Identification and Treatment of Childhood Stuttering

J. Scott Yaruss, Ph.D., CCC-SLP

Stuttering Center of Western PennsylvaniaUniversity of Pittsburgh

Children’s Hospital of Pittsburgh

Pediatric Grand RoundsMercy Hospital Continuing Education Program

September 14, 1999

What Is Stuttering?

An impairment of speech and

language production, typically

characterized by interruptions

in the forward flow of speech

(“speech disfluencies”)

What are the PrimarySymptoms of Stuttering?

• Speech disfluencies come in many forms– Some disfluencies are considered “normal”

(if they occur relatively infrequently)• Interjections (“um,” “er,” “like,” “you know”)• Revisions (“I want- I need that”)

– Others are more characteristic of stuttering• Sound or syllable repetitions (“li-li-like this”)• Sound prolongations (“llllllike this”)• Blocks (“l-----ike this”)

How Does Stuttering Develop?

• Typically begins between ages 3 and 5

• As the disorder progresses, children are likely to develop reactions to stuttering...– Tension and struggle in their speech musculature– More advanced types of speech disfluencies– Concern or anxiety about their speaking abilities

• These reactions can have profound social, emotional, and educational consequences

What Kinds of Consequences?

• Affective, Behavioral, Emotional Reactions:Anxiety about speaking, avoidance of speaking situations (reading in class, talking to friends), embarrassment, shame, guilt, low self-esteem, frustration, fear

• Without intervention, negative reactions can lead to:– Disability: Difficulty communicating with peers or in social

situations (reading in class, talking on the phone),reduced participation in educational opportunities

– Handicap: Reduced ability to fulfil occupational goals,reduced economic opportunities

Disability

Reactions

EnvironmentalInfluences andOther Factors

Behavioral

Affective

Cognitive

HandicapImpairmentPresumedEtiology

After Yaruss (1998)

What Causes Stuttering?

• NO single factor has been shown to beTHE cause stuttering– Stuttering is not caused by children’s parents

– Stuttering is not caused by drawing attention to a child’s normal disfluencies

– Stuttering is not a psychological problem(though it can have psychological consequences)

– Stuttering is not a sign of reduced intelligence, motoric weakness, or neurological injury

– Stuttering is not simply a bad habit

Okay, so…What Does Cause Stuttering?

Current theories point to a complicated

interaction between children’s language

development and their motoric abilities for

producing speech, combined with the multiple

influences of the child’s personality and the

child’s communicative and social environment

Isn’t Stuttering “Genetic”?• Yes, stuttering tends to runs in families...

– If one family member stutters, there is an increased chance that another family member will also stutter

– The few twin studies that have been conducted show only 50% concordance for MZ twins, suggesting that there are also environmental influences

• Language development, motoric development, and personality are all influenced by genetics– Most theorists believe that a predisposition to

stuttering may be heritable but its expression maybe largely determined by the child’s environment

Doesn’t EverybodyStutter Sometimes?

• Yes. Speech disfluencies are a normal part of children’s speech/language development

– All children go through a period of producing speech disfluencies when learning to speak

– Some children, however, will continue producing disfluencies and develop a fluency disorder

• No. Stuttering has emotional consequences not seen with everyday, normal disfluency

Don’t Most ChildrenOutgrow Stuttering?

• Yes. Most children who exhibit disfluencies or even stuttering early in their speech/language development will recover without intervention– Prevalence = 1%– Incidence of Stuttering = 5%– Incidence of Increased Disfluencies: 15-25%

• Because of the high rate of recovery, some have advocated a “wait and see” approach before recommending assessment or treatment

A Critical Period forRecovery from Stuttering

• If children do not recover by age 6 or 7, they are likely to develop chronic stuttering – Older children rarely achieve normal fluency, and

the negative consequences increase over time– Negative social and emotional consequences can

be minimized with appropriate early intervention

• Thus, although the “wait and see” approach may be statistically defensible, it can be very risky for individual children

Who Is At Riskfor Chronic Stuttering?

• No single behavior categorically differentiates children who stutter from children who do not– All children exhibit all types of speech disfluencies

– Sometimes stuttering begins very gradually, but persists for a long time before the family notices

– Sometimes children exhibit very severe stuttering at onset, but still make a full recovery

– Stuttering is highly variable…fluctuating from one situation to another, one day to another

So...Who Is At Risk?• Certain risk factors can provide some clues:

– Number, nature, and types of speech disfluencies

– Length of time the child has been stuttering

– Family history of stuttering

– Child’s reactions to stuttering

– Family’s reactions to stuttering (parent’s level of concern and attempts to help)

– Selected aspects of the communicative environment

– Selected aspects of the child’s overall speech/language development

Who Should Be Referredfor Evaluation?

• It is impossible to determine whether a

disfluent child is at risk for developing a

chronic stuttering disorder through

informal or casual observation

– A thorough speech-language evaluation, with multiple observations from different perspectives is needed to determine whether treatment is indicated

Referral Guidelines• I evaluate if any of the following are true:

– The child produces 3 or more disfluencies during a brief spontaneous conversational interaction

– There is tension or struggle during disfluencies (even if the disfluencies are infrequent)

– The child’s ability to communicate is affected– The child seems to avoid certain sounds, words, or

situations, or substitutes words to avoid stuttering– The parents are concerned about their child’s

speech -- even if the concerns seem unfounded– The child is concerned about his or her speech

• Speech-language pathologists (SLPs), licensed and certified by the American Speech-Language-Hearing Association (ASHA)

• Not all SLPs are comfortable with stuttering, so there has been a move toward specialization– ASHA is currently certifying stuttering specialists who

have additional experience and training with stuttering– Support groups maintain lists of stuttering specialists– The Stuttering Center of Western Pennsylvania

can act as a liaison to help families find specialists

Who Should Evaluateand Treat Stuttering?

How Is Stuttering Treated?• Helping children learn to speak more fluently

– Changing the timing and tension of speech production

• Helping parents learn to facilitate children’s fluency in everyday speaking situations– Parents can change their own speech and manage

children’s speaking situations to help them speak fluently

• Helping children and parents develop appropriate reactions and healthy attitudes toward stuttering– We must educate parents about children’s fluency– It is not sufficient to simply tell parents not to

worry -- they need training about how to react to stuttering

Summary• Early stuttering can be difficult to

distinguish from normal “developmental” disfluency

• Early intervention is critical for preventing the development of chronic stuttering and its negative social and emotional consequences

• The safest practice is to refer children for evaluation by a stuttering specialist, especially if the parents or child are concerned about the child’s speech

Questions? Comments?Please contact me!

J. Scott Yaruss, Ph.D., CCC-SLP

Stuttering Center of Western PA

University of Pittsburgh4033 Forbes TowerPittsburgh, PA 15260

Phone: (412) 647-1367Fax: (412) 647-1370Email: jsyaruss@csd.upmc.edu

tuttering

CSenterof

estern ennsylvaniaW PA joint venture of Children's Hospital of Pittsburgh and the Department of

Communication Science and Disorders at the University of Pittsburgh

Mission of the Stuttering Center

• Provide effective client-centered treatment for individuals who stutter

• Conduct meaningful research on the nature and treatment of stuttering

• Provide on-going education for student clinicians as well as practicing SLPs

• Provide support for individuals who stutter, their families, and their clinicians