Stuttering In Children And Adolescents, Part I
By Karin B. Wexler, Ph.D.
Emergency and Office Pediatrics, Volume 9, Number 3, 1996, p. 73-76.
Introduction
Pediatricians often have to make determinations about dysfluent children. Does this child have a fluency problem requiring a referral for a consultation? Is monitoring him or her enough? Should the parents' minds just be put at ease? When should he be referred? Is any speech-language pathologist qualified to work with dysfluency? To help answer such questions, the objective of this report is to provide current information about dysfluency in children.
How the pediatrician responds to observations that a specific child or adolescent is dysfluent may profoundly affect that child's future, socially, academically, and professionally. Some children go through a period of normal developmental dysfluency. For other children, untreated stuttering will become chronic and exacerbated over the years, often curtailing their lives. Even among famous people who stutter, being unaffected is rare, at best. Also of concern are the children who, if untreated, eventually will outgrow the stuttering itself, but whose years of stuttering and reactions to it will thwart their social and emotional development and lower their self-esteem and aspiration levels.
Research-based information is presented, where available. Where research data are not yet available, information is presented based on the author's 25 years of clinical experience and academic specialization in fluency disorders.
Normal Developmental Dysfluency
Normal developmental dysfluencies in the speech of preschoolers include revisions ("Let me/I want to do it!"), interjections ("uhm", "you know"), and phrase repetitions ("But I - but I was."). Such primarily language-based hesitations are more frequent than speech-motor type dysfluencies. Sound- and syllable-repetitions are among the least frequent dysfluency types, with usually fewer than two per hundred words. The syllable is usually repeated only once or twice, and is easy and free of tension. Other types of dysfluency are only occasional. The level of dysfluency is consistently low (1-4). The child shows no awareness or reactions to these dysfluencies.
Symptoms of Stuttering
Symptoms of stuttering include dysfluency characteristics and reactions to stuttering.
Dysfluency Characteristics of Stuttering
Repetitions are only one of the types of dysfluency in stuttering. Someone may stutter without having any repetitions. He or she may even have no discernible dysfluencies at all, hiding them through crippling avoidance strategies. When a person musters the courage to admit to stuttering, to being bothered by it, and to wanting help, he or she should never be met by a denial of the problem experienced, even if not appearing dysfluent. Dysfluency characteristics can be oral/articulatory, laryngeal/phonatory, and respiratory, and may be described perceptually and physiologically. Dysfluencies may occur singly or cluster on the same or adjacent words. Their characteristics include, but are not limited to, the following.
What the child or adolescent experiences the most vividly, tactile-kinesthetically, when stuttering may be that she "can't get the words out." She may feel "stuck", "paralyzed" or "frozen" in the mouth or in the throat, sensing a loss of control of her speech mechanism.
On the oral level, the child or adolescent may repeat one or more units of sounds, parts of words, or whole words ("Ca-ca-can"; "Can-can"), or phrases ("Can I- Can I"). The repetitions may be easy or hard. Oral structures may appear forced together (articulatory fixations or blocks), with no sound coming out at all or only after a tense pause. Excessive articulatory and/or air pressure may contribute to consonants having an excessively explosive quality ("B!!!ut"). Tension may be strong enough to cause tremors. Prolongations of sounds are common ("Mmmommy").
On the laryngeal level, the child or adolescent may be unable to start or maintain voicing. There may be blocks through apparent fixation of the vocal cords in closed position, or in open position. No sound may come out, with a tense inappropriate pause. Conversely, a rush of unvoiced air may be heard when voice is expected ("hhhOpen"). Laryngeal spasms are implicated for the phonatory symptoms. Research on adults indicates that during stuttering there is decreased reciprocity between agonist and antagonist muscles of the larynx and excessively high levels of activity of intrinsic laryngeal muscles (5). The heterogeneity seen in other findings on stutterers has been found also in electromyogram (EMG) activation patterns in adults (6).
On the respiratory level, running out of air (speaking on expiratory reserve volume), gasping for air, or forcing out air is common. Excessive air pressure may add explosiveness or loudness to speech.
Revisions of phrases and incomplete phrases may occur to cope with physiological difficulty ("I want the /Forget it!").
Reactions to Stuttering
Reactions to stuttering are by far more significant than the dysfluencies in diagnosing the existence of a problem, its severity, and its prognosis.
Reactions to stuttering can exacerbate the dysfluency itself, and worse, become extremely handicapping (usually more so than the dysfluency itself). Out of feelings of embarrassment, and often overpowering shame and fear, many try to hide any dysfluency and the fact that they stutter through an array of agonizing and unreliable avoidance tactics. They may do this at great personal cost, living restricted lives of lost opportunities and devoid of "freedom of speech."
In the early stages of clinical stuttering, the child may show no reactions whatsoever. Increasingly, however, stuttering typically becomes more than just broken words. Reactions to stuttering may be behavioral, affective and/or cognitive (i.e. symptomatic thought patterns).
