From the Desk of Ann Kummer
As the first article for the new monthly 20Q (20 Questions) series for SpeechPathology.com, I am delighted that Scott Yaruss, PhD, CCC-SLP, BCS-F, F-ASHA and Nina A. Reardon-Reeves, MS, CCC-SLP, BCS-F agreed to do one on early childhood stuttering! I first met Dr. Yaruss in Saudi Arabia, where we were both doing seminars for a conference. I couldn’t help but notice how the participants in his seminar were mesmerized by the information that he was providing. Of course, both of these authors are nationally recognized experts in the evaluation and treatment of stuttering and they have developed many educational and clinical resources for this condition. (See the Stuttering Therapy Resources website below.)
Early childhood stuttering is a highly misunderstood condition. Many speech-language pathologists do not feel confident in their skills for helping young children who stutter. (I happen to be one of them.)
This 20Q article provides some key facts regarding current views about stuttering in preschool and young school-age children. The authors specifically focus on characteristics of stuttering in children, ages 2 to 6. They clarify how stuttering differs from the typical disfluencies that all of us experience at times. Importantly, they discuss when therapy is needed in this age group. Finally, the goals of the diagnostic evaluation are explained. This article will certainly help clinicians to become better-prepared to help children who stutter and their families.
Of course, the authors could not possibly provide a full explanation of the many complexities of stuttering in this short article. Therefore, they have promised to do a future 20Q on assessment and treatment strategies for this age group and also for older children who stutter.
In the meantime, the readers can refer to the citations noted in the article and particularly to the following excellent resources: Early Childhood Stuttering Therapy: A Practical Guide (Yaruss & Reardon-Reeves, 2017) and School-Age Stuttering Therapy: A Practical Guide (Reardon-Reeves & Yaruss, 2013). Both are published by Stuttering Therapy Resources, Inc. (www.StutteringTherapyResources.com). (Disclosure: The authors are co-owners of Stuttering Therapy Resources, Inc., and receive royalties for the sale of these and other books about stuttering therapy.)
Now…read on, learn and enjoy!
Ann W. Kummer, PhD, CCC-SLP, F-ASHA
20Q: Early Childhood Stuttering: Background and Assessment
After this course, readers will be able to:
- List three aspects of a child’s development that may contribute to the development of stuttering
- List at least three risk factors that may contribute to the likelihood that a child will continue to stutter
- Define the primary purpose of a diagnostic evaluation of a preschool or young school-age child who stutters
1. A lot of clinicians have questions about stuttering, and the definitions seem to change all the time. So, let me ask you, what is stuttering, anyway?
At its most basic level, stuttering is a communication disorder that involves disruptions in the forward flow of speech (Bloodstein & Bernstein Ratner, 2008). These disruptions, or speech disfluencies, can take a variety of forms, such as pauses, repetitions of parts of words, or complete blockages of speech output. Disfluencies may also be accompanied by physical tension or struggle as the child attempts to “get the word out.”
Stuttering also involves the many consequences that go along with a person’s speech behaviors, including the following:
- frustration and embarrassment when a speaker has difficulty producing sounds or words
- anxiety about speaking in situations where stuttering might occur
- fear about other people’s negative reactions to stuttering
- difficulties communicating in situations, such as in social interactions or at school
- negative reactions by other people, such as being cut off or ignored
- adverse impact on the speaker’s quality of life due to stuttering
All of these consequences (and more) contribute to the speaker’s experience of the stuttering disorder (e.g., Manning, 2010; Shapiro, 2011; Yaruss, 1998; Yaruss & Quesal, 2004). We often sum up the important distinction between stuttering behaviors and the stuttering disorder with the phrase “Stuttering is more than just stuttering” (Reardon-Reeves & Yaruss, 2013, p. 8).
2. Tell me more about the types of disfluencies that are considered “stuttered.”
Certain types of disfluencies are more likely to be produced by people who stutter (see Conture, 2001; Yairi & Ambrose, 2005; Yaruss 1997a). These include sound or syllable repetitions, prolongations, and blocks. This is true for both older children and adults who stutter. Young children who stutter are also more likely to produce monosyllabic whole-word repetitions (Yairi, 1997). Stuttered disfluencies may also be accompanied by physical tension or struggle as the person attempts to “get the word out.” Because all of these disfluencies (sound or syllable or monosyllabic whole-word repetitions, prolongations, and blocks) are commonly seen in people who stutter, they are often called stuttered disfluencies (or stutter-like, after Yairi and colleagues; see Yairi & Ambrose, 1992a, 2005).
Other disfluency types, such as pauses, interjections, revisions, or repetition of phrases, are also produced by people who stutter; however, they are commonly seen in people who do not stutter, as well. These are often referred to as normal, typical, or nonstuttered disfluencies (see Yaruss, 1997a). We prefer to refer to them as nonstuttered to avoid the inherent judgment in calling a child’s speech behavior “normal” or not.
