The Integrated Approach to the Minneapolis Convention (U.S.A)
After several years of work and research, Dr. Antonio Bitetti, as an associate member PhD, was invited by his American colleagues from the American Psychological Association (APA), to the annual convention, which this year took place in Minneapolis, Minnesota, from 3 to 6 August 2022. It was a long-awaited and important event, which allowed the aspects of stuttering therapy, in adults and children, contained in the therapeutic model, called: Stuttering Integrated Approach, to be exported to America. He was the only European psychologist present at the event and this makes the work carried out in Italy even more important. An introductory part regarding the interpretation of the problem of stuttering, with comparisons regarding the genetic hypothesis of the problem and/or the relational hypothesis and a descriptive part regarding the actual operational intervention. Dr. Bitetti focused his speech on the relational aspects, since all his research in this sector has always gone in this direction. He emphasized the fundamental element of the control factor, that on the mouth of the stutterer, a real bulwark to be faced, but above all on the tendency of the stutterer to control his emotions, imbued with anger. Finally, much attention and consideration has been aroused by the intervention that Dr. Bitetti carries out in the treatment of preschool children, in the so-called phase of primary or developmental stuttering, 3 and 4-5 years. A true pioneer in Italy and abroad, in a field in which no one had ever ventured before. An exceptional result, for a cutting-edge treatment, in Italy and abroad.
The control of the dynamics of stammer
The control of the mouth that I systematically observe in my stammering patients, hides a tendency to retain emotions full of anger and aggressiveness. It is possible to also notice a strong tendency to retain positive emotions, made of joy and a trustful abandonment to life. It seems that the stammerer lives everything in a dimension of strong rigidity, with the propensity to close the energy tap, in the irrational fear of who knows what effects. In the scientific literature about stammer there are no specific studies that link the control mechanism of the phonatory apparatus with the stuttering symptomatology. I have started to talk about that many years ago (Bitetti A,. 2001) and I have continued my research even through a constant job with the model of therapy that I conceived and that I called “Integrated approach” (Bitetti A., 2010). Further research in this direction led me to complete another editorial work titled Emozioni, Comportamento e Controllo (Emotions, Behaviour and Control) in 2016. If I have to define in a practical way what is the problem of stammering, thanks to my twenty-year experience in the sector, I will say, with a certain degree of certainty, that the stammerer stutters because he adopts a psychological strategy that is antithetical to the normal functioning of phonation. It is not easy to say that, even for me that I have been treating stammerers for many years, because it is not easy to think that a control mechanism can be so direct to influence language in such a negative way; but all the evidence at my disposal supports that. Sure enough, every strategy that divert attention from the control over words can rapidly allow the stammerer to express himself normally. The control in stammer is a bad habits learned and kept alive for a long time. We are faced with a wrong learning, but probably adaptative to cope with an experience, considered critical in a given period of childhood. The problem arises when that behaviour is protracted over an extended period, believing that the emergency would last necessarily beyond that time. While the normal speaker, that is the one who do not stammer, never controls his mouth under any circumstances of relational life, the stutterer, on the contrary, massively controls his speech and this affects it negatively. When he is alone, closed in his room, the stammerer never carry out this mechanism of control and so he speaks freely. This happens because this mechanism is strictly connected to the fear of being judged negatively by others, because, highly likely, there is already a negative attitude towards himself.
