Journal of Fluency Disorders 67 (2021) 105819

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Journal of Fluency Disorders

journal homepage: www.elsevier.com/locate/jfludis

Bilinguals who stutter: A cognitive perspective

Myriam Kornisch a, 1
a
The University of Mississippi, School of Applied Sciences, Department of Communication Sciences & Disorders, 2301 South Lamar Blvd, Oxford, MS
38655, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: Brain differences, both in structure and executive functioning, have been found in both
Stuttering developmental stuttering and bilingualism. However, the etiology of stuttering remains unknown.
Bilingualism The early suggestion that stuttering is a result of brain dysfunction has since received support
Brain
from various behavioral and neuroimaging studies that have revealed functional and structural
Executive functions
Executive control
brain changes in monolinguals who stutter (MWS). In addition, MWS appear to show deficits in
motor control executive control. However, there is a lack of data on bilinguals who stutter (BWS). This literature
Cognitive reserve review is intended to provide an overview of both stuttering and bilingualism as well as syn­
Brain reserve thesize areas of overlap among both lines of research and highlight knowledge gaps in the current
literature.
Methods: A systematic literature review on both stuttering and bilingualism studies was con­
ducted, searching for articles containing “stuttering” and/or “bilingualism” and either “brain”,
“executive functions”, “executive control”, “motor control”, “cognitive reserve”, or “brain
reserve” in the PubMed database. Additional studies were found by examining the reference list of
studies that met the inclusion criteria.
Results: A total of 148 references that met the criteria for inclusion in this paper were used in the
review. A comparison of the impact of stuttering or bilingualism on the brain are discussed.
Conclusion: Previous research examining a potential bilingual advantage for BWS is mixed.
However, if such an advantage does exist, it appears to offset potential deficits in executive
functioning that may be associated with stuttering.

1. Introduction

It is estimated that approximately 50 % of the world’s population is bilingual and that stuttering is present in all cultures and
languages with an average prevalence of about 1% globally (Bhatia & Ritchie, 2006; Bloodstein & Bernstein Ratner, 2008; Van Borsel,
2011). Therefore, it can be assumed that about half of the people diagnosed with a stutter are likely to speak two or more languages.
However, most research of stuttering has focused either on monolinguals who stutter (MWS) or has not taken into account that subjects
might be proficient in more than one language. As a result, published data on bilinguals who stutter (BWS) is limited.
Although stuttering can be treated to increase fluency, it currently cannot be cured since the exact etiology of developmental
stuttering remains unknown. The early suggestion that stuttering is a result of brain dysfunction (Orton, 1929; Travis, 1978) has since
received support from various neuroimaging studies that have revealed functional and structural brain changes in MWS (Beal, et al.,
2013; Beal, Gracco, Lafaille, & De Nil, 2007; Blomgren, et al., 2003; Braun, Varga, Stager, & Schulz, 1997; Chang et al., 2018; Connally,

E-mail address: kornisch@olemiss.edu.

1
www.olemiss.edu

https://doi.org/10.1016/j.jfludis.2020.105819
Received 20 August 2019; Received in revised form 5 October 2020; Accepted 19 November 2020
Available online 3 December 2020
0094-730X/© 2020 Elsevier Inc. All rights reserved.
M. Kornisch Journal of Fluency Disorders 67 (2021) 105819

Ward, Howell, & Watkins, 2014; Etchell, Civier, Ballard, & Sowman, 2018; Foundas, Corey, Angeles, & Bollich, 2003; Giraud, Neu­
mann, Bachoud-Levi, & von Gudenberg, 2008; Neumann, et al., 2003; De Nil, Beal, Lafaille, & Kroll, 2008; Salmelin, Schnitzler,
Schmitz, & Freund, 2000; Sitek et al., 2016; Van Borsel, Achten, Santens, & Lahorte, 2003; Watkins, Smith, Davis, & Howell, 2008;
Yang, Jia, Siok, & Tan, 2016).
In addition, it has been found that MWS, compared to monolinguals with no stutter (MWNS), show deficits in executive functions
(Bajaj, 2007; Byrd, Bedore, & Ramos, 2015; Byrd, Sheng, Ratner, & Gkalitsiou, 2015; Eggers, De Nil, & Van den Bergh, 2013; Heit­
mann, Asbjørnsen, & Helland, 2004; Jones, Fox, & Jacewicz, 2012; Maxfield, Morris, Frisch, Morphew, & Constantine, 2015).
However, studies examining this topic tend to possess small sample sizes (e.g., Jones et al., 2012), making it difficult to determine if the
executive functioning deficits found in these studies accurately represent the entire population of MWS. In contrast, bilinguals with no
stutter (BWNS) show an advantage over MWNS on tasks involving executive control (Adesope, Lavin, Thompson, & Ungerleider, 2010;
Bialystok, Poarch, Luo, & Craik, 2014; Calvo & Bialystok, 2014; Carlson & Meltzoff, 2008; Kroll & Bialystok, 2013; Soveri, Laine,
Hamalainen, & Hugdahl, 2011). However, research examining executive functioning in MWNS and BWNS is mixed, as some studies
have found no difference between groups on tasks of executive control. Therefore, this review aims to provide an overview of the
independent impact of stuttering or bilingualism on the brain as well as highlight areas of overlap in the current research. Gaining a
deeper understanding of the potential interaction between stuttering and bilingualism can potentially inform diagnosis and treatment
for these individuals.

