Speech Disfluency and Stuttering in Children

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Childhood stuttering (also called developmental stuttering) is a communication disorder that is generally characterized by interruptions, or speech disfluencies, in the smooth forward flow of speech. Speech disfluencies can take many forms, and not all are considered to be atypical. Disfluencies such as interjections ("um", "er"), phrase repetitions (''I want—I want that"), and revisions ("I want—I need that"), which are relatively common in the speech of normally developing children, represent normal aspects of the speaking process. These disfluencies arise when a speaker experiences an error in language formulation or speech production or needs more time to prepare a message. Other types of dis-fluencies, which occur relatively infrequently in the speech of normally developing children, may be indicative of a developing stuttering disorder. These dis-fluencies, often called "atypical" disfluencies, "stuttered" disfluencies, or "stutter-like" disfluencies, include whole-word repetitions ("I-I-I want that'') and, particularly, fragmentations within a word unit, such as part-word repetitions (''li-li-like this''), sound prolongations (''lllllike this''), and blocks (''l—ike this'') (Ambrose and Yairi, 1999).

Stuttered speech disfluencies can also be accompanied by affective, behavioral, and cognitive reactions to the difficulties with speech production. These reactions are distinct from the speech disfluencies themselves but are part of the overall stuttering disorder (Yaruss, 1998). Examples of behavioral reactions, which rapidly become incorporated into the child's stuttering pattern, include physical tension and struggle in the speech mechanism as children attempt to control their speech. Affective and cognitive reactions include feelings of anxiety, embarrassment, and frustration. As stuttering continues, children may develop shame, low self-esteem, and avoidance of words, sounds, or speaking situations. These negative reactions can lead to increased stuttering severity and greatly exacerbate the child's communication problems.

Etiology. Numerous theories about the etiology of stuttering have been proposed (Bloodstein, 1993). Historically, these theories tended to focus on single causes acting in isolation. Examples include psychological explanations based on supposed neuroses, physiological explanations involving muscle spasms, neurological explanations focusing on ticlike behaviors, and environmental explanations suggesting that normal disfluency was misidentified as stuttering. None of these theories has proved satisfactory, though, for the phenomenology of stuttering is complex and highly individualized. As a result, current theories focus on multiple etiological factors that interact in complex ways for different children who stutter (e.g., Smith and Kelly, 1997). These interactions involve not only genetic and environmental factors, but also various aspects of the child's overall development.

Pedigree and twin studies have shown a genetic component to childhood stuttering—a family history of stuttering can be identified for approximately 60%-70% of children who stutter (Ambrose, Yairi, and Cox, 1993). The precise nature of that genetic inheritance is not fully understood, however, and studies are currently under way to evaluate different models of genetic transmission. It is also likely that environmental factors, such as the model the child hears when learning to speak and the demands placed on the child to speak quickly or precisely, may play a role in determining whether stuttering will be expressed in a particular child (e.g., Starkweather and Givens-Ackerman, 1997).

There are several aspects of children's overall development that affect children's speech fluency and the development of childhood stuttering. For example, children are more likely to be disfluent when producing longer, more syntactically complex sentences (Yaruss, 1999). It is not clear whether this increase is associated with greater demands on the child's language formulation abilities or speech production abilities; however, it is likely that stuttering arises due to the interaction between linguistic and motoric functions. As a group, children who stutter have been shown to exhibit language formulation and speech production abilities that are slightly lower than their typically fluent peers; however, these differences do not generally represent clinically identifiable deficits in speech or language development (Bernstein Ratner, 1997a). Finally, temperament, and specifically the child's sensitivity to stimuli in the environment as well as to speaking mistakes, has been implicated as a factor contributing to the likelihood that a child will react negatively to speech disfluencies (Conture, 2001).

Onset, Development, and Distribution. The onset of childhood stuttering typically occurs between the ages of 2% and 5, though later onset is sometimes reported. Stuttering can develop gradually (with increasing frequency of disfluency and growing severity of individual instances of disfluency), or it can appear relatively suddenly (with the rapid development of more severe stuttering behaviors). Stuttering often begins during a period of otherwise normal or possibly even advanced speech-language development, although many children who stutter exhibit concomitant deficits in other aspects of speech and language development. For example, 30%-40% of preschool children who stutter also exhibit a disorder of speech sound production (articulation or phonological disorder), though the exact nature of the relationship between these communication disorders is not clear (Yaruss, LaSalle, and Conture, 1998).

The lifetime incidence of stuttering may be as high as 5%, although the prevalence is only approximately 1%, suggesting that the majority of young children who stutter—perhaps as many as 75%—recover from stuttering and develop normal speech fluency (Yairi and Ambrose, 1999). Children who recover typically do so within the first several months after onset; however, recovery is also common within the first 2 years after onset (Yairi and Ambrose, 1999). After this time, natural or unaided recovery is less common, and children appear to be significantly less likely to experience a complete recovery if they have been stuttering for longer than 2 to 3 years, or if they are still stuttering after approximately age 7 (Andrews and Harris, 1964). Boys are affected more frequently than girls: in adults, the male to female ratio is approximately 4 or 5 to 1, though at onset, the ratio is closer to 2 to 1, suggesting that girls are more likely to experience recovery than boys. This is particularly true for girls who have other females in their family with a history of recovery from stuttering (Ambrose, Yairi, and Cox, 1997).

Diagnosis and Assessment. The high rate of recovery from early stuttering indicates a positive prognosis for many preschool children who stutter; however, it also complicates the diagnostic process and makes it difficult to evaluate the efficacy of early intervention. There is general agreement among practitioners that it is best to evaluate young children soon after the onset of stuttering to estimate the likelihood of recovery. Often, however, it is difficult to make this determination, and there is considerable disagreement about whether it is best to enroll children in treatment immediately or wait to see whether they will recover without intervention (e.g., Bernstein Ratner, 1997b; Curlee and Yairi, 1997).