Behavioral reactions to dysfluency include signs of struggle or tension in speech and in the speech system (e.g., pitch or loudness rises); autonomic nervous system responses (e.g., heart palpitations, blushing, or perspiration); facial grimacing or contortions, or eye squinting; generalized body tension, or bulging muscles or veins; and counterproductive coping mechanisms to get out of stuttering (e.g., mouth opening thrusts, head thrusts, pulling on the tongue, finger tapping, arm swinging, or foot stamping); and crying. Dysfluency hiding and speech avoidance tricks tend to increase with age, but may begin by age 2. The person may lose eye contact, cover his mouth, give up or shorten his speech attempt ("I can't!"), or switch words or topics. He may avoid verbal interactions (e.g., phone calls, class participation, and presentations, reading aloud, or asking for a date). He may have someone speak for him, withdraw socially, and only take courses and choose a profession where little or no speaking is expected. Life may become focused on stuttering and thus distorted. Aspiration levels often become reduced, with the child not developing his potential in life.
Affective reactions may start with frustration and include feelings of helplessness, anxiety, fear, panic, embarrassment, shame, guilt, humiliation, anger, self-hate, bitterness, inferiority, hopelessness, or despair. Cognitive symptoms may include awareness of difficulty beyond the child's capacity, often with generalization of negative thoughts: "I can't talk!" "My mouth doesn't work!" "I can't get the words out, help me!" These are common quotes even from 2-year-olds. The child's or adolescent's self-esteem may be reduced. He may believe that speaking has to be hard and unpleasant, or may feel stupid or crazy. He may spend inordinate time thinking about stuttering and make decisions influenced by the problem.
Parents' reactions may aggravate the child's own reactions, as well as the dysfluency itself.
Severity of Stuttering
The impact of stuttering on a person's life is the most meaningful measure of stuttering severity. Determining the disorder's severity must include separate determinations of the speech-motor symptoms and the reactions. The severity of these two often differ greatly, in either direction. Looking at only dysfluency counts for severity judgements is clearly not sufficient.
Epidemiology of Stuttering
The incidence and prevalence of stuttering are underestimated among the general public, probably in part due to lack of awareness of its full symptomatology, and in part due to lack of openness about it. Life time incidence is just under 5%. The prevalence of stuttering is approximately 1%. The onset of stuttering occurs at any age from the beginning of speech, usually in the early years, to about age 9; in a few instances it starts in adolescence or adulthood. Probability of recovery decreases sharply with age, stuttering becoming chronic for many. The sex ratio for stuttering is 3:1 (boys to girls) (3).
Developmental changes in stuttering include increased and intensified struggle, forcing, tensions, and reactions of all kinds, such as fear, stuttering expectancy, and avoidance, and a self-concept as a stutterer. (3)
Other stutterer-nonstutterer group differences (although not characteristic of all) suggested by research involve cerebral dominance for language and auditory processing, sensory-motor function, fluent speech differences, and increased prevalence of phonological/articulatory and language disorders. (7).
Etiology of stuttering
Research at Yale University suggests a major genetic basis in stuttering, organic factors interacting with environmental factors in complex ways (8). In children with an apparent organic predisposition for fluency breakdown (with or without family history of stuttering), environmental and developmental factors may precipitate, exacerbate, and maintain a stuttering problem. (9) Under stress, the finely timed coordination of the more than 100 muscles of the speech system appears to fail in people who stutter. In spite of their neuromuscular vulnerability for speech system breakdown, they can typically speak fluently under conditions of no stress and conditions that facilitate coordination of the speech muscles. An overload in terms of communicative stress (speech rate, interruptions, excessive language demands etc.), excitement, fear of stuttering or anticipation of speech difficulty, or other environmental stressors, appear to trigger and exacerbate dysfluency in young children with a speech system vulnerable to breakdown (7, 10). Although the occurrence of stuttering is sometimes predictable, much of it is unpredictable (like the occurrence of epileptic seizures). Of twins reared apart, identical twins have higher concordance of stuttering than fraternal twins (11). Conditioning and other learning factors appear to exacerbate and maintain the problem. However, mimicking seems rarely to be a factor in the onset of stuttering.
There appears to be no empirical evidence supporting the old theories that stuttering is an attempt to satisfy an unconscious neurotic need. It is widely believed today that the emotional components of the stuttering problem, which can be so strong and pervasive by adulthood, generally are a result rather than the cause of the dysfluency.
Other Fluency Disorders
Other fluency disorders include cluttering (12) and acquired neurogenic dysfluency (7). Similar to stuttering, although not fluency disorders, are spasmodic dysphonia and Tourette's syndrome.
Thresholds for Action
No longer can professionals say "Don't worry, he'll outgrow it" without the symptomatology of stuttering having been thoroughly ruled out. Those children whose stuttering goes undiagnosed and untreated pay a very high price for such errors, often paying for them every day of their lives. Clinical stuttering is not normal at any age in childhood. An early referral to a fluency disorders specialist can rule out a problem requiring immediate attention and allow the child who does have a problem the best possible prognosis, as well as decrease personal and financial costs for that child.