2. Method

2.1. Literature search

The current study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher,
Liberati, Tetzlaff, & Altman, 2009). The PubMed database was used to search original data and review studies using the keywords
“stuttering” and/or “bilingualism” and either “brain”, “executive functions”, “executive control”, “motor control”, “cognitive reserve”,
or “brain reserve”. Studies were initially screened based on the title’s relevance to the present study. Next, abstracts were screened to
determine whether the study met inclusion and exclusion criteria. A snowballing procedure was then used to examine the eligibility of
references cited in each study. The first search was conducted in June 2019 and updated in May 2020. Studies that did not meet the
inclusion criteria or violated the exclusion criteria were removed, resulting in a total of 148 references. Table 1 outlines the number of
studies obtained from each search term and through reference searching.

2.2. Inclusion and exclusion criteria

Inclusion and exclusion criteria were applied to studies examining the relationship between stuttering, bilingualism, and the brain.
Inclusion criteria required that studies: 1) be available in full-text online via PubMed, 2) be available in English, 3) assess only human
subjects, and 4) include a monolingual control group. Studies were excluded if: 1) they were case studies, commentaries, editorials,
letters, and/or news articles, 2) participants were sign language users, 3) participants were diagnosed with an impairment other than
stuttering, 4) studies contained the term “acquired” in either the title or abstract. Fig. 1 outlines the search process, including reasons
for exclusion.
Of the studies that examined stuttering, only five specifically included information relative to participants’ language history (i.e.,
whether participants were monolingual or bilingual). For example, several studies (Chang et al., 2018; Chang, Zhu, Choo, & Angstadt,
2015; Chang & Zhu, 2013) examined 84, 77 and 56 participants respectively, all of whom were described as monolingual native North
American English speakers. Additionally, Eggers et al. (2013) examined 60 participants total, all of whom were deemed monolingual
Dutch speakers.

Table 1
Studies Obtained from Database Searching and Snowballing Procedure.
Search Term n Examples of studies identified

Stuttering AND
Brain 45 Chang et al. (2018); Etchell et al. (2018); Lu et al. (2017)
Executive Functions 4 Kornisch et al. (2017a), 2017b; Nejati et al. (2013)
Executive Control 2 Bosshardt (2002); Eggers et al. (2013)
Motor Control 7 Connally et al. (2014); Ingham et al. (2004); Neef et al. (2015)
Bilingualism AND
Brain 10 Li et al. (2015); Pliatsikas et al. (2015); Van den Noort et al. (2019)
Executive Functions 8 Arizmendi et al. (2018); Loe and Feldman (2016); Moradzadeh et al. (2015)
Motor Control 1 Mohades et al. (2015)
Cognitive Reserve 3 Abutalebi et al. (2015); Grant et al. (2014); Olsen et al. (2015)
Brain Reserve 1 Perani et al. (2017)
Stuttering AND Bilingualism 1 Lee et al. (2014)
Records identified through snowballing procedure 65 Arizmendi et al. (2018); Eggers, Van Eerdenbrugh, and Byrd (2020); Van den Noort et al. (2019)

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M. Kornisch Journal of Fluency Disorders 67 (2021) 105819

Fig. 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram (Moher et al., 2009).

3. Stuttering

The World Health Organization (WHO) defines stuttering as “disorders in the rhythm of speech, in which the individual knows
precisely what he wishes to say, but at the time is unable to say it because of an involuntary, repetitive prolongation or cessation of a
sound” (WHO, 1977). It is now widely believed that the distal cause of stuttering is genetic (Domingues et al., 2014; Felsenfeld et al.,
2000) and/or neurological (Chang, 2014; Ingham, Ingham, Finn, & Fox, 2003).
Although the specific neurobiological basis is still unknown, research into stuttering provides increasing evidence of brain dif­
ferences in people who stutter (PWS) relative to people with no stutter (PWNS) (De Nil, Kroll, & Houle, 2001; Fox et al., 2000; Sommer,
Koch, Paulus, Weiller, & Büchel, 2002), however the results of these studies may be impacted by potential confounds such as small
sample size (e.g., Fox et al., 2000) and lack of control of therapy history (e.g., Sommer et al., 2002). In general, it has been found that:
(1) The neural system underlying stuttered speech is different from that of normal speech; (2) Motor speech and language production
areas show differences in levels of activation; (3) Stuttering is not necessarily related to one structure or neural pathway; and (4)
Stuttering is most notably associated with hemispheric asymmetry (Blomgren, Nagarajan, Lee, & Li, 2003; Foundas et al., 2003; Kent,
2000; Ward, 2006; Watkins et al., 2008). More specifically, PWS show functional abnormalities in the form of (1) over-activity in the
right hemisphere centered on the right inferior frontal gyrus, (2) under-activity of auditory areas in the temporal lobe, (3) atypical
activation of subcortical structures involved in the control of movements (basal ganglia, cerebellum), as well as structural

