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Application of the ICF in Fluency Disorders

Article  in  Seminars in Speech and Language · December 2007

DOI: 10.1055/s-2007-986528 · Source: PubMed

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 Application of the ICF in Fluency Disorders
J. Scott Yaruss, Ph.D., CCC/SLP1

ABSTRACT

Stuttering is a complicated communication disorder that can affect

many aspects of a speaker’s life. In addition to exhibiting observable
disruptions in speech (e.g., part-word repetitions, prolongations, blocks),
many people who stutter also experience broader consequences in their lives
because of their stuttering. Examples include difficulty with social commu-
nication (e.g., speaking with other people, making introductions) and job-
related tasks (e.g., talking on the phone, participating in meetings). Because
it incorporates these types of daily experiences, the World Health Organ-
ization’s International Classification of Functioning, Disability and Health
(ICF) provides an ideal framework for considering the overall experience of
the stuttering disorder. The purpose of this article is to highlight the ways in
which the ICF can help clinicians, people who stutter, and the general public
understand the multifaceted nature of stuttering. The article will also
describe how clinicians can use the ICF as a framework for developing
comprehensive evaluations and providing individualized treatment plans for
people who stutter.

KEYWORDS: Stuttering, measurement, treatment outcomes, efficacy

Learning Outcomes: As a result of this activity, the reader will be able to (1) describe how the key components of
the ICF relate to the study of stuttering, (2) explain why it is important to consider life experience when evaluating
or treating individuals who stutter, (3) describe two ways that the ICF can be used as a guide for conducting
comprehensive diagnostic evaluations for people who stutter, and (4) describe two ways that the ICF can be used
as a guide for providing individualized treatment for people who stutter.

S tuttering is a communication disorder in cies generally take the form of repetitions of

which the forward flow of an individual’s parts of words (‘‘li-li-like this’’), prolongations
speech may be characterized by the occurrence of sounds (‘‘llllllike this’’), or instances when no
of disruptions, or disfluencies.1 These disfluen- sound is produced at all, sometimes called

1
Associate Professor, Communication Science and Disor-
ders, University of Pittsburgh, Pittsburgh, Pennsylvania;
Associate Director, Audiology and Communication Dis-
orders, Children’s Hospital of Pittsburgh, Pittsburgh,
Pennsylvania.
Address for correspondence and reprint requests: J.
Scott Yaruss, Ph.D., 4033 Forbes Tower, Pittsburgh PA
15260 (e-mail: jsyaruss@pitt.edu).
312
The International Classification of Functioning, Disability
and Health (ICF) in Clinical Practice; Guest Editors,
Estella P.-M. Ma, Ph.D., Linda Worrall, Ph.D., and Travis
T. Threats, Ph.D.
Semin Speech Lang 2007;28:312–322. Copyright #
2007 by Thieme Medical Publishers, Inc., 333 Seventh
Avenue, New York, NY 10001, USA. Tel: +1(212) 584–4662.
DOI 10.1055/s-2007-986528. ISSN 0734-0478.
 APPLICATION OF THE ICF IN FLUENCY DISORDERS/YARUSS
blocks (‘‘l—-ike this’’). The occurrence of dis-
fluencies is inconsistent and variable, and the
frequency of disfluencies can change consider-
ably from one speaking situation or task to
another.2 The varied expression of disfluent
speech is one of the factors that makes stutter-
ing so complicated, both for researchers trying
to understand the disorder and for clinicians
seeking to evaluate and treat individuals who
stutter.
The overt production of disfluencies by
people who stutter is an aspect of the disorder
that has been widely discussed in theories and
definitions of stuttering, and examined in stud-
ies of the characteristics of stuttering.1,3 It is the
primary component of the disorder most fre-
quently addressed in data-based treatment ap-
proaches for stuttering,4 and it is the aspect of
the disorder that most people probably think
about when they hear the word ‘‘stuttering.’’