Based on the understanding that the etiology of childhood stuttering involves multiple interacting factors, the diagnostic assessment of a preschool child who stutters involves evaluation of several aspects of the child's speech, language, and overall development, as well as selected aspects of the child's environment. Specifically, a complete diagnostic assessment includes the following: (1) a detailed interview with parents or care-givers about factors such as family history of stuttering, the family's reactions to the child's speaking difficulties, the child's reactions to stuttering, the speech and language models the child is exposed to at home, and any other information about communication or other stressors the child may be experiencing, such as competition for talking time with siblings; (2) assessment of the observable characteristics of the child's fluency, including the frequency, duration, and type of disfluencies and a rating of stuttering severity; (3) assessment of the child's speaking abilities, including an assessment of speech sound production/phonological development and oralmotor skills; (4) assessment of the child's receptive and expressive language development, including morphological structures, vocabulary, syntax, and pragmatic interaction; and, increasingly, (5) assessment of the child's temperament, including sensitivity to stimuli in the environment and concerns about speaking difficulties.

Together, these factors can be used to estimate the likelihood that the child will recover from early stuttering without intervention or whether treatment is indicated. Although it is impossible to determine with certainty which children will recover from stuttering without intervention, some diagnostic signs that may indicate an increased risk of continued stuttering and the need for treatment include a family history of chronic stuttering, significant physical tension or struggle during stuttered or fluent speech, concomitant disorders of speech or language, and a high degree of concern about speaking difficulties on the part of the child or the family (e.g., Yairi et al., 1996). Importantly, some practitioners also recommend treatment even in cases where the estimated risk for continued stuttering is low, either in an attempt to speed up the natural recovery process or to help concerned parents reduce their worries about their child's fluency.

Treatment. As theories about stuttering have changed, so too have preferred treatment approaches, particularly for older children and adults who stutter. At present, there are two primary approaches to treatment for young children who stutter, traditionally labeled ''indirect'' and ''direct'' therapy. Indirect therapy is based on the notion that children's fluency is affected by specific characteristics of their speech, such as speaking rate, time allowed for pausing between words and phrases, and the length and complexity of utterances. Specifically, it appears that children are less likely to stutter if they speak more slowly, allow more time for pausing, or use shorter, simpler utterances. If children can learn to use these ''fluency facilitating'' strategies, they are more likely to be fluent and, presumably, less likely to develop a chronic stuttering disorder.

A key assumption underlying the indirect treatment approach is that these parameters of children's speech are influenced by the communication model of the people in the child's environment. Thus, in indirect therapy, clinicians teach parents and caregivers to use a slower rate of speech, to increase their rate of pausing, and, in some instances, to modify the length and complexity of their utterances, although there is increasing concern among some researchers that restricting the language input children receive may have unintended negative consequence for children's overall language development (e.g., Bernstein Ratner and Silverman, 2000). Furthermore, although it is clear that children do learn certain aspects of communication from their environment, there is relatively little empirical support for the notion that changing parents' speech characteristics directly influences children's speech characteristics or their speech fluency. Even in the absence of clear efficacy data, however, the indirect approach is favored by many clinicians who are hesitant to draw attention to the child's speech or increase the child's concerns about their speech fluency.

In recent years, a competing form of treatment for preschool children who stutter has gained popularity (Harrison and Onslow, 1999). This behavioral approach is based on parent-administered intermittent reinforcement of fluent speech and occasional, mild, supportive correction of stuttered speech. Specifically, when a child stutters, the parent labels the stuttering as ''bumpy'' speech and encourages the child to repeat the sentence ''without the bumps.'' Efficacy data indicate that this form of treatment is highly successful at reducing the observable characteristics of stuttering, although questions remain about the mechanism responsible for this improved fluency.

Regardless of the approach used in the preschool years, clinicians generally shift from indirect to more direct forms of treatment as children grow older and their awareness of their speaking difficulties increases. Direct treatment strategies include specifically teaching children to use a slower speaking rate or reduced physical tension to smooth out their speech and helping them learn to modify individual instances of stuttering so they are less disruptive to communication (Ramig and Bennett, 1997). Other direct approaches include operant treatments based on reinforcing fluent speech in a hierarchy of utterances of increasing syntactic complexity and length (Bothe, 2002).

A critical component of treatment for older children who stutter, for whom complete recovery is less likely— and even for preschool children who are concerned about their speech or who have significant risk factors indicating a likelihood of continued stuttering (Logan and Yaruss, 1999)—is learning to accept stuttering and to minimize the impact of stuttering in daily activities. As children learn to cope with their stuttering, they are less likely to develop the negative reactions that characterize more advanced stuttering, so the disorder is less likely to become debilitating for them. In addition to pursuing treatment, many older children and families of children who stutter also find meaningful support through self-help groups, and clinicians are increasingly recommending support group participation for their young clients and their families.

Summary. Stuttering is a complex communication disorder involving the production of certain types of speech disfluencies, as well as the affective, behavioral, and cognitive reactions that may result. There is no one known cause of stuttering. Instead, childhood stuttering appears to arise because of a complex interaction among several factors that are both genetically and environmentally determined, such as the child's linguistic abilities, motoric abilities, and temperament. Therefore, diagnostic evaluations of preschoolers who stutter must examine the child's environment and several aspects of child's development. Treatment options include both indirect and direct approaches designed not only to minimize the occurrence of speech disfluencies, but also to minimize the impact of those disfluencies on the lives of children who stutter.

See also Language in chiLdren who stutter; stuttering.

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