[Overton]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 me at:

Overton Speech & Language Center, Inc.
Fort Worth, TX
(817) 294-8408

info@overtonspeech.net

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Last revised: June 8, 2003