Emotions and Stuttering
Stuttering: a tumult of emotions. One thing all living beings have in common: emotions. Whether they are aware of it or not, they experience an extraordinary emotional flow at every moment: joy, sadness, fear, anxiety, anguish, euphoria, etc. We can usually control the manifestation of emotions but we can never control their emergence within us. What we can and would be wisest to do is manage them. Managing one’s emotions, therefore, does not mean controlling them, as the mind would like to do, but modulating them in the light of a new awareness of life and our true essence. Managing emotions is one of the most important steps in the path of personal growth. Emotions are spontaneous, internal, fast, physical and mental functions of the mind that help us deal with situations of danger or pleasure that we experience. They are natural reactions that allow us to put ourselves on alert in situations of risk, threat, frustration, etc. Anxiety and anger, for example, are natural and positive reactions that help to alert us to situations that are considered dangerous; but it can happen that reactions are triggered by harmless stimuli causing discomfort. In general, emotions are activated in order to choose a behavior in a short time between: Emotions are a resource. Emotions, even the somewhat problematic ones, such as anger and resentment, are not the real problem; the real problem is to manage them wisely to resolve the event that generated them. One thing, however, distinguishes the human being from other living beings is that he, in some way, is theoretically able to manage them rationally. It is interesting to reflect on the connection between the mind and the body, their mysterious association with memories of the past that are hidden in our unconscious and that condition our free will and our daily choices. Learning to manage emotions means accepting that they have an important function for us, as they are an indispensable manifestation of our existence. They are the expression of our deepest mind, which has the function of protecting our integrity, both physical and mental. Our brain is equipped to manage emotions very quickly and effectively, through the limbic system, mainly composed of the amygdala and the hypothalamus. When we are prey to strong and uncontrolled emotions it is because our limbic system has taken command and the “emotional hijacking” occurs, which takes control away from the conscious mind for a while. This basically means that when the emergency occurs, the reactive circuits take over and we begin to function according to animalistic automatisms with all the limitations of the case. However, this concept must be demystified: emotions are nothing more and nothing less than energy that passes through us. They are not who we are. When we identify with the emotions we experience, we can get lost in them. Resisting or suppressing them does not help and does not solve anything. We just need to consider that no emotion, and no feeling, is “definitive”. Many emotions arise because you worry about the future or relive the past. Therefore, being present in the present moment can easily resolve an emotion connected to the past or the future. Managing your emotions (especially negative emotions) requires a loving attitude first of all towards yourself and towards others; it requires adopting a strategy that gives us a vision of the event, free of judgment, both towards yourself and towards others. We must learn to get out of the logic of judgment, of the need to continually judge ourselves and others. When the aforementioned emotional hijacking occurs, it is too late to try to truly manage our emotions; the most you can do is try to manage the overflowing river of emotions as best you can; try to manage their form, their external manifestation; while our body and our mind are subjected to the action of this overflowing river. There are emotions that push us to open behaviors, and emotions that push us to close behaviors. The former offer greater possibilities of obtaining advantages and the latter give more possibilities of obtaining disadvantages. In each of us there is the freedom to choose how to live. We always have before us this double possibility of advantage, or disadvantage, the gift of the ability to decide. Thinking in positive terms of oneself and one’s basic qualities increases first at a cognitive level, and then at an emotional level, the vital energy, with a consequent feeling of well-being. Language, like every other human element, uses this energy flow, as lifeblood, creating the conditions for a type of strong and incisive communication. So why be afraid to speak, why control the mouth and consequently the word, already knowing the learned mechanisms of language? The control of the mouth and of all the phonatory activity in subjects affected by stuttering, hides a tendency to hold back emotions full of anger and aggression. As if the stutterer lived everything in a dimension of strong rigidity, with the propensity to close the energy tap, in the irrational fear of who knows what effects. In the scientific literature regarding research on stuttering, there are no specific studies that relate the mechanism of control of emotions and the symptomatology of stuttering. It was Dr. Antonio Bitetti who spoke about it first, in his editorial work (Analysis and perspectives of stuttering, Positive Press, Verona, 2001) and continued his studies, also through his interpretative model and treatment of stuttering called: “La Balbuzie Approccio Integrato, IEB Editore, Milan, 2010”. He states that the stutterer stutters because he adopts a psychological strategy that is antithetical to the normal functioning of phonation. In fact, any strategy that diverts attention from control over speech allows the stutterer to express himself normally (Bitetti A., pag. 119, 2016). Control in stuttering is a bad habit learned in the early years, in the period of so-called primary stuttering and kept active until the chronic phase, which then becomes secondary stuttering, or true stuttering (Bitetti A., Emozioni, Comportamento