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abnormalities in the frontal and temporal lobes and the white matter connections between them (Watkins & Klein, 2011; Watkins
et al., 2008).
A number of brain differences have also been found in recent studies investigating children who stutter (CWS). More specifically,
previous research points to differences in fractional anisotropy among CWS compared to fluent controls, although research on this
topic is mixed. For example, Chow and Chang (2017) and Garnett, Chow, and Chang (2019) suggest reduced fractional anisotropy,
whereas Misaghi, Zhang, Gracco, De Nil, and Beal (2018) suggest increased fractional anisotropy coupled with increased axial
diffusivity within the frontal aslant tracts. However, the results of the aforementioned studies should be interpreted with caution due to
potential limitations, such as small samples of participants who stutter (2020, Chow & Chang, 2017; Koenraads et al., 2019), wide age
ranges of participants (Garnett et al., 2019), and the implementation of novel methodologies that may make it difficult to compare
results across different studies (Misaghi et al., 2018). Furthermore, future research is warranted to examine the longitudinal impact of
stuttering on the brain (2020, Koenraads et al., 2019; Misaghi et al., 2018), as well as identify additional factors that may contribute to
brain differences in addition to stuttering (2020, Koenraads et al., 2019). Lastly, future research may wish to further understand the
causal relationship underlying such brain differences (Chow & Chang, 2017; Koenraads et al., 2019).

3.1. Atypical language lateralization

Among PWS, increased right hemisphere activity during language processing and production is usually found in the frontal
opercular part of the frontal lobe, sometimes extending to the anterior insula and the orbitofrontal cortex (Brown, Ingham, Ingham,
Laird, & Fox, 2005; Kell et al., 2009; Watkins et al., 2008). It has further been suggested that stuttering is associated with left
hemisphere motor impairment (Alm, Karlsson, Sundberg, & Axelson, 2013; Neef, Hoang, Neef, Paulus, & Sommer, 2015). Neef et al.
(2015) proposed that speech-motor plans are primarily controlled in the left motor cortex in PWNS, and that this left hemispheric
asymmetry is not evident in PWS. This implies that stuttering may be a result of atypical motor cortex activation. Interestingly, a more
typical left lateralized activation pattern can be achieved through successful fluency therapy, which may reduce the right inferior
frontal gyrus over-activity or increase left hemisphere activity (De Nil, Kroll, Lafaille, & Houle, 2003; Kell et al., 2009; Lu et al., 2017;
Neumann, Euler, Gudenberg, & Giraud, 2003). Therefore, some researchers speculate that the right inferior frontal activation might
reflect a compensatory mechanism of long-term stuttering rather than bilateral or right hemisphere language dominance (Preibisch
et al., 2003). This contention is further supported by Sowman, Crain, Harrison, and Johnson (2014) who assessed language lateral­
ization in preschool CWS and children with no stutter (CWNS). These researchers found no group differences and observed that brain
activation was significantly left-lateralized in all children during a picture naming task. Therefore, the reasons for atypical laterali­
zation of language for PWS are still a matter of debate.

3.2. Atypical auditory-motor interaction

Fluent speech production requires successful auditory processing, motor planning, and motor execution (Hickok & Poeppel, 2007).
That is, a well-established connection between the posterior (perceive and decode sensory information) and anterior (regulate motor
function) brain regions are essential for coordinating speech production. However, PWS have been found to demonstrate
over-activation of motor regions in the right hemisphere (Chang, Kenney, Loucks, & Ludlow, 2009; Fox et al., 1996), as well as bilateral
reduced activity of the auditory cerebral cortices (Braun et al., 1997; Brown et al., 2005; Ingham, 2001). Brown et al. (2005) conducted
a meta-analysis examining functional neuroimaging studies in stuttered and fluent speech production, which proposed the phe­
nomenon of ‘motor efference copy’ as a unifying account of the decrease in brain activity for auditory processing observed in PWS.
Efference copy refers to motor control and is crucial for motor adaptations. It can be described as a signal from motor to sensory areas
and the result is considered to represent the precise sensory consequences of each motor action (Niziolek, Nagarajan, & Houde, 2013).