Nevertheless, the production of stuttered
speech represents only a small part of a speaker’s
overall life experience of stuttering; the speak-
er’s daily experience of living with the stuttering
disorder can involve far more than just disrup-
tions in speech output.
LIFE EXPERIENCES OF PEOPLE
WHO STUTTER
Many authors have provided personal accounts
of their experiences with stuttering.5–7 Based
on these accounts, it is clear that the types of life
experiences reported by individuals who stutter
vary as widely as the behavior itself. Still, there
are several consistencies that have been re-
ported. Many people who stutter indicate that
they experience emotional and cognitive reac-
tions associated with their speaking difficulties,
such as fear and anxiety, anger, and helpless-
ness. Stuttering has been described as being
accompanied by a feeling of a ‘‘loss of control’’8
(the sensation that the speaker is unable to
make articulators move even though the indi-
vidual knows exactly what he or she wants to
say) and others have described the experience as
a brief ‘‘death’’ during the moment of stutter-
ing.9
Stuttering can be an embarrassing behavior
to exhibit. Disfluencies call attention to them-
selves, for they are different from so-called
313
normal or fluent speech. The struggle and
tension that are often evident during stuttering
is noticeable to listeners, and this, too, causes
the behavior stand out in the minds of both
speakers and listeners. Every time a person
stutters, he may feel embarrassment or expo-
sure, and because a speaker does not always
know when he is going to stutter (due to the
variable nature of the behavior), he may begin
to fear this embarrassment every time he tries to
speak, not just in those instances where he
actually does stutter.
Understandably, people do not want to
experience these unpleasant feelings, and the
shame that often develops through repeated
exposure to negative reactions has additional
consequences for people’s communication and
social interaction.10 Speakers may attempt to
hide their stuttering, by changing words or by
using circumlocution (talking around their
point) to select only the words they will be
able to say fluently. They may try to avoid
some speaking situations altogether (e.g., by
not talking on the phone or ordering food in a
restaurant). Such avoidance behaviors affect
communication even further, for they limit the
speaker’s ability to say what he wants to say and
do what he wants to do in his life. For some
people, the negative consequences of stuttering
are so great that they reduce the speaker’s overall
quality of life. Thus, the consequences of stut-
tering are not limited only to those areas of life
that are directly related to speaking.
DESCRIBING THE ENTIRE
STUTTERING DISORDER
Trying to capture all of these aspects of the
stuttering disorder in a single definition has
been challenging, as evidenced by the wide
range of theories and descriptions of stuttering
that have been proposed over the years. The
majority of definitions have focused primarily on
the surface behaviors most commonly associated
with the disorder (i.e., the speech disfluencies),
although others have incorporated the broader
consequences of the disorder.1,3 Several issues
arise when considering broad-based frameworks
for stuttering, however. The models must be
sufficiently broad that they can capture the wide
range of behaviors and experiences reported by
314 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 28, NUMBER 4
people who stutter, while still being specific
enough to permit detailed descriptions of the
similarities and differences in those people’s
experiences. The availability of a comprehensive
method of describing stuttering would yield
significant benefits, not only for conveying the
nature of the disorder, but also for the evalua-
tion of treatment approaches that focus on
different components of the disorder.
In other writings, the author and col-
leagues have tried to capture this broad-based
and multifaceted nature of the stuttering dis-
order in the statement that ‘‘stuttering is more
than just stuttering.’’11–14 This means that the
experience of the stuttering disorder in a
speaker’s life involves far more than just the
production of certain types of disfluencies in the
individual’s speech. What is needed to com-
plete this statement is a structure, or a frame-
work, that is broad enough to encompass
everything from the speech disfluencies exhib-
ited by the speaker to the avoidance behaviors
those disfluencies might foster, to the difficul-
ties the speaker may experience in daily com-
munication, to the negative impact of the
disorder on the speaker’s quality of life.
