02.18.2011 – A still small voice

The much-acclaimed film ‘The King’s Speech’ has helped raise awareness of the problem of stuttering – which is, naturally, not a particularly ‘sexy’ media topic. Local experts now point to organic, rather than environmental or social, causes for the phenomenon.

By Aviva Lori | Feb.18, 2011 | 11:26 AM

sorek - Daniel Tchetchik - February 18 2011

Sorek. “I didn’t dare to speak in class.” Photo by Daniel Tchetchik

For a moment in time it seemed that the phenomenon of stuttering had disappeared from the world, and that those suffering from it were only to be found in the antiques department of human evolution. At least this may have been true until the recent film came out about England’s King George VI, entitled “The King’s Speech,” which restored to stuttering the respect and attention it deserves. It turns out that the phenomenon still exists, of course, despite many advances in its treatment over the years. Indeed, at any given time there is a fixed and stable proportion of people who stammer among us: 1 percent of all people, and 5 percent of all children. There are about 70 million stutterers in the world, and their voice is not often heard.

“If there is one thing that characterizes stutterers,” says Benny Ravid, chairman of the Israel Stuttering Association (known by the Hebrew acronym AMBI ), “it’s that they all want to hide their stutter, and will do everything possible to avoid being seen and heard.”

A stutterer lives in his own world. He can be an atomic scientist, a revered professor, an experienced lawyer, a famous singer or a monarch. In his own eyes, first of all, he has a speech impediment, and for at least part of his life – depending on the therapy he has received – he constantly suffers. Now it emerges that one movie has done what decades of a not-very-serious search for the offending gene haven’t accomplished.

Prof. Yair Lampel, head of the department of neurology at the Wolfson Medical Center, who treats stutterers, and Israeli-born Prof. Ehud Yairi, an international expert on stuttering who lives in the United States, agree that there is nothing attractive or “sexy” about this problem, and thus it lacks a lobby and famous people who are willing to mobilize for it. Stutterers simply do not constitute a pressure group, don’t photograph well, and naturally it is hard to interview them in the media or to conduct awareness campaigns on their behalf.

At the moment there are no medications that can help people with this impediment and no real cure. Communication therapy helps only about a third of people who stammer, and aside from a few centers in the world and a few people who are obsessed with the subject, little money is being invested in researching the causes of it.

Stuttering is a phenomenon that surfaces only in conversations: The person in question, when he talks to himself, to the cat or to his infant, does not stammer. “What is certain is that under certain conditions, anyone who stutters can speak fluently,” says Yairi. “That means that the ostensible cause of stuttering is the person who is listening to you.”

This is an inborn phenomenon, almost certainly genetic, whose causes and connection to a precise physical location in the brain are as yet unknown. There are theories only, and a lot of folklore. For example, stuttering is not the result of an emotional problem, as people once believed, with the exception of extreme cases in which it arises after a serious trauma or a stroke. The reason for it is also apparently not a mechanical problem in the vocal chords.

Yairi: “We have an accumulation of data about many differences in the anatomical and physical structure of the brain between stutterers and non-stutterers. In the former, you see differences in the gray matter and a certain absence of white matter (which links the parts of the gray matter ), plus we have found stronger wave activity in the right part of the brain.”

Stuttering becomes evident usually at a very young age, shortly after children begin to speak. It is more common in boys than girls, a 2:1 ratio, and more in adult men than women: a ratio of 5:1. During a person’s childhood, the phenomenon is often called “lack of speech fluency.” In about 80 percent of young people who experience it, the stuttering will disappear on its own, naturally, about four years after it began. The rest will continue to stutter.

