing a high level of thiaminases (which impair thiamine), including certain raw freshwater fish, raw shellfish, and ferns. When buying rice, try to get brown rice, as white rice has been milled, which means that most of the thiamine in the rice has been removed.
• Substances high in anti-thiamine factors, such as coffee, tea and betel nuts (it is not just the caffeine in coffee and tea that impacts on thiamine - the tannins in these products also work against thiamine. So also avoid decaffeinated tea and coffee, rather take herbal tea such as rooibos tea.) 
• Sulfites are added to many processed foods as a preservative. Sulfites destroy thiamine.
• Foods that are high in simple carbohydrates (in candies, cakes, syrups, sugar, fizzy drinks and others).

Alcohol consumption blocks thiamine assimilation and also injures the small intestine and reduces its ability to absorb thiamine. Smoking also has a negative effect on thiamine.

Certain medications can deplete vitamin B1. These include:

Acid blockers: cimetidine (Tagamet), esomeprazole (Nexium), famotidine (Pepcid and Pepcid Complete), lansoprazole (Prevacid 24hr), nizatidine (Axid), omeprazole (Prilosec OTC), pantoprazole (Protonix), rabeprazole (Aciphex) and ranitidine (Zantac).

Antacids: Aluminum & magnesium hydroxide (Maalox, Mylanta), aluminum carbonate gel (Basaljel), aluminum hydroxide (Amphojel, AlternaGEL), calcium carbonate (Rolaids, Titralac, Tums, Digestif Rennie), magnesium hydroxide (Phillips’ Milk of Magnesia) and sodium bicarbonate (Alka-Seltzer, baking soda).

Antibiotics (just a few listed here, but all deplete vitamin B1):

Aminoglycosides, amoxicillin (Amoxil), azithromycin (Z-pak), cefdinir (Omnicef), cephalexin (Keflex), ciprofloxacin (Biaxin), doxycycline (Doryx), erythromycin (E.E.S.), levofloxacin (Levaquin), minocycline (Minocin), penicillin (Pen VK), sulfamethoxazole and trimethoprim (Bactrim, Septra) and tetracycline (Sumycin).

Anticonvulsants: phenytoin (Dilantin) - space supplement at least 4 hours away from the medication; zonisamide (Zonegran).

Antivirals: delavirdine (Rescriptor), lamivudine (Epivir), nevirapine (Viramune), foscarnet (Foscavir), zidovudine, AZT (Retrovir), zidovdine and lamivudine (Combivir).

Aromatase inhibitors for breast cancer: anastrozole (Arimidex).

Cardiac glycoside: digoxin (Lanoxin, Lanoxicaps and Digitek).

Blood pressure drugs: bumetanide (Bumex), ethacrynic acid (Edecrin), furosemide (Lasix), torsemide (Demadrex), indapamide (Lozol), hydrochlorothiazide or HCTZ (Hyrodiuril). Any combination drug that contains HCTZ or hydrochlorothiazide (dozens of drugs contain this), chlorothiazide (Diuril), chlorthalidone (Hygroton), methyclothiazide (Enduron) and metolazone (Zaroxolyn).

Diuretics: loss of thiamine through renal excretion can occur with most, if not all, diuretics. It has been seen with the use of such diuretics as mannitol, acetazolamide, chlorothiazide, amiloride and loop diuretics. Thiamine loss is associated with the increase in urine flow rate.

Bronchodilators: theophylline (Uniphyl, Theo-24 or Theo-dur).

Hormone replacement therapy/oral contraceptives: estradiol (Estrace, Climara, Estraderm, Estring, Activella, Femring, Combipatch, Strogel, Menostar and many others), estrogen-containing drugs (hormone replacement therapy and birth control), conjugated estrogens (Premphase, Pempro) and ethinyl estradiol (found in many birth control pills).

Sulfonamides: sulfa antibiotics, some diabetes medications.

ERMs (selective estrogen receptor modulators used for breast cancer): raloxifene (Evista), tamoxifen (Nolvadex) and toremifene (Fareston).