How Can You Tell if Childhood Stuttering is the Real Deal?

One of the more challenging clinical decisions that confront speech-language pathologists is what to do with a young child who stutters. Do we recommend intervention? Do we wait and see if the child recovers without formal therapy? A recent study published in Pediatrics by Reilly and colleagues has generated a significant amount of press, with headlines declaring that preschool children who stutter will “do just fine.”

Even though this message does not appear to be the intent of the authors (as per their more detailed podcast on StutterTalk), it is the message the media chose to run with in their headlines. There are several key points about the Reilly article, preschool stuttering, and our current research base that need to be evaluated before we make claims such as those put forward by the media.

First, the Reilly et al. study used temperament and behavior scales, which were not designed to assess reactions to stuttering or communication. In fact, of the three scales used, only one had a question relating to communication, and it was not about stuttering. So, while it certainly may be true that young children who stutter may exhibit normal temperament and behavior (a finding we should not be surprised by), this study did not actually assess reactions to stuttering or communication, as the misleading media headlines have suggested.

This brings us to the second point of discussion, which is the difference between early stuttering and normal disfluencies. For a child with normal disfluencies, a “wait and see” approach is much more acceptable than for a child with early stuttering. We often use the term “emergent” to describe skills that are developing, but have not fully emerged. Children with normal disfluencies have emergent fluency. Their skills are developing in this area. Children who exhibit signs of early stuttering are much more at risk for continued stuttering, without proper intervention. As such, the question for parents, physicians, SLPs and others, is “How do we know the difference?”

The chart below describes some characteristics of “normal disfluency” and “stuttering.”
Normal Disfluency (less risk)                               Stuttering (higher risk)
Phrase Repetitions Sound                                                Syllable Repetitions
Interjections                                                                          Prolongations
Revisions                                                                                 Blocks
Multi-syllabic Whole Word Repetitions                     Tension/Struggle
No tension or struggle                                                       Changes in pitch/loudness
No secondary behaviors                                                   Secondary behaviors
No negative reaction or frustration                             Negative reaction/frustration
No family history of stuttering                                       Family History of stuttering

This can be a starting point to help determine risk. In addition, the child’s gender (boys are at a higher risk), time since onset (greater than 6 to 12 months is higher risk), age of onset (children who start stuttering at age 3 ½ or later are at higher risk), overall speech and language skills (it is important to assess all areas of speech and language), and level of parent concern also need to be considered.

Third, much of the problem that persists in our understanding the risk of early stuttering lies in the difference between population studies and clinical studies. Studies that have looked at recovery rate have been population studies, and thus likely captured many children who were experiencing “emergent fluency” rather than “stuttering.” The research does not translate well into clinical settings. While up to 80 percent of children in population studies may outgrow their “stuttering,” that number is far lower in a clinical setting.

Of the children seen in a clinical setting, many have several of the above risk factors that would put them at higher risk for continued stuttering without proper intervention. Children in a clinical setting are not a random sample of the population, but a specific subgroup with an identified concern (usually on the part of the parents) about stuttering. As such, speech-language pathologists need to be careful about discussing recovery rates with parents that may not apply to their child.

Finally, a “gold-standard” that allows us to predict with 100 percent accuracy which children need intervention does not currently exist. As such, we have to rely on current best practice: the integration of research evidence, clinical experience, and client values. Even if we assume that waiting to intervene will result in a similar outcome later, the reality is we do not know if waiting has a negative impact on social skills, self-confidence, and peer relationships.

Given the above information, what do we recommend to parents, physicians and SLPs? Parents are often the most reliable judge of their children. When they come to us with concern, it is warranted in most cases. Parents should trust their instincts. If they are concerned about their child’s stuttering, they should discuss those concerns with the child’s pediatrician and advocate for a consultation with a speech-language pathologist. Parents do not need a referral for an SLP. They can contact an SLP on their own (go to ASHA’s ProSearch directory of clinicians to find one in their area) or go through their public school or Child Find.

Pediatricians should refer to an SLP when any of the following are present in a child who is stuttering:

• A family history of stuttering
• Child has been stuttering for more than six months
• Child exhibits any negative reactions toward stuttering
• Child exhibits physical tension or secondary behaviors (e.g., eye blinking, head nodding, etc.) associated with stuttering
• Other speech/language concerns are also present
• Parents are concerned
• Child is experiencing negative reactions from other family members or peers

Through a collaborative effort between the parents, physicians, SLPs and others in the child’s community, we can make a significant difference for children who stutter.