STUTTERING AND THE
INTERNATIONAL CLASSIFICATION
OF IMPAIRMENTS, DISABILITIES,
AND HANDICAPS
It was while searching for a means of encom-
passing the broader consequences of stuttering
that the present author learned of early attempts
by the World Health Organization (WHO) to
develop a framework for describing the conse-
quences of a wide range of disorders that affect
people’s lives. That original framework, the
International Classification of Impairments,
Disabilities, and Handicaps (ICIDH),15 pro-
vided an excellent means of capturing the state-
ment that ‘‘stuttering is more than just
stuttering,’’ for it included not only a description
of the surface behaviors of stuttering (the im-
pairment), but also a description of the difficul-
ties the speaker might experience in daily
communication (the disability) and the broader
consequences that this could have on the speak-
er’s life experiences (the handicap). The ICIDH
had previously been applied to stuttering,16–18
2007
and it was clear that such a framework could be
used to enhance not only the description of the
disorder but also the evaluation of treatments for
people who stutter.
As was apparent to many researchers, how-
ever, the original ICIDH contained several
inherent shortcomings, both in its structure
and in its terminology, that limited its useful-
ness for explaining, for example, why people
with the same disorder might have different life
experiences.19–22 Thus, the present author pub-
lished an article that adapted the ICIDH to
stuttering, expanding the framework to account
for the ways in which personal and environ-
mental reactions might determine the likeli-
hood that the speaker would experience
disability and handicap as part of the overall
stuttering disorder.12 The resulting article
formed the basis of the author’s clinical work
as a stuttering specialist, as well as research on
the development of a comprehensive tool for
measuring treatment outcomes for a wide vari-
ety of treatment approaches.14
STUTTERING AND THE
INTERNATIONAL CLASSIFICATION
OF FUNCTIONING, DISABILITY,
AND HEALTH
As noted, there were several shortcomings in the
ICIDH framework, and many articles were
written about various ways in which the original
model did not adequately account for the
breadth of human health experience. As a result,
the WHO published a revised framework, the
International Classification of Functioning,
Disability and Health (ICF).23 In the ICF, the
WHO replaced the original three-part classifi-
cation (impairment, disability, handicap) with a
revised classification that described Body Func-
tions and Body Structures on the one hand, and
Activities and Participation on the other. Thus,
the ICF describes what the body has (Structure)
and what the body does (Function), and how
that relates to what a person wants to do on a
daily basis (Activities) and in his or her life as a
whole (Participation). When something goes
wrong with body structure or body function,
that difficulty is termed an impairment, just
as in the original ICIDH. Difficulties with
activities are referred to as limitations, and
 APPLICATION OF THE ICF IN FLUENCY DISORDERS/YARUSS
difficulties with participation are referred to as
restrictions. The individual’s experiences in each
of these domains are referred to by a series
of codes reflecting the specific nature of the
experience. For example, a coding in Section
b330 indicates an impairment of speech fluency,
and subcodes can then be used to indicate the
severity or specific nature of the impairment.
Importantly, the ICF represents a significant
expansion from the original framework in that it
describes not only the consequences of disorders
(as in the ICIDH), but also the overall nature of
human health experience in general. Thus, the
ICF describes both positive and negative expe-
riences, affected by both hindering and facilitat-
ing forces. In other words, discussions involving
the ICF are not limited to impairments of body
function and structure, limitations in daily ac-
tivities, or restrictions in participation. The ICF
can also be used to describe ways that daily
activities may be facilitated or participation
may be supported. In addition, the ICF is
designed to capture individual differences by
incorporating both personal and environmental
factors. These contextual factors describe ways
in which an environment can, for example,
support or hinder an individual’s ability to
participate in life in the desired way.
Together, these changes enhanced the
ability of the ICF to describe key aspects of
the stuttering disorder, and provided the
needed breadth and specificity for describing
the varying experience of the stuttering disorder
from the perspective of individuals who stutter.
The next sections of this article review how
each component of the ICF relates to stuttering,
in terms of Body Functions, Body Structures,
Activities and Participation, and Contextual
Factors (both Personal and Environmental) .