Description and analysis of the stuttering problem
Stuttering affects approximately 1-2% of the population, with a higher incidence in the male sex, out of ten cases of stuttering, eight are certainly male, affecting people from all social backgrounds and in every part of the world. This aspect alone could be an important reason for research in trying to demonstrate the socio-relational value of the disorder or, possible implications of a different order. The stutterer knows what he wants to verbalize but is unable to express it, there is no synergy between thought and word. In the majority of stuttering subjects, for extremely variable reasons, there is a disorganization between thought and language. Too much time passes between what needs to be said and the possibility of saying it. A precise diagnosis of stuttering can only be made when the mechanism has now consolidated in the child’s way and type of communication, that is, when it is: CHRONICIZED. Stuttering, from a strictly symptomatic point of view, consists of a set of alterations in the rhythm and fluidity of verbal expression and is experienced by those who suffer from it with great suffering and discomfort. SOLUTIONS AND INTERVENTIONS PROPOSED ON THE BASIS OF SCIENTIFIC EVIDENCE Currently, there is a substantial contradiction in the therapeutic offer regarding stuttering. In fact, all the phonatory and language re-education techniques, so massively proposed, start from the assumption that this disorder is of language. But in essence this is not the case, because as has already been described, the stutterer in the privacy of his own room, not subjected to the judgment of others, never stutters. It is therefore evident that the stutterer in his heart, knows that he speaks well, but he also knows and would like to explain to everyone, that his real problem is only one of relationship. Supporting the eminently relational matrix of this widespread disorder, it is important to highlight another relevant aspect of this whole dynamic, that is, that the stutterer is also conditioned by the feedback generated by listening to his stuttering. In fact, an important research by the University of Edinburgh produced in the 80s a technological tool that allowed to cancel, through a buzzer, emitted during the emission, the listening of one’s own voice (Edinburgh Masker). This further evidence inevitably leads to the fact that the stutterer is strongly conditioned in his verbal performance, because he tends to suffer the human relationship, rather than manage it in a proactive and productive way. All the dynamism of stuttering translates into a huge waste of potential resources, of missed personal affirmations and that go to impact on the general and above all social dynamism. Sometimes we underestimate the many human resources wasted through useless and sterile attitudes, but we should not continue to close our eyes in the face of such annihilation. The health of a population is the basis of its realization and affirmation, since everyone contributes to this project. The stutterer is also called to this intent and can no longer hide behind this symptom. CULTURAL CRITICALITY AND STUTTERING The criticality is represented above all by the cultural factor. After several decades of re-educational culture, the health world, at various levels, directs patients affected by stuttering towards re-educational or rehabilitative therapeutic solutions, neglecting the many aspects listed above. A culture has been structured over time and in a stereotyped way, it is considered the most suitable, simply because historically it is the one proposed by public health. In all these years, serious research has never been done and this has also facilitated the proliferation of the strangest and most disparate treatment responses, it would be enough to take a look on the internet, to the detriment of the quality and effectiveness of the service offered. There is a need for a cultural and methodological change, but this requires proposals and above all, training that pushes towards a modern vision of the problem. But as we all know, it is not easy to adapt to a new model, especially if it is not supported by statistical evidence and results. Hence the need for widespread experimentation involving the structures already present in the territory, but which have at heart the interest of the population in need of care, the best available in the territory.
Stuttering Integrated Approach
In his long research work on stuttering, thanks to his personal experience of complete and profound recovery from stuttering, Dr. Antonio Bitetti has laid the foundations for a cutting-edge interpretative and methodological model, which he has spread throughout the entire national territory and which for many years has also crossed the borders of our country. For over twenty years, Dr. Antonio Bitetti has introduced a decidedly innovative interpretative and therapeutic model in our country, regarding the treatment of stuttering: the Integrated Approach. Stuttering has always been treated with re-educational models of language, based on peripheral concepts, given that the final aspect of the problem is the difficulty in speaking normally like everyone else. However, it is important to underline that the stutterer, whether a child, a teenager or an adult, in the privacy of his own room, speaks very well, does not show any type of language difficulty. The operating model called: “INTEGRATED APPROACH” is the natural evolution of a path of research and reflection of years and years of work on stuttering and stutterers. Dr. Bitetti’s research aims to clarify, grow and give the best possible answers in this field of work, with humility, without neglecting the path taken so far, but improving it, always and only in the interest of research and at the service of patients. Dr. Bitetti has always wanted to delve into the real reasons behind this widespread disorder which, let us remember, affects 2-3% of the national population. In a recent interview he gave to the Spanish television station TVSE in Madrid, the