3.3. Atypical cerebellar and basal ganglia function

Neuroimaging studies have revealed a large area of over-activity in the midbrain during speech in PWS irrespective of fluency
(Watkins et al., 2008), as well as considerably higher levels of dopamine in several cortical and subcortical structures (Wu et al., 1997).
A number of researchers have suggested atypical basal ganglia and cerebellar function to be involved in stuttering (Alm, 2004;
Craig-McQuaide, Akram, Zrinzo, & Tripoliti, 2014; De Nil et al., 2001; Giraud et al., 2008; Ingham et al., 2004; Wu et al., 1995). For
example, Fox et al. (1996) observed increased cerebellar activation with right hemispheric cerebral dominance in PWS. In addition,
atypical basal ganglia function has also been implicated for PWS. Researchers (Wu et al., 1995) found decreased activity in the caudate
nucleus during both fluent and dysfluent speech in PWS, although these results should be interpreted with caution due to the small
sample size (n = 8) and the 12-year age differences between stuttering and fluent groups. Furthermore, Alm (2004) reviewed the
possible relationship between basal ganglia impairment and dopamine in developmental stuttering. He proposed that basal ganglia
thalamocortical motor circuits through the putamen are likely to play a key role. That is, stuttering is a disorder of motor timing (Van
Riper, 1971), and the core dysfunction in stuttering is an impaired ability of the basal ganglia to produce timing cues for the initiation
of the next motor segment in speech (Cunnington, Bradshaw, & Iansek, 1996). In addition, Ingham et al. (2004) replicated the
methodology used in Fox et al. (2000) and reported positive correlations between stuttering and (1) basal ganglia activity in females
and (2) cerebellum activity in males. However, Ingham et al.’s was the first imaging study focused on females who stutter, highlighting
the need for additional gender-oriented investigations.
More recently, Lu et al. (2010) suggest that developmental stuttering may be the result of impaired interactions among many neural

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networks within in the left hemisphere, particularly in regard to the basal ganglia-thalamus and cerebral cortex within the
cortico-basal ganglia-thalamo-cortical loop (CBGTC loop). In addition, Toyomura, Fujii, and Kuriki (2015) suggests that PWS
demonstrate significantly lower basal ganglia activity than PWNS. This study also suggests that the cerebellum is involved in stut­
tering, as the cerebellar vermis shows significantly decreased activation following treatment. Lastly, it was also proposed that the
underlying impairment in PWS is a malfunction within the CBGTC loop, which is responsible for initiating speech (Chang & Guenther,
2020).

3.4. Atypical brain structure

Chang, Erickson, Ambrose, Hasegawa-Johnson, and Ludlow (2008) found reduced grey matter volume in the bilateral temporal
regions (planum temporale) for CWS. Interestingly, they observed no left to right asymmetry differences. This is in contrast to findings
in adults that show bilateral increases in the planum temporale and atypical right to left asymmetry (Foundas, Bollich, Corey, Hurley,
& Heilman, 2001).
Both adults and children have also been found to have decreased white matter in the corpus callosum and in tracts that link
auditory and motor areas (Beal, Gracco, Brettschneider, Kroll, & De Nil, 2013; Cai et al., 2014; Chang et al., 2008, 2015; Civier,
Kronfeld-Duenias, Amir, Ezrati-Vinacour, & Ben-Shachar, 2015; Connally et al., 2014). For example, Civier et al. (2015) observed
reduced myelination in the corpus callosum in PWS compared to PWNS and found that greater decreases in white matter were
associated with greater dysfluency. It was suggested that these structural changes might reflect a maladaptive decrease in inter­
hemispheric inhibition, which could in turn result in the atypical activation of the right frontal cortex in PWS. However, the con­
clusions that can be drawn from this study may limited due to its small sample size (n = 28) and heterogeneous group of participants
across a wide age range (19–52 years) . Furthermore, structural white matter changes, such as a reduction in white matter volume of
the corpus callosum, have also been found for CWS, although more longitudinal studies with larger groups of participants are needed to
further determine the developmental nature of such neuroanatomical abnormalities (Beal et al., 2013).
Watkins and Klein (2011) reviewed several studies which investigated brain structure in developmental stuttering and concluded
that the most consistent differences associated with developmental stuttering were in white matter microstructure. Both children and
adults have been found to have decreased white matter in the corpus callosum and in tracts that link auditory and motor areas.
Interestingly, preliminary results indicate persistent stuttering is linked to decreased white matter underlying the sensorimotor cortex
in the left hemisphere, while childhood stuttering is associated with reduced grey matter volume in speech-related areas. However,
more research with larger samples is warranted (Chang et al., 2008).
To date, neuroimaging studies on stuttering have either only focused on MWS or have not taken into account that subjects might be
proficient in more than one language. This is rather surprising in light of the fact that both stuttering and bilingualism have been found
to have a considerable impact on the brain with many overlapping brain areas that are affected by those two conditions. However, the
difference between these two conditions is that while research in the field of stuttering has found several deficits in brain anatomy and
activity, bilingualism has been associated with a number of advantages.

