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Stuttering in Young Children: When Is It Time to
Intervene?
by Valerie Johnston, MS, CCC-SLP
Most of the one-half million adults in the U.S. who stutter report that
their stuttering began in early childhood (Bloodstein, 1981). Paradoxically,
when parents express concern that their toddlers are beginning to stutter, they
are usually told to ignore the problem. This advice is given because disfluency
(interruptions in the smooth, easy flow of speech) is a “normal” phase of
speech and language development. Indeed, many children experience problems with
speaking fluently (smoothly and easily) between the ages of 2 and 5. Most of
these children do resolve the problem without any special help. For them, it
seems that the rapid growth of speech and language skills temporarily
“overloads” their linguistic systems. As they mature, these children’s systems
adjust to the motoric and cognitive demands placed upon them. Fluency then
returns. For other children, however, early disfluency is the first phase of a
problem that follows them into adulthood.
When, then, should concerned parents be told not to worry? How long
should a parent “wait and see” if their child will develop normally fluent
speech? How can we reliably differentiate normal disfluency and beginning
stuttering in young children? These questions have been the subject of much
research.
Speech fluency (and disfluency) can best be described as points on a
continuum. Research has revealed that along this continuum, certain types of
speech interruptions are more typical of “normal” speakers, while other types
are more typical of abnormally disfluent speakers and stutterers. Phrase
repetitions, revisions, interjections (“well”, “uh”, “let’s see”) and
incomplete sentences are the kinds of disfluencies experienced most often by
people who do not stutter. Conversely, disfluencies such as part-word
repetitions (b-b-boat), audible prolongations (“sssssun”) and silent
prolongations (holding an articulatory posture with no sound coming out) are
more typical of stutterers. Despite these differences, stutterers and
nonstutterers display behaviors from both ends of the spectrum. This is
especially true of young children.
How, then, can we reliably identify the young stutterer? While there is
no single trait that can
differentiate the normally disfluent child from the young stutterer, there are patterns of speech behaviors and other
risk factors for continued stuttering which can be used to aid in the
identification of young stutterers.
Martin Adams (1977) outlined a procedure for differentiating the
normally disfluent child from the young stutterer. This protocol is based on
speech characteristics and allows the speech-language pathologist to analyze
the types of disfluencies the child is exhibiting along five different
parameters for which Adams has collected data. (See chart: “Comparison of Disfluencies”.)
Analysis of a child’s speech along these parameters allows us to identify
patterns or clusters of traits. These clusters can be used to place a child
into one of the following three groups:
·
normally disfluent
speakers
·
beginning stutterers
·
borderline stutterers
|
Comparison of Disfluencies |
|
|
Speech Characteristics More Typical of the Normally Disfluent Child |
Speech Characteristics More Typical of the Beginning Stutterer |
|
1. 9 or fewer disfluencies per 100 words (includes all types) |
1. at least 10 disfluencies per 100 words (includes all types) |
|
2. whole-word and phrase repetitions, interjections and revisions are the predominant types |
2. part-word repetitions, audible and silent prolongations and broken words are the predominant types |
|
3. 2 or fewer unit repetitions per part-word repetition ("b-b-ball") |
3. at least 3 unit repetitions per part-word repetition ("b-b-b-ball") |
|
4. schwa vowel ("uh") not present, ("bee-bee-beet" not "buh-buh-beet") |
4. schwa vowel ("uh") present, ("buh-buh-beet" not "bee-bee-beet") |
|
5. little if any difficulty starting and/or sustaining voicing or air flow for speech; interruptions are generally brief and effortless |
5. frequent difficulty in starting and/or sustaining air flow or voicing for speech; interruptions are generally more forced and of longer duration |
Following Adams’ guidelines, the child who demonstrates four or five of
the speech characteristics of the normally disfluent child is probably not a
stutterer. On the other hand, the child who demonstrates four or five features
of the beginning stutterer, is most likely, a beginning stutterer. The child
who exhibits two or three features from each category is considered a
borderline stutterer.