journalist recalled that in Spain there are at least 800,000 people affected by stuttering. The stutterer knows very well what he wants to say, but is unable to express it in a fluent and serene way, as the vast majority of the population does. At this point, it is natural to ask why the stutterer has difficulty speaking when he relates to others, and instead does not stutter when he is alone. The answer cannot be simple and banal, since it involves those cognitive, emotional and relational aspects that language has in itself. Through language, human beings create connections, express emotions, ideas, projects and therefore, we all recognize the intrinsic value of this powerful tool. Language has a structural or genetic basis and an acquired basis, of a cultural or environmental type (N. Chomsky). In childhood, the child experiences an important phase in his delicate evolutionary period and is called the stuttering phase, in which the child engages in the best possible research to converge structural aspects and cultural aspects. Just as happens in walking, the child gradually learns to coordinate his movements, based on a series of trials and errors, also on the basis of a process of strengthening his musculoskeletal system. Once the entire sequence is acquired, the child will be able to walk alone and without the help of adults. Language follows the same logic, but unlike motor activity, language has an important relational value, since through it we are able to express emotions, sometimes, in some negative or traumatic experiences, even with a strong aggressive value. This research by Dr. Bitetti, who is also the author of three books on stuttering (2001, 2006, 2010) the last one also translated into English and German, has focused on the mechanism of emotional control and in the case of those who suffer from stuttering, it becomes a control of the peripheral part of language, that is, the word. The vast majority of the population does not control the word while speaking, they know that it will be an automatic process, just as it happens in walking. No one would dream of controlling and verifying the movements of the legs during a walk or during a run, if we did, we would risk blocking ourselves or strongly conditioning the spontaneous activity. Therefore, control is the real negative element of those who stutter ( Bitetti A., Emotions, Behavior and Control, 2016) and it is an aspect learned as a child, in conjunction with events with a strong negative valence, such as the birth of a sibling, conflict between parents or different experiences in which frustration and consequent aggression predominate. If left free to consolidate, in the long run, the control mechanism can create a chronic disorder, commonly called stuttering. If kept active, this disorder risks compromising the normal relational and emotional growth of the child, to the point of making him acquire as an adult, what Dr. Bitetti defines: “the stutterer’s habit”. Stuttering, or rather stuttering, in the initial stages is an adaptive mechanism that should be abandoned in a short time, this is why it is necessary to intervene early, especially before adolescence, even better before it becomes definitively chronic. The Integrated Approach is a cutting-edge therapy, a cure for stuttering, definitive, in the true sense of the word. There is no more precise and profound therapy than this, precisely because it goes in the right direction, which is to resolve the delicate internal and external mechanisms of the problem. The dissemination of books on stuttering is a completion of a process of in-depth study, of a disorder that should absolutely not be underestimated. Dr. Antonio Bitetti, moreover, has extended his model of intervention of care also in a preventive manner, in those children under 4-5 years of age, who have maintained active stuttering, but cannot be defined as stuttering children. This extension of his Integrated Approach is an achievement and an absolute novelty in the national panorama and is aimed at parents who would like to intervene quickly, but do not receive adequate answers from any area in Italy.
Social and relational aspects of the stutterer
The symptoms of stuttering vary depending on the context in which the stutterer interacts and the people with whom he relates. For example, the stuttering child strongly fears questioning at school or being asked to repeat a topic already covered. He is in a constant state of fibrillation in fear of being asked to express himself in front of his classmates. Instead, he is helped by relationships with friends, who do not require much commitment on the level of personal value and preferably, not inclined to judge him. Sometimes, if the symptoms are strong, he may even be exempted from reading aloud, with repercussions on his self-esteem and with a consequent stigmatization of his entire condition. In the stuttering adolescent, the difficulty of language can have strong repercussions on the normal evolution of character, already difficult in itself at that age. Moments of isolation may arise in not being able to express oneself adequately with the peer group, also showing signs of strong self-deprecation and sometimes even self-pity, with marked depressive overtones. All aspects that must make us reflect on the importance of a problem, which is expressed in language as the final data of the symptomatology, but which involves a much wider sphere, that of one’s personality and above all, the way of thinking about oneself in relation to others. Without effective change processes, the stuttering child or adolescent is at high risk of becoming a stuttering adult, with serious impairment of the relational structure, at the various operational levels of the entire personality. This is why it is highly reductive to think of the problem of stuttering as a simple language problem. Thinking this strongly limits the whole discussion and neglects the importance of the psychological and relational meaning that language represents for the human being in his daily interaction. Those who are stuck in believing that