4. Bilingualism

Definitions of bilingualism vary, and there is no commonly agreed upon method of defining bilingualism. However, two types of
second language acquisition have been identified: simultaneous bilingualism and sequential bilingualism (Krashen, 1987; Owens,
2008). According to Field (2011), simultaneous (or early) bilingualism refers to individuals introduced to both languages from birth.
Thus, languages are acquired at the same time and considered to be first or native languages (L1). In contrast, sequential bilingualism
refers to individuals introduced to a second language (L2) after they have already mastered a first language, which is also known as late
bilingualism. Bilingualism can also be defined with respect to levels of language proficiency. Language proficiency is a term often used
to indicate general ability in a language. It is not simply confined to spoken language but includes the four language modalities:
listening, speaking, reading, and writing (Lim, Liow, Lincoln, Chan, & Onslow, 2008).
Several researchers have suggested a neural signature of bilingualism (Indefrey, 2006; Kovelman, Baker, & Petitto, 2008; Mechelli
et al., 2004; Olsen et al., 2015). Abutalebi et al. (2012) conducted a combined functional and structural study and found that bilinguals
required fewer neural resources since their brain showed better adaptation to deal with tasks involving cognitive conflicts. Specifically,
they used the dorsal anterior cingulate cortex more efficiently than monolinguals to monitor non-linguistic cognitive conflicts. The
dorsal anterior cingulate cortex, located in the limbic lobe, encompasses various specialized subdivisions that play key roles in
cognitive, motor and visuospatial processing (Bush, Luu, & Posner, 2000).

4.1. Brain function

Grady, Luk, Craik, and Bialystok (2015) assessed older monolingual and bilingual adults and observed increased brain activity in
the frontoparietal control network for the bilingual group. These researchers proposed that the difference in brain network connec­
tivity indicates that bilingual language experience may provide a neural advantage among the elderly, although this study is limited in
its ability to determine when the influence of bilingualism on the brain emerges as well as whether this influence remains stable across
the lifespan or develops over time. Li et al. (2015) suggested that bilingualism alters functional connectivity between control regions (i.
e., cingulate cortex, left caudate nucleus) and language regions of the brain among bimodal bilinguals, and more research is needed to
determine if this finding exists among unimodal bilinguals. Nevertheless, a number of researchers agree that the degree to which brain

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regions are involved in bilingual language processing is determined by several factors, such as age of L2 acquisition (Wartenburger
et al., 2003) and language proficiency (Perani et al., 1998), as well as by the language assessed and the type of language processing skill
engaged (Frenck-Mestre, Anton, Roth, Vaid, & Viallet, 2005; Tan et al., 2003; Xu et al., 2006).

4.2. Brain structure

Various anatomical changes in brain structure associated with bilingualism have also been observed (Abutalebi et al., 2015;
García-Pentón, Pérez Fernández, Iturria-Medina, Gillon-Dowens, & Carreiras, 2014; Mechelli et al., 2004; Olsen et al., 2015; Pliatsikas,
Moschopoulou, & Saddy, 2015). Overall, grey matter changes are typically found in the left frontal and parietal regions, and the
increase in grey matter seems to be linked to increased language competence. For example, Mechelli et al. (2004) found greater grey
matter volume in bilinguals compared to monolinguals, in simultaneous bilinguals compared to sequential bilinguals, and in proficient
bilinguals compared to non-proficient bilinguals. Luk, Bialystok, Craik, and Grady (2011) found more white matter volume in the
corpus callosum for bilingual than for monolingual older adults. These white matter changes have been noted in various bilingual
groups, including simultaneous bilingual adults (García-Pentón et al., 2014), sequential bilingual adults (Pliatsikas et al., 2015), as
well as simultaneous and sequential bilingual children (2015, Mohades et al., 2012). Therefore, it appears that bilingualism enhances
structural connectivity between brain areas.