Appropriate treatment varies according to which category most
accurately describes the child’s speech and risk factors that have an impact on
when a young child who is identified as a beginning stutter should receive
treatment (Zebrowski, 1997). These risk factors include:
·
the age of the child
when the stuttering began (more likely to recover without treatment if it began
before 3 years of age)
·
how long the child has
been stuttering (more likely to recover without treatment if it began less than
12 months ago)
·
the course of
stutter-like disfluencies over time (more likely to recover without treatment
if stutter-like disfluencies decrease over time, rather than remain the same or
increase)
·
the sex of the child
(more likely to recover without treatment if the child is a girl)
·
family history of
stuttering (more likely to recover without treatment if there few or no
relatives with persistent stuttering or if relatives who once stuttered have
recovered)
·
the presence of other
speech and language disorders (more likely to recover without treatment if
there are no other speech or language disorders present)
·
negative reactions to
the disfluencies by either the child or the parents (more likely to recover
without treatment if there are no negative reactions present)
·
self-expectations
(more likely to recover without treatment if the child has reasonable
self-expectations)
At Overton, we begin our diagnosis by using the speech characteristics
to place the child in one of the three groups (normally disfluent speakers,
borderline stutterers, beginning stutterers). How intervention proceeds from
this point depends on the specific speech characteristics that the child
demonstrates, any risk factors that are present, and the parents’ desires
regarding treatment for their child after all the information has been
discussed.
All parents who are concerned about their child’s fluency are counseled
regarding the normal types of speech interruptions young children generally
experience. This information is usually all that is needed by the parents of a
child who is normally disfluent.
For parents of children who fall in the borderline group and have just
a few risk factors, strategies for increasing fluency are discussed and modeled
in the conference following the evaluation. In addition, it is recommended that
the child’s fluency be reevaluated in three to six months or anytime the
problem becomes more pronounced.
For children in the beginning stutter group and the borderline group
that have many risk factors, the types of disfluencies the child is
experiencing and the child’s risk factors for continued stuttering without
treatment are discussed in detail with the parents. Based on this discussion, a
decision is made about whether to begin direct treatment immediately. If the
decision is to defer treatment, the parents are given strategies to improve
their child’s fluency. These strategies are modeled and practiced with the
parents and, if necessary, additional sessions are scheduled so that the
parents can master the techniques and feel comfortable using them. It is
recommended that the child’s fluency be reevaluated monthly in order to
determine if the stutter-like disfluencies are increasing, staying the same, or
decreasing. In addition, these monthly rechecks allow the clinician to observe
whether any negative reactions, such as frustration or avoidance, have
developed. After each of these monthly evaluations, the results are discussed
with the parents and the decision about whether to begin direct treatment
immediately is made again. Depending on how long the stuttering has been
present, this cycle can be repeated many times. With each repetition, more
information should be available to aid in making the decision about whether to
begin treatment. This information comes from the dynamic risk factors, such as
the change in the frequency of the stutter-like disfluencies, the length of
time the stuttering has been present and whether or not any negative reactions
have developed.
Treatment for young stutterers is of paramount importance. Research has
shown that stutterers who receive appropriate treatment at an early age (before
5) are much more likely to become normally fluent speakers than are older
children and adults (Ingham and Andrews, 1973). This does not mean that
treatment has to be initiated immediately after the stuttering begins, but it
does mean that an evaluation by a qualified professional should be sought soon
after a parent becomes concerned about their child’s fluency.
The blanket advice “ignore it, he’ll outgrow it” comes from a time when
professionals were unable to reliably differentiate the young stutterer from
the normally disfluent child. That time has passed. If, as current research
indicates, early identification is the key to successful treatment of
stuttering, shouldn’t speech behaviors and other risk factors rather than age
be the criterion for seeking professional help? With this in mind, today the
best advice for a parent concerned about a child’s fluency is to seek an
evaluation by a qualified speech-language pathologist. As more young stutterers
receive appropriate and early intervention, we can expect that percentage of
the adult population which stutters will decline. We have the tools to
effectively identify and treat stuttering in early childhood. Why not use them?
References:
Adams, M., A Clinical Strategy for Differentiating the Normally Disfluent Child and the Incipient Stutterer, Journal of Fluency Disorders, 2, 141-148 (1977).
Bloodstein, O., A Handbook on Stuttering, Chicago: The National Easter Seal Society, 1981.
Ingham, R. and Andrews, G., Behavior
Therapy and Stuttering: A Review, Journal of Speech and Hearing
Disorders, 38, 405-441 (1973).
Zebrowski, P., Assisting Young Children Who Stutter and Their Families: Defining the
Role of the Speech-Language Pathologist, American Journal of Speech-Language Pathology, 6, 19-28 (1997).
If you have questions or need more information you can contact us at:
Overton
Speech & Language Center, Inc.
4763 Barwick Drive, Suite 103
Fort Worth, TX 76132
(817) 294-8408
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