With stuttering, as with strep throat, there is no definite clinical marker to indicate prognosis for an individual child, requiring intervention on the side of caution. Review by the pediatrician of a taped sample from home may make the need for a referral obvious. However, if symptomatology of stuttering has not been fully ruled out by the pediatrician, a fluency consultation is the only safe alternative.
With expert and early intervention, prognosis for the stuttering child is maximized. Parts II and III of this short course will show how fluency evaluation and therapy for the child or adolescent must be a positive experience, both in process and results.
There is cause for alarm and immediate referral to a fluency specialist when
- The child shows any reactions to his dysfluency (no matter how young the child, no matter how recent the onset of dysfluency, no matter what frequency or type of dysfluency, and no matter how much the dysfluency comes and goes).
- There is physical struggle to get words out.
- Frequency of dysfluency is excessive at times (even with complete fluency periods or periods of lower levels of dysfluency).
- There is strong concern in parents about possible stuttering (regardless of apparent level of dysfluency).
There is a need for monitoring when the child is using a fair (not excessive) amount of easy repetitions and
- There is a family history of stuttering.
- The child was a late speaker and/or has a language or a phonological/articulation (speech sound) problem.
- Language development is advanced in comparison to oral-motor skills.
- The child shows signs of signs of neurological abnormalities, (e.g., learning disabilities, attention deficit disorder, drooling, or atypical laterality).
- The child's personality makes him vulnerable to reactions to dysfluency, being perfectionistic, sensitive, shy, or unassertive.
There is no need for concern about dysfluency when the child exhibits only normal developmental dysfluency.
The Type of Professional to Whom to Refer
Stuttering is a speech disorder, with neuromuscular symptoms that respond to speech therapy. The type of professional to whom to refer is therefore a speech-language pathologist (SLP). However, at this point, the minimal credentials for the profession do not require a single course on stuttering or any clinical experience with it (i.e., certification by the American Speech-Language-Hearing Association [ASHA] and a state licence). The required expertise in this area cannot be assumed, but requires careful inquiry. Specialization in fluency disorders is the recommended qualification for an SLP for any dysfluent child. At a minimum, treatment by an SLP with a fluency disorders specialist in supervising or consulting capacity must be sought. SLPs in general practice are increasingly referring patients to fluency disorders specialists, the way pediatricians refer patients to neurosurgeons. Specific requirements and a formal mentoring program for fluency disorders specialists are being developed within ASHA. In addition, the scope of any prospective stuttering evaluation and therapy must be explored. The official guidelines of the national association for practice in stuttering treatment (13) state that "Stuttering treatments that do not address the complete problem in whatever complexity it presents are not within the guidelines of good practice"(p. 27).
Fluency disorders specialists may be located through the Stuttering Foundation of America, ASHA, the National Stuttering Project, Speak Easy International, and university programs.
References
1. Wexler KB. Developmental disfluency in 2-, 4-, and 6-year-old boys in neutral and stress situations. J Speech Hearing Res 25:229-234, 1982.
2. Wexler KB, Mysak ED. Disfluency characteristics of 2-, 4-, and 6-year-old males. J Fluency Dis 7:37-46, 1982.
3. Bloodstein O. A handbook on stuttering. Easter Seals, Chicago, 1987.
4. Gregory HH, Hill D. Differential evaluation-differential therapy for stuttering children. In: Curlee RE (ed). Stuttering and related disorders of fluency. Thieme, New York, 1993.
5. Freeman FJ, Ushijima T. Laryngeal muscle activity during stuttering. J Speech Hearing Res 21:538-562, 1978.
6. Smith A, Denny M, Shaffer L, Kelly E, Hirano M. Activity of intrinsic laryngeal muscles in fluent and disfluent speech. J Speech Hearing Res 39:329-348, 1996.
7. Bloodstein O. Stuttering: The search for a cause and cure. Allyn and Bacon, Needham Heights, 1993.
8. Kidd KK. Recent progress on the genetics of stuttering. In: Ludlow C, Cooper J (eds). Genetic aspects of speech and language. Academic Press, New York, 1983.
9. Conture EG. Stuttering. Prentice Hall, Englewood Cliffs, 1990.
10. Starkweather CW, Gottwald SR, Halfond MM. Stuttering prevention. Prentice Hall, Englewood Cliffs, 1990.
11. Howie PM. Concordance for stuttering in monozygotic and dizygotic twin pairs. J Speech Hearing Res 24:317-321, 1981.
12. Daly DA. Cluttering: Another fluency syndrome. In: Curlee RF (ed). Stuttering and related disorders of fluency. Thieme, New York, 1993.
13. American Speech-Language-Hearing Association. Guidelines for practice in stuttering treatment. ASHA 37, Suppl 14:26-35, 1995.
added with permission, September 23, 1997