Body Functions
One of the key functions of the human body is
communication, and there are several sections
in the ICF that address this important process.
Examples include Chapter 1 (Mental Func-
tions), Chapter 2 (Sensory Functions), and
Chapter 7 (Neuromusculoskeletal and Move-
ment-Related Functions). Chapter 3 (Voice
and Speech Functions) is the most directly
relevant to stuttering, for it addresses aspects
315
of communication related to producing voice
(b310), articulation (b320), and fluency (b330).
More specifically, it can be said that people who
stutter experience, to varying degrees, impair-
ments in body functions related to fluency of
speech (b3300), rhythm of speech (b3301), and
speed of speech (b3302).
People who stutter may also experience
affective and cognitive reactions to their speak-
ing difficulties. In some cases, these reactions
may be strong enough that they warrant an
additional diagnosis (typically provided by a
professional other than the speech-language
pathologist). In such cases, relevant diagnoses
may including those affecting mental functions
(Chapter 1) and include impairments such as
global psychosocial functions (b122), tempera-
ment and personality functions (b126), or emo-
tional function (b152).
Body Structures
The section of the ICF that describes Body
Structures includes chapters addressing all of
the major structural components of the human
body. As with the chapters on Body Functions,
many structures are involved in communica-
tion. The most relevant for stuttering are those
described in Chapter 1 (Nervous System) and
Chapter 3 (Structures Involved in Voice and
Speech). Although the anatomical structures of
the vocal tract, respiratory system, and larynx
are generally considered to be intact in people
who stutter,1 recent research has revealed evi-
dence of specific neuroanatomical differences
between people who stutter and people who do
not stutter.24,25 Such neuroanatomical differ-
ences, once confirmed and expanded through
additional research, may warrant the applica-
tion of a code indicating an impairment in body
structure, for example, within section s110
(Structure of the brain). In addition, individuals
exhibiting neurogenic stuttering26 would also
receive a code indicating a structural impair-
ment of the nervous system.
Activities and Participation
Because of the centrality of communication in
daily activities, many categories within the
Activities and Participation section of the ICF
316 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 28, NUMBER 4
are relevant to stuttering. This is why the ICF is
so ideally suited to describing stuttering.13
Chapter 3 (Communication) is the most
directly related to stuttering, given that people
who stutter frequently experience difficulty
producing messages (d300 to d349) and partic-
ipating in conversations and discussions (d350
and d360). Examples of ways that communica-
tion may be affected include difficulty starting
(d3500), sustaining (d3501), or ending (d3502)
a conversation, and having a conversation with
one (d3503) or more (d3504) people.
These difficulties with communication can
also have a broader affect on the speaker’s life,
affecting activities and participation in many
ways. Examples are found throughout
Chapter 6 (Domestic life, e.g., acquiring of a
place to live [d610] or goods and services
[d620]), Chapter 7 (Interpersonal interactions
and relationships, e.g., forming relationships
[d7200] and interacting according to social
rules [d7203]), Chapter 8 (Major life areas,
such as succeeding in education [d810 to
d839], securing and maintaining gainful
employment [d840 to d859], and achieving
economic self-sufficiency [d870]), and
Chapter 9 (Community, social, and civic life,
including participating in community events
[d910], social interactions and recreation
[d920], religious practices [d930], and civic
endeavors [d950]). Indeed, there are few aspects
of life that are not at risk of being affected by
stuttering; the ICF provides the flexibility to
address the full range of experiences associated
with this disorder.
One added feature of the ICF, a distinc-
tion between capacity and performance, is
designed to differentiate how a person may be
able to function in an ideal or standardized
setting (such as the clinic) from how a person
actually functions in day-to-day or real-world
settings. This concept is particularly difficult to
apply to the study of stuttering, however, be-
cause of the extreme variability seen with this
disorder.2 Put simply, all individuals who stut-
ter are capable of achieving perfectly fluent
speech, at least for a short period of the time.