3. Doesn’t everyone stutter sometimes?
When thinking about different types of disfluencies, remember that the so-called stuttered types are not unique to people who stutter. Even people who don’t stutter produce them on occasion. For this reason, we cannot simply say that all sound or syllable repetitions are stuttered and all interjections are nonstuttered. We must allow for overlap between the disfluency types—and between the people who exhibit them.
At the same time, we should NOT be tempted to say that “All people stutter,” for this certainly is not true. Stuttering is a unique experience, and we do not want to minimize or discount the difficulties that people who stutter experience in their speech. Therefore, we prefer to say that, “All people exhibit speech disfluencies,” and that, “All people exhibit all different types of speech disfluencies.”
One important consequence of this view is the fact that the moment of stuttering cannot entirely be defined based on the surface characteristics that a listener can observe (e.g., Moore & Perkins, 1990; Perkins, 1990). Instead, we must recognize that there is something special about the moment of stuttering that only the speaker can perceive. Thus, it appears that stuttered disfluencies involve a moment when the speaker knows exactly what he or she wants to say but, for some reason, is unable to say it.
4. How do I know if a child is really stuttering?
Disfluency is a normal part of speaking—everyone is disfluent, and everyone exhibits all different types of disfluencies at one time or another. Thus, differentiating stuttered disfluencies from other types of disfluencies is an important component of the diagnostic process.
Importantly, many children show an increase in disfluencies when they are learning to talk. This is due, in part, to the fact that speaking is a challenging task, and it is not surprising that children experience greater difficulty in performing this task while they are still learning how to formulate language and produce speech. Some of these disfluencies simply reflect typical development, but some may be indicative of stuttering.
The lack of a clear differentiation between nonstuttered and stuttered disfluencies can cause confusion about whether a child is exhibiting typical disfluencies or whether the child is actually stuttering. This, in turn, can lead to uncertainty about whether or not a child needs treatment. We can overcome many of these uncertainties by conducting a comprehensive evaluation that examines the child’s speech fluency—as well as other aspects of the child’s development that may contribute to the likelihood of continued stuttering.
5. Hey, wait – I thought we weren’t supposed to call it “stuttering!”
It is true that some clinicians are uncomfortable using “the S-word” with their clients. It is likely that at least some of this discomfort traces back to older theories of stuttering that suggested, directly or indirectly, that people should not “draw attention” to a child’s speaking difficulties (Johnson, 1941). For this reason, some clinicians and parents use euphemisms such as “nonfluency” to describe disruptions in a child’s speech. Others (particularly those who work with preschoolers) may not want to “label” a child as stuttering if his speech disruptions may eventually resolve into normal speech (dis)fluency.
We agree that clinicians do not want to draw negative or unwanted attention to a child’s speaking difficulties. As with all questions about the use of specific terminology to refer to people with communication disorders, it is important to keep in mind that it is not the word that matters so much as the intent with which the word is used. Also, as with all aspects of stuttering, there are differences between individuals in how they prefer to refer to their speech.
If a child, family member, or teacher uses the word stuttering, we do not encourage them to pick a different word. Rather than avoiding the word, we prefer to be straightforward with children about the name of their communication difficulty. We work to help them understand that the word stuttering is simply a term that is used to describe the interruptions in their speech. The more comfortable they can become with the term, the less likely they will be to react negatively when other people, such as teachers or peers, talk about their speech.
6. What if the child is aware of his stuttering?
Traditionally, researchers and clinicians feared negative consequences if a child were to become aware of stuttering. Thus, they went to great lengths to not talk about stuttering in front of the child in an attempt to prevent the child from becoming aware.
Today, we know that awareness of stuttering by young children is not as problematic as we once feared it to be. In fact, a growing body of research has shown that many young children are aware of stuttering—and some, acutely so (Boey et al., 2009; Ezrati-Vinacour, Platzky, & Yairi, 2001; Langevin, Packman, & Onslow, 2009, 2010; Vanryckeghem, Brutten, & Hernandez, 2005).
It is important to recognize that awareness, in and of itself, is not necessarily a bad thing. Awareness of stuttering gives parents and clinicians the opportunity to teach children about stuttering in an open, accepting, matter-of-fact manner. Rather than fearing awareness, we can use this opportunity to prevent the negative reactions that may be associated with more severe stuttering.
7. Why do young children start to stutter in the first place?
Throughout the history of our field, countless researchers and clinicians have endeavored to explain the cause(s) of stuttering (see Bloodstein, 1993; Bloodstein & Bernstein Ratner, 2008). Today, much research focuses on neurological differences in individuals who stutter. Put simply, the brains of people who stutter differ from those of people who do not stutter, and these differences are seen in both neural structure and function (e.g., Chang, 2014). These neurological differences likely arise from a complicated interaction between genetic inheritance (e.g., Kraft & Yairi, 2012; Yairi & Ambrose, 2013) and the child’s experiences or environment (e.g., Felsenfeld et al., 2000).
