How Parents and Professionals Can Help the Stuttering Child

by Richard Shine

The following article first appeared in North Carolina Medical Journal for Doctors and Their Patients, The Official Journal of the North Carolina Medical Society, December 1983, Volume 44, No. 12

What Is Stuttering?

The best way to understand stuttering is to first know what it is not. Stuttering is not a learned behavior, a nervous condition, a psychological problem, an emotional problem, nor is it a problem caused by parental pressures and environmental stress. Stuttering is not caused by the reaction of parents to a child's nonstuttering dysfluencies such as pauses or hesitations within a sentence or before beginning to talk; interjections such as "uh," "um," "like uh," "you know," etc.; revisions of words like, "I rode the hor- pony"; phrase repetitions, "we had a . pause . - . We had a good time"; or incomplete phrases, "Yesterday we took the - pause . . . Yesterday we went to the fair."

There has never been any research or clinical evidence to support the historical belief that stuttering is a problem caused by psychoses, neuroses, or nervousness, but there are children who exhibit these problems and who also stutter. These other problems do not cause the stuttering but they can complicate the steps to alleviate the stuttering.

There has never been one shred of evidence to support the assumption and long-accepted theory that parents cause stuttering by pressuring the child to talk correctly, by labeling stuttering (erroneously referred to by experts as "normal nonfluency"), or by reacting to a child's way of speaking before he becomes fluent in the language. In fact, the literature reveals that directing the child to change the way he talks (slow down, take it easy, stop and try again) helps him overcame the stuttering.

Stuttering is the whole-word repetition (I-I-I, he-he-he), part-word repetition (pu-pu-part, wu-wu-went), prolongation (SSSSSSunday, wwwwwwwe), and struggle behavior (any, stuttering that is. primarily characterized by tension, i.e., increased loudness and/or pitch of the voice, facial grimaces, head jerking, associated body gestures, etc.) exhibited by an individual when talking. The order in which the four types of stuttering are listed above represents a general hierarchy of severity from mild to severe and the frequency of each type helps determine the need for direct professional fluency training. For instance, if the primary type of stuttering is whole-word repetitions, generally the problem will be rated as mild and may be overcome by parental intervention. If the primary types include part-word repetitions and prolongations, the general severity rating will be moderate and the need for direct fluency training will depend to a great degree on the frequency of stuttering and the concerns of the parents and the child about the problem. If struggle behaviors are predominant, the problem will be rated as severe and immediate direct fluency training will almost always be recommended.

Stuttering is a coordinative disorder involving the child's lack of ability to coordinate the muscles used in speaking; that is, the muscles of respiration (the speech breathing system), phonation (the larynx/voice box), and articulation (the tongue, lips, jaw. palate). The stuttering child's lack of coordination can be likened to that of the child who is clumsy in running, throwing or other motor activities except that the child who stutters is clumsy in controlling the muscles of the speaking mechanism.

It's not surprising that the child with coordination problems of the speaking mechanism cannot maintain conversational rates of speaking without a breakdown (stuttering) if we realize that during conversation we produce approximately 170 words per minute, with each word containing an average of about 3 or 4 sounds, or 10 sounds per second. To help understand rate-of-speaking, time yourself for 30 seconds while saying out loud "one thousand one," a phrase containing 11 sounds that is typically used to count seconds. If a child becomes excited and attempts to speak more rapidly as well as use the muscular system more vigorously, it is highly probable that the breakdowns (stuttering) will become more frequent.

Stuttering is a universal problem; that is, it exists in all cultures and all languages of the world, and no matter what language the child (age 2 to about 9 years) speaks -- English, Spanish, German, or Dutch -- the following identical "types" of stuttering behaviors will be exhibited: whole-word repetitions, part-word repetitions, prolongations, and struggle behaviors. Of course the frequency of each type and the nature of the struggle behaviors will differ from child to child and from time to time

Stuttering is a problem of childhood which is significantly greater in males than females (the ratio is approximately 3 to 1 with findings as high as 8 to 1) Almost all stuttering begins between the ages of 2 and 9 years with the majority beginning between 3 and 5 years of age. Some children do overcome their stuttering as a result of maturation, but most of the 40 to 50% reported to recover from childhood stuttering do so as a result of parents' and others' suggestions for the child to change the way he talks (Slow down take it easy, stop and try again. . . .)