“Lack of fluency means problems searching for a word and organizing language,” says Dr. Ruth Ezrati of the Department of Communication Disorders at Tel Aviv University and a communication therapist at Sheba Medical Center, Tel Hashomer. She is a leading researcher in the field in Israel. “Stuttering is when a child knows exactly the word he wants to say, but it doesn’t come out of his mouth. Stuttering occurs between the stutterer and the listener, who is often an authority figure who causes stress. But there are some who will actually stammer more with their family members, because they feel comfortable. There are also some who want to make their parents happy, and to show that they’re all right, and then they get excited and stutter more.”

What should parents do when their child’s speech gets stuck?

Ezrati: “Once we used to say not to do anything and today we intervene, but through the parents. We create an environment for the child that is most suited to his communications needs: They have to speak slowly [to him], and not ask complex questions, so the answers will be simple.”

Should we help him complete sentences?

“As opposed to others, I believe you have to behave as in any other situation and to complete the words – if you know exactly what the child wants to say. When your child has difficulty with a puzzle, you let him try for a few seconds and then you help him, so it’s the same here: Don’t leave him alone in his distress. It doesn’t have to be a secret that you don’t discuss. If a child can ask himself why, when I have a fever, Mom immediately pays attention to me, but when I have such trouble speaking she ignores it – this immediately becomes something mysterious, empowering or burdensome.

“You have to treat the problem more naturally. You can create an interactive environment that bypasses language, like drawing or playing music together with your child. Not enough studies have been done – maybe a few in Australia, where they’re doing more research – to enable us to know clearly how to behave, but it’s been shown that therapeutic intervention at preschool age contributes to reducing and abbreviating the phenomenon.”

Prof. Yairi is a leading, prize-winning international experts in research on stammering. He teaches at the University of Illinois at Urbana-Champaign and at Tel Aviv University in the Department of Communication Disorders. His expertise is stuttering in children, which usually begins between the ages of two and four. There is no scientific tool that can predict which children will continue to stutter as adults, but there are some hypotheses.

“The chances that a boy will continue to stutter are higher,” says Yairi. “If there’s a family history of natural recovery from stuttering, then the child’s chances of that are greater, and if there’s a family history of chronic stammering, the child’s chances of that are higher. If a decline in the phenomenon begins within two months of its onset, that’s quite a good sign; if there’s no change, that’s not so good. If you don’t see a big change after nine months to a year, then there’s a great chance of stuttering [continuing]. Each factor separately is not enough, but when you combine the factors you can receive a more precise picture.”

‘Idol worship’In the past the predominant feeling was that emotional problems caused stuttering; today the attitude is more complex and more sophisticated.

Ezrati: “Today the theory is not commonly accepted. Today people believe more in the organic theories – that you’re born with the tendency and it’s not related to your relationship with your parents.”

Yairi also supports the organic theory, and notes that the major shift in understanding the problem of stammering took place in the second half of the 20th century.

“Until then it was widely believed that the reason for stuttering was the negative reactions of parents that caused the child to be tense, and because of the parents, what would have disappeared naturally develops into stuttering,” he says. “Today it’s clear that this theory has ‘gone bankrupt.’ Our studies have proven that from the start one can see clear differences between a lack of fluency that will pass, and a lack of fluency that indicates the beginning of stuttering. There’s undoubtedly a genetic factor involved here. Today the methods of treatment are much more direct than in the past – today the child is the center of the therapy, and not the parents, as in the past.”

If there were any doubt about the genetic origins of the problem, Yairi, himself a former stutterer, brings clear proof from his own “private laboratory”: Among his close relatives, his father, his grandfather, all his uncles, half his male cousins and one of his sons (for a short time only ) – all suffered from stuttering. Yairi’s own childhood in Israel involved constant suffering.

Yairi: “My stuttering was very bad, mainly in school, where you have to speak and read aloud and you try to avoid all kinds of interaction. Even if you’re the only one in class who knows the answer – you don’t speak up. Even when the teacher turns to you, you say, ‘I don’t know.’ In a store you don’t ask, you point. As an adult I would come to meetings late so I wouldn’t have to introduce myself. I didn’t speak on the phone until after the age of 20. In the morning roll call in the army, when the commander would read the names, I would ask my friend to answer in my place, ‘Yes, sir.'”