This may be achieved through the use of
artificial fluency-enhancing strategies, such as
singing, speaking in a rhythmic manner, speak-
ing simultaneously with another person, using
2007
delayed auditory feedback, or other means.1 Or,
it may be accomplished naturally or spontane-
ously, if the person is simply not experiencing a
high degree of fluency disruption at a particular
time. Because of this variability, observable
fluency does not provide a meaningful baseline
for judging a speaker’s capacity. In addition,
there is no way to identify a standard situation
or environment that consistently evokes more
fluency or stuttering across all individuals (or
even within a single individual over time) to
assess performance. Thus, the concepts of ca-
pacity and performance are not considered
further within this article.
Contextual Factors
One of the most challenging aspects of the
stuttering disorder is the fact that different
people can have such different experiences
associated with their stuttering. Some people
stutter significantly on the surface, but experi-
ence relatively little negative impact in their
lives as indicated by limitations in daily activ-
ities or restrictions in participation opportuni-
ties. Others may stutter less frequently or less
severely, yet be devastated by the disorder. The
reason that different people who stutter have
different experiences can be described via the
Contextual Factors component, specifically,
Personal Factors and Environmental Factors.
In the ICF, the section on Personal Fac-
tors was intentionally left broad, and no spe-
cific categorizations or codes were defined.
The reasons for this appear to be related to
the difficulty in identifying a consistent set of
personal factors that apply across different
individuals and disorders. Importantly, some
of the key personal factors that are cited in the
ICF include the effects of habits, coping styles,
upbringing, social background, past and cur-
rent experiences, overall behavioral patterns,
and individual psychological assets. The liter-
ature on fluency disorders contains a substan-
tial body of knowledge addressing these types
of personal factors,12,14,27,28 often categorized
in terms of the affective, behavioral, and cog-
nitive reactions a speaker may have to his or
her stuttering. Examples of such reactions
include the embarrassment, shame, anxiety,
and fear one may experience as a result of the
 APPLICATION OF THE ICF IN FLUENCY DISORDERS/YARUSS
ability to cope with stuttering (affective reac-
tions); the tension and struggle during fluent
or stuttered speech; avoidance of words or
situations that become habitual ways of re-
sponding to stuttering (behavioral reactions);
and reduced self-esteem or low self-confidence
associated with the individual’s overall psycho-
logical ability to deal with stuttering (cognitive
reactions). These reactions, which derive di-
rectly from the individual’s personal coping
styles, upbringing, psychological resources,
etc., are particularly important in stuttering
and other communication disorders because
they determine, at least in part, the extent to
which a speaker will experience limitations in
daily activities or participation restrictions as
describe above.
For example, an individual with a broken
leg (a structural impairment) may be limited in
his or her ability to perform activities involving
walking. The person’s attitude about that bro-
ken leg will definitely influence how he or she
faces the experience, but the ability to walk
will be directly determined by the nature and
degree of the impairment. With stuttering,
the degree of impairment does not, by itself,
determine the degree of limitations or restric-
tions.28 As noted, some people stutter fre-
quently yet still participate fully in life,
whereas others stutter relatively little but are
severely limited. Thus, it is not the frequency
of stuttering (the impairment) that makes the
difference; it is how the speaker (and others)
react to that impairment that matters.12,14 The
consideration of personal contextual factors in
the ICF dramatically enhances the frame-
work’s ability to describe the true nature of
the stuttering experience. Furthermore, the
speaker’s personal reactions to stuttering often
form a key component of the overall treatment
process,9 so the ability of the ICF framework
to describe these aspects of the disorder facil-
itates the description and ultimately assess-
ment of treatment procedures and outcomes.
Although personal reactions play a signifi-
cant role in the speaker’s experience of stutter-
ing, it is also true that people who stutter are
affected by the environment in which they live.