In other words, stuttering arises due to differences in the brain that appear to be affected by an interaction between genetic and environmental factors.
8. Okay, so stuttering is due to both genes (nature) and experience or environment (nurture). What specific aspects of the child’s genetic and environmental development are we interested in?
For the purposes of guiding our clinical decision-making process, we think of these factors as being loosely organized in terms of three key aspects of the child’s development, which include:
- language skills, including syntactic organization, lexical access, phonological encoding, and speech sound development (e.g., Bernstein Ratner, 1997)
- motor skills, including oral motor control, speaking and articulation rate, and coordination of movement (e.g., Riley & Riley, 1986)
- temperament, including the child’s emotional reactivity to his speaking difficulties and his ability to regulate any difficulties that arise (e.g., Jones, Choi, Conture, & Walden, 2015).
All of these factors are still developing at the age when stuttering starts, typically between the ages of about 2½ and 4 (Yairi & Ambrose, 1992b, 1999). During that time, the child is still learning how to combine words into sentences and to formulate words and sentences with increasing complexity (language skills), how to move and coordinate his articulators (motor skills), and how to react to the world around him (temperament).
It is not surprising, therefore, that we see some disruption in the child’s ability to plan what he or she wants to say, to produce it rapidly and precisely, and to respond to any difficulties that might arise in the process.
9. Does this mean that young children who stutter have a disorder in their language development, motor development, or temperament?
Current theories do not propose that a deficit in any one of these aspects of the child’s overall development is specifically to blame for stuttering. The child who stutters does not necessarily exhibit a disorder in language skills, motor skills, or temperament. Of course, some children who stutter do experience concomitant disorders in other aspects of their development (e.g., St. Louis & Hinzman, 1988), but this is not required in order for them to develop stuttering. Rather, it is the interaction among factors that appears to contribute to stuttering.
10. Many clinicians have noticed that children’s stuttering changes over time. Sometimes, they seem to be so fluent in the therapy room but then have more trouble on the playground. Why does stuttering vary so much?
One of the most important facts for clinicians and parents to recognize about stuttering is that it varies (e.g., Constantino, Leslie, Quesal, & Yaruss, 2016; Costello & Ingham, 1984; Yaruss, 1997b). We don’t fully understand the reasons for this variability. Children may go through periods, or episodes, of having increased difficulty with their speech that can last for days, weeks, or even months. Likewise, they can also go through periods of increased ease in speaking (along with a resulting increase in speech fluency) that can last for varying lengths of time. They may also stutter more or less because of how they think, feel, or react to different aspects of the speaking situation, such as the person they are talking to, the topic they are discussing, the activity they are doing, and more.
We must keep this variability in mind so we don’t fall into the trap of thinking that a child is not working hard enough if he or she stutters more in a given situation, or wondering if there’s something wrong just because stuttering severity has increased. Chances are that there is something about the situation that contributed to the increased severity, but trying to figure out what it is will not always be helpful. Sometimes, stuttering just varies.
11. Is it true that more boys stutter that girls?
Yes. Research has confirmed that boys are more likely to stutter than girls (see Yairi & Ambrose, 2005). In adults, the male-to-female ratio is approximately 3 or 4 to 1. In children, this ratio is closer to 2 to 1, suggesting that young girls who stutter are more likely to recover than boys.
12. Speaking of recovery…I’ve heard that a lot of children recover from stuttering entirely on their own. Is that true?
Research shows that at least 75% of young children who stutter will ultimately stop stuttering and go on to develop typically fluent speech—even without therapy (e.g., Andrews & Harris, 1964; Månsson, 2000; Reilly et al., 2013; Yairi & Ambrose, 2005). This recovery is often called “natural” or, historically, “spontaneous” recovery. Most natural recovery occurs within the first year after the onset of stuttering. Recovery can still occur 2, 3, or even 4 years post-onset, though the percentage of children who recover after this prolonged period of stuttering decreases with time.
Ultimately, not all preschoolers who stutter “grow out of it,” and some children do develop persistent or chronic stuttering. Therefore, we must be diligent in our assessment and treatment for this age group to reduce the likelihood that a child falls through the cracks and does not get needed treatment.
13. How do I know which children will recover and which children will continue to stutter?
Unfortunately, we are unable to predict with absolute certainty which young children will recover from early stuttering without intervention and which young children are at risk for continuing to stutter. Thus, appropriate early intervention for children who are at risk for continuing to stutter is critical if we are to give young children the greatest possible opportunity to overcome the challenges of stuttering.