Yairi registered for studies in the Faculty of Agriculture, but didn’t pass the admissions interview: “I told them I wouldn’t have any problem talking to the corn, but it didn’t help. They said outright that they weren’t accepting me because of the stutter.”

He was accepted to the psychology department at TAU, however, and after completing his bachelor’s degree he completed his master’s degree and doctorate at the University of Iowa. Today, he refers to the treatment for stuttering, which he received here as a teenager in the 1950s, as “idol worship.”

“At the time there was a small number of doctors who had an interest in stuttering,” he explains, “and there were no communication therapists. One doctor told me to put my feet in a bucket of cold water every evening for 15 minutes. Another suggested sitting next to the window, looking out at the greenery, and breathing in the good wind and letting out the bad wind. They told me to read passages from the newspaper aloud and … to talk along with a metronome. I received electric shocks to my face and neck muscles, I was injected with sodium pentathol that was supposed to reach my subconscious, I moved my right thumb from side to side, I practiced breathing, someone gave me an injection in the behind that was supposed to calm me. They worked on me with hypnosis, for two years I was in psychoanalysis. Everything was a total waste of time.”

Personal ‘trademark’In spite of the prevailing assumption that the tendency to stutter is innate, apparently environmental factors and personality also affect the way a person deals with the phenomenon.

“There are some people who will seclude themselves and prefer not to talk,” says Ezrati, “or they will speak in simple language and use words that are easy to pronounce. There are also some who will chatter without any problem. Several studies have been done on the connection between identical twins and stuttering. In cases where the biological father stuttered and the identical twins were separated and grew up with adoptive families, there were more similarities between the children and their birth father, than with the man who raised them. That underlines the importance of genetics as a factor affecting stuttering.”

Benny Ravid, chairman and founder of AMBI, suffered from speech problems at about the age of nine, after immigrating to Israel with his parents from Poland, in 1957. A year earlier his younger brother was born.

“My stutter simply appeared and that was that, and it’s become my trademark,” he explains. “Because of my activity in AMBI I sort of have to stutter, but then I actually stutter less … The worst problems are when you want to make a good impression, at work interviews, on dates with girls. One of the biggest problems of stutterers is that they live in a society of non-stutterers; as children, they feel deprived and have low opinions of themselves. Their entire self-image is concentrated on stuttering. That’s the worst thing in life, an excuse for all failures. Because of the stuttering a person doesn’t find a job, a wife – he suffers from all the problems in the world; if he only stops stuttering, all the problems will be solved, he thinks. From my personal experience I know that’s not the case. You can live with a stutter and deal with the problems.”

Ravid, an aeronautical engineer, works for Israel Aerospace Industries. He is married, he has a family, gives lectures and tries as much as possible to ignore the fact that the words sometimes simply get stuck in his throat. When he was young, it was different: “I had problems in school with children who mocked and made fun of me, but I was fat and strong so my strength solved that problem. In class I wouldn’t talk because I didn’t want to reveal the stutter.”

Were your teachers optimistic?

Ravid: “Every teacher is different. I remember the problematic ones. In high school the math teacher, who was also the homeroom teacher, asked people to give a lecture about some subject and I overcame my fear and said I wanted to talk, but he said: ‘We don’t have time for that.'”

Hanan and Miriam Verbicek, Ravid’s parents, recall the difficult period they went through.

“[It was] quite a serious trauma,” says Hanan. “We were new immigrants, we didn’t know Hebrew, we didn’t have money and we didn’t know how to handle it. When he had a bar mitzvah and we received some money, we went with him to the therapist for the first time.”

Since then Ravid has undergone psychological therapy dozens of times; the professionals all tried to treat the cause instead of the effect. At the time he thought it was totally unnecessary and ineffective. Today he understands that even if he didn’t learn to speak better, he learned how to be at peace with himself.