Sadly, the environment as a whole does not
understand the stuttering disorder. Parents29
and teachers30 may be misinformed about the
317
goals of treatment, peers may bully or tease
children who stutter,31–33 coworkers or em-
ployers may misunderstand how stuttering af-
fects a colleague’s working ability,34 and
speech-language pathologists may not be ad-
equately trained about the disorder in gen-
eral.35,36 Within the ICF, these hindering
forces of the environment can be described
through Chapter 3 (Support and Relation-
ships), Chapter 4 (Attitudes), and Chapter 5
(Services, Systems, and Policies). Of course, the
environment can also play a facilitative role, and
the ICF allows for the coding of helpful parents
(e310), supportive teachers (e330), antidiscrimi-
nation legislation (e5500), and effective speech
therapy (e580). Again, the framework offers the
flexibility and breadth to encompass the entirety
of the stuttering experience, making it an ideal
tool for clinicians to use in the evaluation and
treatment of individuals who stutter.
STUTTERING ASSESSMENT AND
THE ICF
Numerous instruments for evaluating stutter-
ing have been presented in the literature, and it
is not surprising that clinicians have some
difficulty selecting assessments. There are pro-
cedures and protocols for assessing the surface
characteristics of stuttering,37,38 procedures for
assessing speakers’ communication attitudes
and cognitive reactions to stuttering,39–43 pro-
cedures for examining the challenges speakers
face in different speaking situations,44 and
many others. For the most part, these assess-
ments tend to focus on one particular aspect of
the disorder, although some have examined the
disorder more broadly.45,46 A problem arises,
however, in trying to determine which of these
assessments to use for a given client or study.
Clearly, not all of these assessment procedures
can or should be used for every client. Some of
the instruments overlap, and others approach
the disorder from vastly different perspectives.
The ICF offers some guidance in this respect,
however. If one assumes that the ICF frame-
work describes the entirety of the stuttering
disorder (through its components of Body
Functions and Structures, Activities and Par-
ticipation, and Personal and Environmental
Contextual Factors), then one can select or
318 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 28, NUMBER 4
design a comprehensive assessment instrument
to address each of these ICF components, in
turn.
Indeed, this is precisely what the present
author and colleagues have attempted to do in a
new series of measurement instruments de-
signed to assess the entire experience of stutter-
ing from the perspective of the individual who
stutters.14,47 These instruments are called the
Overall Assessment of the Speaker’s Assess-
ment of Stuttering (OASES), with versions for
adults, teenagers, and school-age children.
Each instrument contains four sections that
are directly tied to the components of the
ICF. The first section gathers information
about the speaker’s perception of the stuttering
impairment (thereby addressing the Body
Functions and Body Structures components of
the ICF). Examples of questions from this
section include ‘‘How often are you able to
speak fluently,’’ or ‘‘How often does your speech
sound ‘natural’ to you?’’ The second section
addresses the speaker’s affective, behavioral,
and cognitive reactions to stuttering that result
from the individual’s coping styles, habits,
psychological resources, past experiences, etc.
(thereby addressing characteristics of the
disorder that result from personal contextual
factors). Examples from this section include
questions about how often the individual expe-
riences emotions such as shame or embarrass-
ment associated with stuttering (affective), how
often the individual exhibits physical tension
or struggle during stuttered or fluent speech
(behavioral), and how much stuttering affects
the individual’s self-esteem or self-confidence
(cognitive). The third section examines func-
tional communication abilities in key speaking
situations, such as home, work or school, and
social settings (thereby addressing both the
Activities and Environmental Contextual com-
ponents). Examples include questions about
how much difficulty the speaker has in talking
with another person one on one or in groups,
reading out loud in class, giving presentations at
work, talking on the phone in social or work
settings, interacting with family, etc. The
fourth section examines the impact of stuttering
on the speaker’s overall quality of life (thereby
addressing both the Participation and Environ-
mental Contextual components). Examples in-
2007
clude questions about how much stuttering
affects the person’s satisfaction with their com-
munication ability and relationships with
others, as well as questions about how much
stuttering interferes with the individual’s ability
to participate in educational, occupational, re-
ligious, or social endeavors. Together, these
components of the OASES capture the entire
experience of stuttering using the ICF as a
foundation to ensure comprehensive consider-
ation of the disorder.