Parents Are Valid Judges of Stuttering

In my 16 years of experience in working with young children who stutter, I have found that parents rarely if ever misdiagnose stuttering and they validly estimate its rate and severity. If parents report that their child is stuttering and that it is severe enough to cause communication problems, we can be assured that they are correct and that careful consideration and appropriate advice needs to be provided. The professional is guessing when he dismisses the parents' concern by explaining that it is merely a stage the child is going through (data indicate he will be correct by chance about 40 to 50% of the time).

What To Do When Your Child Begins Stuttering

Do not read the sections on stuttering in current baby books or child development texts and do be extremeiy critical of articles in popular magazines, newspapers, and particularly tabloids. Critically evaluate anything written by speech clinicians prior to the 1980's and much of what is still being written.

Do have confidence in your own evaluation of whether your child has a stuttering problem and do not hesitate to seek assistance, but be aware that inappropriate or incorrect advice may be given by speech clinicians, psychologists, physicians, and other professionals who have not kept up with recent developments.

What You Should Know about Professional Advice

Traditionally, advice to parents has been both inappropriate and incorrect. Inappropriate advice includes suggestions that would be beneficial in raising any child (i.e., providing opportunities for enjoyable and rewarding speaking experiences; developing and maintaining the health of the child including diet, exercise, rest, and sleep; developing other interests, hobbies, and abilities; etc.) but are not specific to the needs of the stuttering child. Advice may involve an attempt to deceive the child by telling him, "It's all right because everybody has troubie talking and it'll be okay." If the child had a cut finger we wouldn't say, "It's all right, everybody cuts his finger and it'll be okay"; rather, we would help by bandaging the finger or seeking medical attention and giving advice to the child an how to avoid future cut fingers.

A source of incorrect advice has been the assumption that stuttering is to be expected or is common in young children and that it is merely a stage of normal development that most children go through. This is not true! It is estimated that less than 20% of all children ever stutter, but most children, including those who do stutter, do exhibit nonstuttering disfluencies. Stuttering disfluencies, being different from nonsluttering disfluencies, are easily identified by parents and other lay persons but, because of bias, are often misdiagnosed as normal developmental disfluencies by professionals. If it were merely a stage of normal development that children go through, there would not be an estimated 2 million Americans who never overcome the "normal" stage and thus continue to stutter.

Other incorrect advice includes suggestions to refrain from doing anything that might cause the child to become aware of the problem and thus begin to fear or avoid talking. Again, my experience has been that children, even the 3-year old, know when they talk different from their peers. Unfortunately when the problem is not handled directly by the parents, the child may begin to think that the problem is so bad even the parents won't talk about it. The parents are mistakenly advised to listen quietly to what their child has to say and to wait patiently even if the child is struggling severely to say a word. The parents are told never to help the child by filling in words he is struggling to say even though experience reveals that saying the word for the child enables him to simply repeat the word and to continue with what was being said without repeating the word. We now know that we should not let the child continue to struggle but should eliminate the struggling by providing the word. Finally, it is incorrect to imply or to blatantly state that parents cause stuttering or that the environment causes the problem.

Examples of inappropriate/incorrect advice, regardless of the professional who offers the advice, include: "Don't worry about it, Mom, it's just a stage that most kids go through"; "It's just normal nonfluency and you really need to be careful not to call attention to it or to cause your child concern by reacting or by trying to help him correct the problem"; "Just ignore the stuttering and try to find out what things in the child's environment cause it, particularly what things you (Mom and/or Dad) are doing"; "It's an emotional or psychological problem because he has a lot of trouble only when he's excited."

Why Does My Child Stutter?