He started dating late – when he was already a student in the Technion Israel Institute of Technology in Haifa. He told his dates that he was quiet because he was a new immigrant who didn’t understand Hebrew: “But of course it didn’t work, because it’s impossible to base a relationship on a lie and on silences. Today I can say from experience that there are girls who like stutterers.”

Are there fewer stutterers today?

“No, there are many stutterers who manage not to reveal it. They try not to be seen. Anyone in the know, like me, immediately identifies one.”


“I sense it, I have the soul of a stutterer.”

Mark of stupidityAnd if having the problem itself is not enough, popular folklore has also attached stigmas of lack of intelligence and intellectual disabilities to stutterers.

“That’s one of our problems,” says Ravid, “that the culture labeled the stutterer with all kinds of nonsense, as though he is stupid, unsuccessful and incapable of all kinds of things. Here and there he is even treated as mentally ill. I’ve heard about all kinds of matchmakers who matched up stutterers with the mentally ill. These are things that we’re trying to deal with, not only in Israel but all over the world.”

“It’s as though the burden of proof is on the stutterer to prove that he’s all right,” says Ezrati. “When you meet such a person you immediately wonder about his intelligence and ask what else is wrong with him, and often the stutterers themselves are to blame for that. Because in order not to stutter they distort language, replace certain words with easier ones, or remain silent and don’t speak at all. History is full of smart people who stuttered, like Moses, Newton, Darwin, Churchill. And they say that Marilyn Monroe stuttered, too.”

Shai Sorek, 52, from Kfar Haoranim near Modi’in, found time to take care of his stutter only three years ago, when he retired from his job at Bezeq, where he worked for 30 years; in his last position, he managed the communication company’s digital centers from Jerusalem to Eilat.

“Therapy is something I’ve never done,” says Sorek, who was born in Jerusalem to a father who stuttered. “I didn’t dare to speak in class, I was scared and didn’t want the teacher to ask me things, because I was afraid of not speaking fluently and that the children would start laughing at me. I didn’t look people in the eye when I talked to them because I was afraid that at any moment I’d get stuck. I don’t remember if they really mocked me, but that was my inner feeling.”

As a reaction, Sorek developed the behavior patterns of a clown. He became a funny and cynical guy and hoped that this would make people forget his speech problem: “I couldn’t speak fluently, but I could throw out a word here and there, and that made the children laugh and [was a habit that] stayed with me for years.”

Three years, ago Sorek began therapy with a communication therapist at Hadassah University Hospital in Jerusalem, and today he describes himself as a slight stutterer. He dances in a Modi’in troupe and is active in AMBI. He even lectures occasionally, which previously he had never imagined doing.

“I’ve accepted the fact that I stutter sometimes,” Soreq explains. “I’ve learned how to talk. Now, for example, I lower the speed and speak slowly and then I control my speech and don’t stutter at all. I learned that in therapy, but you also have to work hard every day and practice.”

A few months ago, with other members of AMBI, he became involved in psychodrama with a theater group, which will perform a play next month in Nesher, in Haifa, as part of a community project. All the participants stammer.

Sorek, surprisingly, thinks that his impediment is a gift that he received in order to prove all kinds of things to himself, and says: “If I didn’t stutter I might have done something else, but thanks to it, I now have the energies to prove that I can succeed.”

Ravid agrees with that, but at the same time says he would be happy to be reborn as a non-stutterer.

“I would be the happiest person,” he explains. “If you had asked me 20 years ago what I could have done without the stutter, I would immediately have said – be prime minister. Today I’m not sure. On the other hand, I am grateful to the stuttering for what it gave me in life. For the determination and persistence. Today I’m proud to be a stutterer. I believe that people who stammer have some kind of special wisdom that they have developed thanks to the stutter, a wisdom that non-stutterers don’t have.”