STUTTERING TREATMENT AND
THE ICF
Just as the comprehensive assessment of stut-
tering involves consideration of all of the com-
ponents of the ICF, comprehensive treatment
also requires that clinicians consider the full
experience of the disorder. At present, a vast
number of treatment options for people who
stutter is available.1,3 On the one hand, the
broad range of treatment strategies provides a
benefit for people who stutter, for it gives them
options from which they can select their own
preferred method of treatment. On the other
hand, the vast array of options can be confusing.
One way of minimizing this confusion is
through the application of consistent terminol-
ogy about the components of treatment, both in
the description of the treatment approaches and
in the evaluation of treatment outcomes. In
fact, one of the primary benefits of using the
ICF as a framework for describing treatment
comes from the fact that not all people benefit
from the same treatment, and not all people
need to address the same components of the
disorder in treatment. By adopting a consistent
framework for describing the experience of
stuttering, researchers and clinicians could spe-
cifically identify which aspect of the disorder
their treatment program addresses. Then, peo-
ple who stutter could evaluate each treatment in
light of its targeted audience and targeted out-
comes. At present, the author is not aware of
any stuttering treatment approaches that have
been specifically described and implemented in
terms of the ICF (although the author has
related much of his own treatment-related
work to the ICF11,48). With more widespread
implementation of the ICF, the field may see a
 APPLICATION OF THE ICF IN FLUENCY DISORDERS/YARUSS
time when different treatments can be com-
pared side-by-side using consistent terminol-
ogy and consistent evaluation standards.
CASE EXAMPLES
As a board-recognized specialist in fluency
disorders, the author has worked with many
people who stutter and has seen a wide range of
reactions and experiences associated with this
disorder. Using the ICF as a framework for
understanding stuttering has proven to be a
useful way of describing the differences be-
tween individuals, as well as the differences
individuals experience in their disorder over
time.49 In the examples that follow, the com-
ponents of the each speaker’s experience of the
stuttering disorder are presented using the
terminology and coding of the ICF. Note that
because it is not possible to determine whether
the speakers in these examples exhibit differ-
ences in neuroanatomical structure associated
with stuttering, coding of Body Structures is
omitted. In addition, because the reactions of
the speaker, and those in the speaker’s environ-
ment, directly affect the experiences outlined in
the Activities and Participation sections of the
ICF, the following case studies are reported in
order of (1) Body Functions, (2) Personal
and Environmental Contextual Factors, and
(3) Activities and Participation.
Speaker A is a male college graduate in his
early 20s who works as a research assistant.
Body Function. This individual exhibits
severe overt stuttering behaviors, consisting of
repetitions of parts of words, occasional pro-
longations, and frequent blocks with significant
physical tension. Thus, the impairment of Body
Functions related to fluency would be coded as
b3300.3. The rhythm of his speech is also
affected because of the severe tension, so an
additional coding of b3301.3 would be added.
Furthermore, he exhibits such severe stuttering
that the quality of his voice, even during per-
ceptibly fluent speech, is also moderately af-
fected (b3101.2). The speaker appears to be
depressed, which would warrant a code in
section b152, though no prior diagnosis has
been applied and it is beyond the speech-
language pathologist’s scope of practice to pro-
319
vide such a diagnosis. (Referral to appropriate
mental health professionals was provided.)
Personal and Environmental Factors. The
speaker is very concerned about his stuttering.
Although personal contextual factors are not
specifically coded in the ICF, scores on the
OASES measurement instrument14 reveal
that the speaker exhibits strongly negative af-
fective, behavioral, and cognitive reactions to
his speaking difficulties, associated with his past
history of speaking difficulties, his general cop-
ing styles, and his habits (which had prevented
him from facing his stuttering more directly).