4.3. Bilingualism and stuttering

Little research exists examining the relationship between stuttering and bilingualism specifically. However, synthesizing previous
research that has focused on the brains of BWNS or MWS can potentially uncover relationships between the two traits. More spe­
cifically, differences between BWSN and MWS have been found in regard to grey and white matter. In BWNS, increased grey matter
within the anterior temporal lobe, anterior cingulate cortex, and prefrontal cortex may provide a form of “neural reserve” among aging
bilinguals (2015, Abutalebi et al., 2014). In contrast, decreased grey matter is found in the brains of MWS, specifically in the left
inferior and superior frontal gyrus, bilateral temporal regions, and the posterior portion of Broca’s area (2020, Beal et al., 2013;
Koenraads et al., 2019). Similarly, differences in white matter exist within the brains of BWNS as well as MWS. For example, increased
white matter integrity is found in the corpus callosum of BWNS (Luk et al., 2011), whereas decreased white matter is found in the same
region of MWS (Beal et al., 2013; Cai et al., 2014; Chang et al., 2008, 2015; Civier et al., 2015; Connally et al., 2014).
In addition, differences in the brains of BWNS and MWS may reflect differences in motor processing abilities. For example, BWNS
have been shown to utilize the dorsal anterior cingulate, which plays a role in motor processing, more efficiently than MWNS
(Abutalebi et al., 2012). However, MWS typical demonstrate atypical motor speech activation in both the basal ganglia and cerebellum
(Watkins & Klein, 2011; Watkins et al., 2008), a left hemisphere motor impairment (Alm et al., 2013; Neef et al., 2015), and atypical
motor cortex activation (Neef et al., 2015). Taken together, motor processing may be improved in BWNS while it is deficient in MWS.
Previous research also suggests that stuttering is more prevalent among bilingual than monolingual speakers (Travis & Knott,
1937), and that children learning more than one language tend to be at a greater risk for stuttering (Howell, Davis, & Williams, 2009;
Karniol, 1992). However, Byrd, Bedore, et al. (2015) and Byrd, Sheng, et al. (2015) argue that bilingual speakers are at a higher risk of
a false positive identification of a stuttering disorder. These mixed results examining the prevalence of stuttering in bilingual speakers
may be the result of various methodological issues, such as different methods of assessing bilingualism, who diagnosed the child with
stuttering, how soon after onset the diagnosis was made, and when exposure to their second language first occurred (Brundage,
Corcoran, Wu, & Sturgill, 2016).
Furthermore, Ambrose and Yairi (1999) suggest that speech that contains 3% SLD is indicative of a stuttering disorder. However,
Byrd, Bedore, et al. (2015) and Byrd, Sheng, et al. (2015) investigated the use of the 3% guideline in a sample of monolingual and
bilingual children. The results of the study indicate that significantly more bilingual children exceeded the 3% guideline than
monolingual children. Thus, these researcher argue that the 3% guideline for diagnosing stuttering is inappropriate for bilingual
children. To combat the potential of misdiagnosing a child with a stuttering disorder, it might be helpful to utilize other characteristics,
such as physical tension or arrhythmic speech when determining the presence of a stuttering disorder (Eggers et al., 2020).
In the event that a bilingual speaker does in fact stutter, it is likely that they will do so in both languages (Shenker, Conte, Gingras,
Courcey, & Polomeno, 1998; Van Borsel, Maes, & Foulon, 2001), although research examining this topic is limited. Therefore, when
treating BWS, it may be more beneficial to treat stuttering in the dominant language while promoting generalization of the
non-dominant language (Vong, Wilson, & Lincoln, 2011). While limited, previous research examining this topic suggest the Lidcombe
approach may be beneficial for generalization to the non-dominant language in preschool-aged BWS (Roberts & Shenker, 2007;
Shenker, 2004). Furthermore, the Lidcombe approach may promote generalization to the non-dominant language, even when the
non-dominant language is linguistically and phonetically diverse from the dominant language (e.g., Mandarin to English; Vong,
Wilson, & Lincoln, 2016).

5. Executive functions

Executive functions are considered to be a primary subcomponent of metacognition and refer to the management and control of
complex cognitive processes, including inhibitory control, cognitive shifting, and updating of information (Jurado & Rosselli, 2007;
Miyake et al., 2000). Inhibitory control refers to the ability to deliberately block interfering responses. In contrast, cognitive shifting,
also referred to as attention or task switching, describes (1) the ability to shift between several tasks, (2) attending to relevant