What kind of wisdom is that?

Ravid: “You have to be someone who stammers in order to understand what I’m saying.”

Ruby Belinko, 49, of Netanya, understands Ravid’s feelings.

“I often used the stuttering in a manipulative way,” he explains. “When the teacher asked me to read from my notebook, and I hadn’t done homework that day, I would start to stutter badly until the teacher gave up. He didn’t know that my notebook was actually blank. A person who has a stammer is not necessarily stupid. He can be a smart and even manipulative child.”

Belinko, the coach of Israel’s cadet team in basketball, grew up on Kibbutz Nahsholim and has stuttered from an early age; he says he didn’t let the stutter bother him.

“Sports and basketball helped me,” he says. “I was a big and physically strong boy, so on the few occasions that they tried to laugh at me I beat up some kids and it was over. Sports at an early age is much stronger than stuttering. It gives you a lot of self-confidence, especially when you’re at a high level. I was a basketball coach and a counselor in youth movements, in spite of my stammering. In the army I was an officer, a company commander in the Paratroops. When I was discharged I went on to study education; I was a physical education teacher and a homeroom teacher for 17 years. Paradoxically, I went into professions where I had to stand in front of people all the time and talk, until I became a basketball coach, which isn’t just talking but talking fast and under pressure.”

Today Belinko is also the head coach in a boarding school for gifted young athletes at the basketball academy of the Wingate Institute of Physical Education.

On a tightropeTova Artzi, head communication therapist at Clalit health maintainance organization, says the treatment of stuttering is similar to that of obesity.

“You have to be on the alert all the time,” she notes, “and people who stammer have to practice constantly, because they speak according to a technique they’ve learned rather than spontaneously.” She says that in studies that have been conducted about brain activity during performance of various activities, such as reading, speaking, thinking, remembering, it turns out that there is a clear difference between stutterers and non-stutterers: “They’ve discovered that while stutterers are speaking, there’s an unfocused scattering [of activity] in their speech center, as opposed to ordinary people, whose activity there is more focused when they’re speaking. They examined stutterers whose speech had improved, and there was better focus in the speech center.”

Art has also been mobilized to treat people with this impediment. “You can use art therapy only after the age of five,” says Bracha Ofir, a communications therapist at Kaplan Medical Center in Rehovot. “Very young children can be treated just through games. This bypasses the bottleneck of words and opens an alternative channel for speech.”

Does it help one speak fluently?

Ofir: “No, but it opens a broader spectrum of self-observation for the stutterers. All a stammerer is doing is searching for strategies and alternative ways to express himself, and it works like a car that is stuck in the sand, which we are trying to extricate: When we step on the gas, and it only gets stuck deeper. That’s why the moment there’s an opportunity for spontaneous expression and less fear of speaking, that helps. There are stutterers who won’t draw with crayons or watercolors but only with a pencil, because with a pencil you can always erase and be in control. We’ll suggest that they gradually switch to other materials, the kind that smear more and where there’s less control. Stuttering is a phenomenon that cannot be controlled and that affects the entire behavior of the person. He has to be in control all the time; the more he’s in control, the more he digs in. We know that many of them are obsessive. Through art we try to release them – to help connect their bodies to their souls.”

There are people who stammer who do indeed need psychological treatment. Dr. Zofi Marom, head of behavioral cognitive therapy at the Geha Mental Health Center, treats people with social anxiety, including stutterers.

“When experiencing social anxiety, people complain about a range of symptoms,” says Marom, “such as trembling, blushing and stammering … Often it happens that there’s a gap between what is called objective and subjective stuttering. Some will say that they get stuck at every word, and others will insist that they don’t stammer. We work on the aspects related to thinking, and do a lot of homework connected to changing the self-perception of people – changing their assessments [of others], like the feeling that, ‘If I have to lecture everyone will probably make fun of me.’