stuttering is just a simple disorder of verbal fluency, as usually happens in a culture set on the simple verbal re-education of stuttering, tend to lose sight of the highly psychological value of language, an extremely sophisticated tool that mankind has developed to convey thoughts and emotions. The presence of a large population of adolescent and adult stutterers says a lot about the fact that much more could not be done in childhood, or was not known how to do. It goes without saying that many sacrifices have been made by families with stuttering children, precisely because it was impossible to find adequate answers in the right time to try to reverse the condition. So much so that in the field of stuttering intervention there is a large presence of ex-stutterers, self-treated or treated with speech therapy models, who try to propose phonetic-based approaches, the result of an always re-educational and symptomatic conception of the problem. But deep down, the person who stutters knows that the internal situation is not as simple as it is made out to be. The stutterer knows his internal fears, his rigid cognitive positions, the irrationality of some of his ideas, and that they compromise the realistic possibility of having an adequate interpersonal relationship. Human communication should not be a painful experience, as it is in the case of the stutterer, who sometimes is not capable of making a simple phone call, or experiences great suffering even in asking for a simple drink at the bar. In terms of interpersonal communication, what is simple and sometimes pleasant for the normally speaking person, becomes pure suffering for the stutterer. This state of affairs prevents the stutterer from being able to adequately invest his cultural and human resources in the social sphere, and this is why the stuttering problem can become a limitation in personal fulfillment, even to the detriment of the richness of the entire context of the reference group. If it is true that emancipation and participation in relational life create wealth, a strong limitation of such possibilities certainly creates impoverishment, obviously to the detriment of the entire community. At this point it is legitimate to think that stuttering no longer represents a disorder that is only subjective, of the personal sphere. The attitude of the individual, with his fears and uncertainties in communicating, creating a block of that psychological and relational energy, leads to a certain impoverishment in the collective growth process. This is why it is important to limit the incidence of this problem from childhood, trying to give the best opportunities to the child who stutters. Not allowing him to cross the threshold of adolescence, an important limit, so that it does not become a serious element of relational difficulty and therefore, working hard to unhook get out of this communication model as soon as possible.
Stuttering in preschool age
Usually, when a family with a child with primary stuttering turns to public health facilities, they are told that it is necessary to wait until school age to be able to intervene. In fact, until recently, it was necessary to wait until a child reached the age of 6 for him to be taken in charge by voice professionals to receive the first treatments. Until that time, families and their children had to be patient and suffer in silence. For some years, this has no longer been the case. Through the research I have conducted, even small or very small children can peacefully overcome their discomfort by taking advantage of the specific treatments I was the first to introduce in Italy and Europe. It was an intuition dictated by continuous requests for help from families with children who are disfluent and too young to be treated with speech therapy methods. The Integrated Approach aimed at treating so-called primary stuttering, which represents an initial phase of stuttering, is proposed to avoid the phenomenon of chronicity of the disorder and to avoid useless and sterile suffering, both in the child who directly experiences the discomfort and in the family, passive spectator of the situation. These studies represent an absolute novelty in the current panorama of research on childhood stuttering. Preventive therapy for stuttering is specifically aimed at parents and not at the disfluent child, who receives the benefit of the therapeutic approach, directly from them, under my careful guidance and supervision. The results so far are nothing short of exceptional and all the cases treated underline the value of this type of intervention. Now, even children aged 3-4 and 5 affected by primary stuttering, or childhood stuttering as others define it, can be treated without any contraindications and families can thus regain their serenity. As is often said in these cases: “Prevention is better than cure” and in fact, by addressing this disorder early, negative repercussions are avoided, both in the child and in the parents. In this video of a 3 and a half year old girl, you can see a bending of the trunk in the maximum expression of difficulty in trying to express herself. The girl in question was going through a difficult period in the family dynamics and obviously her stuttering represented a powerful defense mechanism to the emergence of strong aggressive dynamics regarding the situation she was facing. The bending of the trunk expresses all the difficulty of the girl in trying to find the right energy to support the language, but she cannot find it because she is strongly blocked by the aggressive value that at that moment the girl was giving to her language. Language should not be loaded with strong psychological connotations. In the case of the stutterer, however, it is exactly like this. The mouth becomes the target organ of negative emotions and this aspect compromises the serenity and the necessary fluidity to speak. This is why stuttering cannot be defined as a language problem. It is indirectly a language problem because it is really a problem of control of phonation, regarding underlying emotions strongly imbued with anger.