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information, and (3) ignoring irrelevant information. The third component, updating, refers to the constant monitoring and rapid
addition or deletion of information in working memory. Executive functions are thought to be mainly but not exclusively regulated by
the prefrontal cortex (Alvarez & Emory, 2006; Moriguchi & Hiraki, 2013). This finding may support the notion of a bilingual
advantage, as BWNS show increased grey matter in the prefrontal cortex (2015, Abutalebi et al., 2014). Interestingly, some brain
structures that are associated with executive control, such as the cingulate cortex and the caudate nucleus, have also been linked to
motor control (Grahn, Parkinson, & Owen, 2008; Hoffstaedter et al., 2014; Paus, 2001), which is essential for fluent speech. In fact,
BWNS have been shown to utilize the anterior cingulate cortex more efficiently and have increased grey matter in the cingulate cortex
(Abutalebi et al., 2012). In contrast, MWS show decreased activity in the caudate nucleus (Wu et al., 1995). The same has been
suggested with respect to the supplementary and pre- supplementary motor areas (Ikeda et al., 1999; Nachev, Kennard, & Husain,
2008). Taken together, previous research suggests that stuttering may operate under the same mechanism as executive functioning
deficits, specifically in regard to self-regulation and inhibition (Felsenfeld, van Beijsterveldt, & Boomsma, 2010)
Both stuttering and bilingualism have been found to have a considerable impact on executive functions. For MWS, differences in
executive functions have been observed with respect to linguistic processing (Maxfield et al., 2015), working memory (Bajaj, 2007),
and attentional functions (Heitmann et al., 2004), as well as reaction times (Eggers et al., 2013; Jones et al., 2012) and error rates in
word recall accuracy and recognition. For example, MWS appear to experience difficulties with dividing attention between several
concurrent tasks (Bosshardt, 2002, 2006). In contrast, bilingualism appears to have a positive effect on performance when engaging in
cognitive challenging activities, particularly with respect to inhibitory control and task switching. (Bak, Vega-Mendoza, & Sorace,
2014; Bialystok et al., 2014; Sullivan, Janus, Moreno, Astheimer, & Bialystok, 2014). This bilingual advantage is presumed to be due to
the constant practice with language switching, which requires a high degree of cognitive control since bilinguals are constantly
required to (a) inhibit the language not in use and (b) switch from one language to another language.
However, some previous research argues against the presence of a bilingual advantage in BWNS on tasks involving executive
functions. For example, Loe and Feldman (2016) investigated the effect of bilingualism on executive functioning skills in
preschool-aged children. The results of the study indicate that the bilingual advantage did not exist in their sample of 119
preschool-aged children. Furthermore, Arizmendi et al. (2018) did not find evidence of a bilingual advantage in executive functioning
among their sample of 247 children.
Paap, Johnson, and Sawi (2015)) further argues that studies supporting a bilingual advantage in executive functioning should be
interpreted with caution and warrant further examination. For example, studies that report a bilingual advantage often possess a small
sample. Additionally, Paap et al. (2015) argues that studies supporting positive findings were not well matched on demographic
factors. Lastly, studies indicating a bilingual advantage often used tasks and measures that do not demonstrate high convergent
validity. Therefore, the presence or absence of bilingual advantage observed in BWNS may actually be the result of methodological
differences in the studies themselves, rather than differences in executive functioning (Van den Noort et al., 2019). These methodo­
logical differences include varying methods of bilingual participant selection, use of nonstandardized assessments, neglect of indi­
vidual differences, and lack of longitudinal studies.
Recent studies, using behavioral measures, assessed executive functions in BWS compared to MWS, as well as BWNS and MWNS as
controls (Kornisch, Robb, & Jones, 2017a, b). It was found that BWS showed the same bilingual advantage as BWNS with no per­
formance differences between the two groups on any of the measures. In contrast, the MWS group performed significantly poorer
compared to all other subject groups. Moreover, dual-task and visual hemifield performance increased with bilingual language pro­
ficiency. These results indicate that bilingualism might have a greater influence on executive control than stuttering. Therefore, it
appears that bilingualism is able to offset some of the deficits in executive control that have been associated with stuttering. However,
both studies only examined sequential bilinguals, making it difficult to determine if the same pattern of performance would be found in
simultaneous bilinguals who did not did not stutter. Additionally, both studies relied on participant self-report to determine left or
right handedness, language history and proficiency, and stuttering history and severity. Therefore, it is possible that participants may
have, knowingly or unknowingly, over or underestimated their abilities. Lastly, these were the first studies examining the performance
of BWS on such paradigms, thereby limited the comparisons that can be made to past research.

5.1. Brain reserve and cognitive reserve

If bilingual speakers do, in fact, possess superior executive functions compared to monolingual speakers, this phenomenon may
suggest that bilingualism provides a form of neural reserve (2015, Abutalebi et al., 2014; Perani et al., 2017), which is considered to be
a protective mechanism and assumed to increase the brain’s ability to cope with aging and various brain pathologies (2012, Stern,
2009; Tucker & Stern, 2011). Higher neural reserve enables brain networks not only to be more efficient but also to recruit additional
resources when faced with highly demanding tasks. According to Stern (2009), neural reserve can be divided into brain reserve and
cognitive reserve. Brain reserve refers to individual differences in brain structure, such as more neurons or synapses. In contrast,
cognitive reserve refers to individual differences in brain function, such as better processing and task performance. Both may increase
tolerance to brain pathology. Brain reserve and cognitive reserve are thought to have a close interrelationship with the executive
control system (Grant, Dennis, & Li, 2014). That is, superior executive functions provide the foundation for enhanced cognitive
reserve, and cognitive reserve is in turn enhancing brain reserve in terms of increased white matter connectivity and grey matter
density. Interestingly, bilinguals show increased white matter connectivity (Luk et al., 2011) and grey matter density (2015, Abutalebi
et al., 2014), indicating that they may possess such superior executive functions. In contrast, PWS show decreased white matter
connectivity (Beal et al., 2013; Cai et al., 2014; Chang et al., 2008, 2015; Civier et al., 2015; Connally et al., 2014) and grey matter
density (Beal et al., 2013; Koenraads et al., 2019, 2020), indicating an absence of such executive function superiority.