14. If so many young children recover from stuttering, shouldn’t we “wait and see” if a child recovers before initiating therapy?
Remembering that awareness of stuttering is not necessarily a problem, we no longer have to fear the old warning that working with children who stutter will somehow “make them worse.” Thus, we feel that we should no longer follow the age-old advice to wait and see if a child will recover before initiating treatment. Our belief is that we can and should work with children who are at risk for continuing to stutter using methods that are based upon current literature, appropriate for each child, and guided by ongoing data collection. This is the best way to help young children who stutter overcome their speaking difficulties and have the greatest opportunity to develop typical speech fluency.
15. How do I decide which young children need treatment?
If at least 75% of preschool children who stutter will recover, the key question we need to ask in our diagnostic evaluations and in our interactions with parents is, “Which children are at risk for continuing to stutter?” Or put another way, “Which children will recover on their own, and which ones will benefit from speech therapy?”
Currently, this question has no definitive answer, but research has identified several potential risk factors that may indicate a greater need for intervention. No one of these factors completely determines whether a child will continue to stutter, but SLPs can consider a collection of risk factors when making decisions about whether to recommend therapy. Put simply, if the child is likely to continue stuttering, then it is appropriate to recommend therapy.
16. So…What are those risk factors?
A considerable body of research has sought to identify risk factors that indicate whether a child is more likely to continue stuttering (and therefore benefit from therapy). Much of what we know in this area is based on the work of Yairi and colleagues (see Yairi & Ambrose, 2005), Conture and colleagues (see Conture, 2001), and more recently, Smith, Weber and their colleagues (e.g., Spencer & Weber-Fox, 2014; Usler & Weber-Fox, 2014, Usler, Smith, & Weber, 2017).
A full consideration of the risk factors is beyond the scope of this brief article; however, key risk factors include characteristics such as whether the child has a family history of stuttering; the length of time the child has been stuttering; the child’s speech, language, and oral-motor abilities; the child’s temperament; and more. The more risk factors a child exhibits, the more likely he or she is to continue stuttering—and the more appropriate it is to recommend treatment.
17. Are those the only factors that contribute to a decision to recommend treatment?
No. Although we base our recommendation for treatment primarily on our assessment of risk factors, we also take into account other characteristics and experiences that the child and family may have. These additional factors help us focus our efforts on providing treatment for those children and families who are most in need of support, even if it is possible that some children might recover on their own.
18. Why would you recommend therapy for children who might ultimately recover on their own? Isn’t it better to just wait it out so you’re not wasting resources that may be needed for other children?
This is an important and valid question. We do not want to over-recommend therapy, just as we do not want to under-recommend therapy. Still, we feel that the consequences of over-recommending therapy and treating children who might have recovered on their own are far less worrying than missing some children who could benefit from our services.
Moreover, research has shown that treating stuttering can actually help children develop typical speech fluency more quickly than waiting for natural recovery to take place (e.g., Jones et al., 2005). If we can help the child recover more quickly, or if we can help the child and family worry less and reduce negative impact during the period of time while the child is stuttering, then treatment (adjusted to the needs of the individual child and his family) seems to us to be an appropriate course of action for those children who appear to be at risk.
19. Let’s get down to some specifics: What is involved in a complete diagnostic evaluation of preschool child?
The goal of our diagnostic evaluation is to collect the information we need in order to assess the child’s risk for continuing to stutter. Thus, the evaluation will include components that directly relate to the set of risk factors listed above. We conduct interviews with parents or other caregivers to learn about factors such as the child’s family history of stuttering, time since onset of stuttering, and reactions to stuttering. We observe the child’s speech fluency and reactions to stuttering. And, we directly test the child’s speech and language development, temperament, and other characteristics and skills. (For more details on all of these aspects of the diagnostic process, including intake forms and assessment worksheets, see Yaruss & Reardon-Reeves, 2017.)
Only by conducting a thorough evaluation will we be able to make a sound judgment about a child’s risk for continuing to stutter. Even then, our predictions are just predictions. We cannot (yet) tell for certain which children will indeed continue to stutter without intervention. When recommending therapy, it is our practice to err on the side of caution: we recommend treatment when a child appears to be at risk for continuing to stutter or when the child or family is sufficiently concerned about stuttering that such concern might affect the child’s communication abilities. In this fashion, we are able to help those families who most need help, while monitoring those children who are most likely to recover.
20. Last question (for now): What is the most important thing for speech-language pathologists to know about stuttering in young children?
Oh, that’s an easy one. The most important thing that we want clinicians to know is that they can provide effective intervention for children who stutter and their families. The first step is to learn more about the condition, then build on that knowledge for each individual child and family by conducting comprehensive evaluations to determine which children are most in need of intervention. There is still much to learn about the treatment itself, but the good news is that research supports the idea that early treatment can help to prevent children from developing chronic stuttering!