Stuttering: What it is, Causes and Treatment
There have always been attempts to explain the causes of stuttering. Various theories have been proposed: psychogenetic, neurological, theories that focus on language, laterality and the dominance of one hemisphere over the other, or theories that focus on the role of heredity. It is also possible to hypothesize a multifactorial nature in the etiopathogenesis of stuttering. From a medical point of view, there is a tendency to interpret problems that are difficult to understand on an organic basis. In fact, one cannot blame those who, seeing an undoubted interpretative complexity of stuttering, tend to believe in an organic implication. In fact, in an important international symposium on stuttering, held in Rome in 2000, at Palazzo Barberini, the famous professor Yairi, of the University of Chicago, argued with a certain amount of certainty that stuttering could have a solid genetic basis, and foresaw the discovery of the gene or genes implicated in this problem. After many years, 17 years in fact, no gene has been discovered as a direct or indirect cause of stuttering. This organic or genetic hypothesis, however, always fails against the evident fluidity of speech that the stutterer manifests in the quiet of his own room or in any other context where he is not subject to the gaze and judgment of others. The strange thing is that for several years there has been a succession of news from different sources that speak of genetic identifications of the problem, announcing imminent gene therapies, but after a while everything is forgotten and we wait for the next news. A very recent example is this article, taken from the AGI source: (AGI) – Washington, – Stuttering is genetic. A group of researchers from the American National Institutes of Health has identified three genetic mutations that affect the way the brain processes speech and that are very common in people who stutter. The results were presented at the meeting of the American Association for the Advancement of Science underway in Washington. “It is clear that these defects are not the sole cause of the disorder,” said Dennis Drayson, the scientist who coordinated the study. “A large fraction of the disorder,” he continued, “is probably not genetic for everyone, but these genes are providing us with a lot of surprises.” “At a rough estimate,” Drayson said, “about half of stuttering is due to what we inherit from our families.” At the moment, American scientists have created a genetically modified mouse in the laboratory that has the genetic mutations identified. Now researchers are convinced they can find a cure to treat genetic stuttering. It is clear that the study on mice is very different from the study on humans, also because mice have not developed language, unlike humans who are the only creatures to possess it, with the very clear relational implication that language entails. They are clockwork information, never seriously documented and never expressed in detail, through the identification of the gene or genes that cause stuttering. One suspects that from various quarters there is an attempt to shift interest towards a sector of intervention on a medical basis, with that rehabilitative culture that in itself is obsolete, clumsily attempting to maintain a curative domain, which is now largely dated. In the vast majority of stutterers, however, there is certain knowledge of that variability of the problem in relation to the presence of people, especially strangers or those considered important. It seems that the rhythm and melody disorders and also the apparent breathing and articulation disorders are of a secondary nature since they are superimposed on stuttering. Instead, motor development disorders, associated or not with lateralization disorders, speech or language delay, at a mental or linguistic level, are by far the most important. From these difficulties arises a state of tension to which psychological components of variable entity are added (Dinville C.). Psychological factors that can develop in a more or less serious way during conflicts and emotional situations, risk generating serious changes in the mental development of the subject and in his future behavior. In the growth period that represents a moment in the life of the child, in which all affective situations play a decisive role, psychological factors risk intensifying particularly during the pre-puberty period, due to the aggressive reactions typical of this period. This way of being will be structured during adolescence and risks worsening in adulthood, causing major disorders of verbal communication. However, it cannot be said in any way that once the presence of multiple factors associated in a variable manner depending on the case occurs, the subject necessarily becomes a stutterer. It seems certain that several factors will be associated with a constitutional factor. The problem of investigating the role that limitation plays in the onset of stuttering has often been raised. It should not be considered as a trigger factor in a subject who is not predisposed to stuttering. In this case, imitation is nothing more than a game that the child tires of and everything falls back into place. Instead, the child who lives in a tachycardic environment or with a family member who stutters will have great difficulty controlling his speech speed and his impediments, if he himself is predisposed to stuttering. It is necessary to highlight the correlation between stuttering and the different types of language processing disorders (delay in the onset of speech, dyslexia, dysorthographia) that have an evident relationship. Some claim that this prevalence is due to the delay in language development in males compared to females.