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M. Kornisch Journal of Fluency Disorders 67 (2021) 105819

5.2. Brain connectivity

Brain reserve and cognitive reserve have also been linked to brain connectivity. Fluent speech production requires successful
auditory processing, motor planning, and motor execution (Hickok & Poeppel, 2007). Therefore, it is essential to have a
well-established connection between the posterior (perceive and decode sensory information) and anterior (regulate motor function)
of the brain in order to successfully coordinate fluent speech production. However, various changes in functional connectivity have
been observed in PWS. For example, Yang et al. (2016) observed changes within basal ganglia thalamocortical networks in the form of
reduced connectivity of the putamen to the superior temporal gyrus and inferior parietal lobules. These atypical changes of resting
state functional connectivity are considered to negatively affect both language planning and motor execution, although more research
is needed to fully understand the specific contributions of these regions in PWS.
In contrast, functional connectivity changes in bilingualism have been found to be favorable. Li et al. (2015) suggested that
bilingualism alters functional connectivity between control regions (i.e., cingulate cortex, left caudate nucleus) and language regions
(e.g., left superior temporal gyrus) of the brain. Furthermore, other researchers other researchersfound anatomical connectivity
changes in bilinguals in two sub-networks associated with language processing and monitoring, which were more connected by white
matter tracts (García-Pentón et al., 2014). The networks found included the left frontal and temporal/parietal regions, as well as the
left occipital and temporal/parietal regions and the right superior frontal gyrus. Hence, with respect to individuals who are bilingual
and also happen to stutter, a protective mechanism might be on place to better cope with the disorder and its symptoms.

5.3. Clinical implications

The diagnosis of stuttering is typically confined to the collection of speech samples and determining the amount and types of
dysfluencies (Jani, Huckvale, & Howell, 2013; Lee, Robb, Ormond, & Blomgren, 2014). However, executive function training, such as
dual-tasking and attention exercises, may contribute to the management of speech fluency (2006, Bosshardt, 2002; Nejati, Pour­
etemad, & Bahrami, 2013). The speech of PWS seems to be more sensitive to interference from attention-demanding, concurrent
cognitive processing tasks, and it has been suggested that stuttering frequency increases on dual-tasks (Metten et al., 2011). Inter­
estingly, there is evidence that attention training not only enhances executive functions but also reduces stuttering severity in children
(Nejati et al., 2013). Therefore, it seems plausible to assume that integrating dual-task conditions/ attention training into intervention
programs might assist patients not only to transfer treatment effects into everyday life situations but also to maintain them. More
specifically, this approach may provide extra support in situations where attentional resources are frequently diverted away from
controlling fluency by the demands of other tasks. In addition, this untraditional speech therapy approach might also be an alternative
for people who haven’t had success with traditional intervention programs or who refuse to use techniques of stuttering modification
and/or fluency shaping as they sometimes do not sound like natural speech.

6. Concluding remarks

As Howell and Van Borsel (2011), p. 383) noted:

“The main lessons learned are that the only common thing about people who stutter is that they are not fluent and that the only
thing bilinguals have in common is that they are not monolingual.”
While these comments seem to acknowledge the challenge of collectively studying stuttering and bilingualism, data emerges that
bilingualism may to be able to offset deficits in executive functioning associated with stuttering (Kornisch et al., 2017a, b). This raises a
number of questions and further research in the area of stuttering and bilingualism, assessing their combined impact on the brain, is
required. In particular, there remains an absence of neuroimaging studies that have specifically assessed brain structure and function in
BWS. Therefore, it would be important to expand the database of studies assessing these brain characteristics of BWS. A combination of
neuroimaging and behavioral studies on the effects of stuttering and bilingualism are likely to provide a better understanding of the
nature of fluent and disfluent speech. That is, without the assessment of BWS, we remain ill-informed about a side of stuttering that
may be essential to gain a better understanding of the disorder, finding the cause of it, and developing new intervention approaches.

Declaration of Competing Interest

The author reports no conflicts of interest.

Acknowledgement

Support for the preparation of this manuscript was provided in part by the School of Applied Sciences at the University of
Mississippi.

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Dr. Kornisch is an assistant professor in the Department of Communication Sciences and Disorders at the University of Mississippi. Her general research interests are in
cognitive neuroscience. Specifically, she is interested in the interrelationship of developmental stuttering and bilingualism and their combined impact on the brain. Her
current research examines (a) brain reserve and cognitive reserve and (b) motor control and cognitive control in monolingual/bilingual people who stutter and non-
stuttering controls.

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