In the past (the early t960s) we used to think that children stuttered primarily because someone, usually a mother, was putting pressure on the child to talk correctly or she was correcting or calling attention to the child's normal developmental nonstuttering disfluencies. Since then we have discovered that parents do not cause stuttering (parents cause children).

A child stutters because he/she is different: different like the child who has a reading problem or a math problem or the child who has to wear glasses. If your child had a reading or math problem or needed glasses, would you feel that you did something to cause the problem? No, the reason for the problem is that the child is different; that is, the child has a weakness which, however, could be a hereditary problem.

The reason your child stutters is because he has a coordination problem. In a way it is like the kid who is clumsy and cannnot control or coordinate his muscles to run well or throw well - except that your child is clumsy in controlling the muscles used for talking. Our task is to teach the child to talk in a different way to compensate for the discoordination and to speak in a normally fluent manner. Once the child establishes fluency his speech will not be identifiably different from that of his peers and in later life he will probably not remember his stuttering.

What You Can Do to Help

The best advice is to do what works as long as it is reasonable. The child should never.be punished for stuttering. Parents, particularly mothers, have an intuitive sense about how to help their child overcome problems including stuttering, and thus it can be beneficial to know what things you have done that help your child and continue those that improve fluency. If the suggestions upset your child or do not seem to help, explore other possibilities of parental intervention.

Specific advice includes having the parents talk more slowly and quietly to their child. We suggest that they talk openly about the problem and/or about the way the child talks; they can "talk about talking," about easy talking, quiet talking, slow talking, or whatever they feel might be beneficial. If the child is having a particularly bad day, they can engage him in activities requiring little talking or short, simple responses. The parent should not be afraid to experiment and should try all kinds of things, using those which are most effective and informing the speech clinician about all successes and failures.

The parents are not given a list of do's and don'ts but are trained to identify their child's stuttered words and develop procedures that are effective do's and don'ts unique to their child's environment. Determining appropriate management procedures for stuttering is much like determining disciplinary procedures for your child; if one thing doesn't work we try something else. Generally it is apparent or quickly becomes apparent that what works for one child in a family does not work with the other child or children. And, of course, with some children nothing really seems to be effective and we may need to seek assistance. We should realize that our effectiveness may depend an awful lot on the general makeup or personality of the child.

One Word of Caution

As with anything we do, we shouldn't overdo it. If something is said to the child every time he opens his mouth, it may become upsetting and not be beneficial - even though it won't be harmful or cause the stuttering to worsen. It will do no good to stop the child, particularly while he is speaking fluently, and ask him to repeat a word on which he stuttered. Primarily we should follow the rule of giving suggestions only when the child is having obvious difficulty communicating because of the frequency and particularly the severity of the stuttering. Same parents have developed effective hand signals or gestures to remind the child when he begins talking too fast, too loud, too hard, or in a way that results in discoordination and stuttering.

When to Refer: Guidelines for Parents and Professionals

The best guideline for the professional to follow is to listen to the concerns of the mother. If the mother states that the child is stuttering and it's a problem for either the child or the parent, do not hesitate to refer them to a speech clinician. It's rare that parents cannot easily distinguish between normal developmental nonstuttering disfluencies and stuttering disfluencies or determine whether the rate and severity of stuttering is causing communication problems.

An important point to remember is that young children tend to be cautious about what they say and how they say it, using short telegraphic phrases or even a different manner of speaking and thus can often speak fluently during an interview or while answering questions in the office of any professional. Always ask the parent if the stuttering or manner of speaking heard during the interview is characteristic of what the child typically does. Remember that children tend to stutter most when they are happily excited or when they are relaxed and engaging in a meaningful conversation with someone they enjoy being with and talking to, usually a mother. The need for referral can also be determined by answering and evaluating the results of the following five questions:

How old is the child? Many children begin stuttering with the onset of speaking, while others begin around 2 1/2 to 3 years or at about the time they begin using two-and threeword phrases, with the majority beginning by 5 years of age. The preschool and young schoolage child up to about 9 or 10 years of age finds it generally easier to change speaking patterns and overcome stuttering than do older children and adults. Fluency training is most successful when initiated near the time when stuttering first begins and thus early referral is necessary.
How long has the child been stuttering? If the child has been stuttering for six months or longer, immediate referral to a speech clinician is advised. Many children (somewhere between 40 and 50%) do overcome their stuttering due to parental intervention, development of language skills and/or maturation (neurologic development leading to improved motor skills), but the majority do not and thus early intervention and fluency training are necessary.
Is the severity of stuttering increasing? The severity of stuttering may be expected to increase gradually as the child's language develops and the demands of increased length and complexity of expression require greater coordination of the speaking mechanism, but we frequently get reports that the stuttering began overnight or developed to its greatest severity within a week or two and then remained rather stable except for episodic periods of fluency (which are to be expected even with the most severe child). In general, the more frequently the periods of fluency occur, and the greater their length, the better is the prognosis that the child will overcome the stuttering; however, if an extanded period (6 months or so) of increasing severity is reported, professional help is necessary.
What type of stuttering is the child exhibiting? If the child exhibits primarily prolongations and/or struggle behaviors, immediate referral is necessary. If the types of stuttering are whole-word and part-word repetitions the mother should observe the stuttering for 3 to 6 months to see if the problem remains stable or decreases in severity. If stuttering persists, even though mild to moderate, it is advisable to refer the child before he/she enters school. As a result of Public Law 94-142, public school speech clinicians can provide services for preschool children and definitely should not delay fluency training with kindergarten children.
Is there a history of stuttering the family? If the father or mother or close relative stutters and the child has a moderate to severe stuttering problem, the need for referral and fluency training is seldom questioned. Contemporory literature indicates that there is a genetic basis for stuttering; however, a family history of stuttering is not conclusive evidence that it was inherited.

What Can I Expect from Professional Fluency Training?

At the East Carolina University Speech and Hearing Clinic we have been engaged in direct fluency training with the beginning stutterer (ages 2 to 10 years) since 1974. A followup study of the first 18 children enroIled in the program (1974 through 1979) revealed that all 18 established normally fluent speaking patterns and all but one maintained fluency. The one child who regressed was severe when enrolled and was found to have a mild to moderate problem when re-evaluated four years later. His current prognosis for re-establishing fluency is good. During the past four years we have worked with approximately 30 more young stuttering children, four of whom had difficulty establishing or maintaining fluency. Prognosis for only one of the four is poor because of the severity of his involvement and his resultant inabilitv to change his speaking patterns. The average time it takes a child to establish fluency has been sixty 40-to 50-minute sessions spread over a 9-month period. Two children established fluency in less than 20 sessions and it took almost 135 for two others and almost 200 sessions for one child.

Summer Residential Program for the Beginning Stutterer and Parents (note - this summer program ceased operation in 1989 due to cuts in funding - JAK)

A 3-week (June 25 through July 13) intensive fluency training program for 15 stuttering children (ages 3 to 10 years) and their parents is being planned at East Carolina University for the summer of 1984. The program will include 3 hours of fluency training per day, one hour of music therapy, and one hour of adaptive motor training. Parents will participate in a parent training/counseling program designed to help them understand stuttering and help them work directly with their own child. For additional information, write to the author at Speech and Language Department, East Carolina University, Greenville 27834.

Referral Sources and Where to Seek Assistance

An excellent book available for parents and for professionals advising parents is written by Dr. Eugene B. Cooper and is entitled Understanding Stuttering. It may be purchased from The National Easter Seal Society for Crippled Children and Adults, 2023 West Ogden Avenue, Chicago 60612.

The Board of Examiners for Speech and Language Pathologists and Audiologists publishes a directory of licensed personnel practicing in North Carolina. The address is Post Office Box 5545, Greensboro 27435-0545.

The North Carolina Speech, Hearing, and Language Association publishes a directory listing institutions and professionals practicing in North Carolina. The address is NCSHLA Publications, 530 N. Pearson St., P.O. Box 28350, Raleigh, NC, 27611-8350, 919-833-3984

added March 7, 1997, with permission