These include significant embarrassment and
shame about stuttering, anxiety about speaking,
avoidance of certain words and speaking sit-
uations, and very poor self-esteem. (The Per-
sonal Factors most relevant to him are his age
and that he is a college graduate and a research
assistant; these assume certain level of intelli-
gence.) His environment is generally supportive
of his speaking difficulties. For example, his
family is accepting of his speaking difficulties
and helps him attend speech therapy (e310,
e410, e355, e450, e580), and appropriate ac-
commodations are made by friends, colleagues,
and employers (e320, e420, e325, e425, e330,
e430). Still he is experiencing significant diffi-
culty doing the things he wants to do in his life.
Activities and Participation. Because of the
severity of his stuttering and his negative re-
actions to stuttering, the speaker has difficulty
interacting with others, both at work and in
social settings. In communication, he has trou-
ble producing speech (d330), engaging in con-
versation (d350)—particularly in one-on-one
interactions (d3503)—engaging in discussions
(d3550), and talking on the phone (d3600). In
his domestic life, he hesitates to talk with
people while shopping, and this has caused
difficulty when he could not find items he
wanted (d620). He also has difficulty in inter-
personal relations. For example, he is reluctant
to say ‘‘thank you’’ in stores because he is afraid
he will stutter (d7100, d7101) and he has
difficulty making friends (d7200, d7202,
d7203). In fact, he reports that he does not
participate in a social life (d910, d920),
although he does have friends from high school
320 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 28, NUMBER 4
and social groups associated with his religious
practice (d930). In part due to the understand-
ing of his friends and coworkers, he is employed
full time (d8502), although he is not satisfied
with his job. He reports that this is partly due to
the level of income (d870) and partly due to the
fact that he is not making the impact in the
world that he wants to make (he wants to be a
speech therapist and help other people, d998).
Although he has completed college, he is not
sure if he will pursue graduate school (d830) to
train for a new job. He reports that stuttering is
the cause for this uncertainty about his future
and for his difficulty in participating in life in
the way he wants. Through the components of
the ICF, the broader implications of stuttering
can be described and measured in a way that
cannot be accomplished through the statement
that ‘‘this person stutters.’’
Speaker B is a female in her 20s. Because
of the specific pressures of her job, she feels
that stuttering in the workplace is not accept-
able. Still, she reports that she does not stutter
frequently at work, and that she only experi-
ences difficulty when speaking on the phone.
She explains that she does not stutter in other
situations, and that she is not held back in her
life because of stuttering. Upon further exami-
nation (e.g., administration of the OASES), it
is apparent that she exhibits a mild impair-
ment of body function associated with overt
stuttering behaviors (b3300.1), with minimal
negative impact on daily activities or partic-
ipation in life other than those associated with
using the phone at work (d350, d360).
Exploration of reactions associated with per-
sonal contextual factors reveal that she exhib-
its significant embarrassment about her speech
(affective reactions), but only on the phone at
work, when she feels that other people may be
listening. (Note that this embarrassment did
not reach the level of an impairment; it simply
reflected difficulties she was having with per-
sonal coping styles and habits she had devel-
oped in reaction to stuttering.) Evaluation of
Environmental Contextual Factors reveals
that her boss has been highly critical of
her performance on the phone at work
(e330, e430), but that others are supportive.
Thus, this is the only area in which she has
2007
difficulty. In this case, the use of the ICF
helped pinpoint issues that were relevant to
this speaker’s life. This, in turn, supported the
development of an individualized treatment
program that helped her address her issues
with stuttering.
SUMMARY
This article has attempted to show how the
complex nature of stuttering, which often
presents challenges for people who stutter,
their families, and their clinicians, can be
described succinctly and completely through
the framework of the ICF. The ICF not only
helps to account for the broad nature of the
speaker’s experience of stuttering—it also
helps to capture the wide range of experiences
seen among different people who stutter.
Therefore, the ICF provides an ideal frame-
work for both assessment and treatment of
individuals who stutter, as well as an excellent
starting place for research on the nature of
stuttering and the assessment of stuttering
treatment outcomes.
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