“We teach them to speak automatically and not pay attention all the time to the voice coming out of their mouth, because then it’s clear that they’ll stutter. A stutterer is like an acrobat walking a tightrope between two buildings. He has to pay attention only to the tightrope and to his feet, not to the audience around him, because otherwise he’ll fall; in other words, not to look at himself from the outside. With relatively short therapy, you can achieve impressive results. But just as it’s impossible to learn how to swim or to dance via correspondence course – people who stammer have to practice speaking at home all the time.”

There are, however, still differences of opinion among the experts. For instance, Dr. Yochi Ben Nun, head psychologist at Meir Hospital and an expert on children, says that among stutterers there is no synchronization between the parts of the brain in the speech areas: “There are parts that are responsible for motor activity and we can identify them, and there are parts that are responsible for knowledge of language. And we believe that in the process of language development these two areas aren’t coordinated.”

In addition to the genetic origins of stuttering, Ben Nun thinks that the phenomenon also has a psychosomatic component, as is also true with respect to asthma and psoriasis.

“There’s a large group of illnesses with a very dominant psychological element,” she explains. “It’s like a kind of weak point in the system, in each person for a different reason, and the moment there’s pressure and the system weakens, phenomena like asthma, stammering or psoriasis will worsen.”

Ben Nun believes that proper treatment involves a combination of psychological assistance and communication therapy.

There are also cases of people who began stuttering as adults, as a result of brain damage. Prof. Yair Lampel, head of the department of neurology at Wolfson Hospital, treats such people.

“In what we call acquired stuttering, we see a very specific picture in the brain, in a particular, known location,” he says. “On the other hand, there is no clear information with respect to those who stutter from birth: We can’t know clearly, by means of imaging, who really stutters and who’s pretending. They still haven’t isolated the specific gene that causes people to stammer. In terms of treatment, communication therapists are the most highly recommended.”

In good companyHere is a list of famous stutterers, past and present:

• Public figures: Roman Emperor Claudius, King George VI of England, U.S. Vice President Joe Biden, Winston Churchill

• Writers: John Updike, Lewis Carroll, Somerset Maugham

• Actors: James Earl Jones, Rowan Atkinson, Julia Roberts, Harvey Keitel, Anthony Quinn, Hugh Grant

• Singers: Carly Simon, Elvis Presley, Yehuda Poliker, Kylie Minogue

• Athletes: basketball player Bill Walton (today a sportscaster ), golfer Tiger Woods, diver Greg Louganis, sprinter Ben Johnson

Local effortsThe Israel Stuttering Association was registered as a nonprofit organization in 1999. Today the organization has about 1,000 registered members. According to worldwide statistics, Israel has between 70,000 and 100,000 people who stammer. The vast majority prefer not to be exposed in public, and not to be identified as being exceptional. The association has a website and its activity is mostly related to information and awareness: There is a hot line, information about treatments and types of therapy, advice for parents, referrals, annual conferences, scientific lectures featuring professionals, weekly activities including speech practice after therapy, and now a theater group, too.

Swiss insight

Last year, a scientific journal of psychology in Europe published the findings of a study conducted over six years in the Swiss army. Participants were 9,814 inductees who had no psychiatric problems. The researchers were looking for initial and secondary risk factors for stuttering; 408 of the participants (4.1 percent ) reported stuttering problems in childhood.

The factors that remained relevant, in the opinion of the researchers, after multi-variable statistical analyses, were: premature birth and spending time in an incubator; attention deficit and concentration problems; alcoholism in one or both parents (a connection was found between alcohol use and stuttering ); obsessive-compulsive disorder (OCD ) in the family, which may indicate shared genetic, biological connections; and the fact that one parent is not native born. This last risk factor can be explained by the fact that there is a difficulty in speaking two languages. Indeed, studies have found that bilingualism constitutes a risk factor in terms of stammering in some children, as compared to other youngsters who speak only one language.