Q: “I’m worried that my child is stuttering, but my husband says stuttering is normal in childhood and he’ll grow out of it. What should I do? Should I have him evaluated?”
A: People ask me this question all the time. It seems to be a very common concern among mothers of preschool children. To answer this question we have to get some basic terminology out of the way first. Stuttering is a disorder of fluency. Fluency refers to how easily words are produced. Stuttering is the best known, but not the only, fluency disorder.
Disfluency means an interruption in the flow of speech. It is perfectly normal to be disfluent while speaking some of the time, even for very fluent speakers. Disfluencies that might be seen in normal speech include pauses, filler words such as “um” or “well”, and occasional repetition of words or phrases (“I was … well, I was thinking…”) Everyone does this at least some of the time.
While children are learning to use words to communicate, it is common for them to experience a period of normal disfluency. It is believed that this occurs because their emerging language skills are growing fast but not quite fast enough to communicate all the new ideas in their heads. As language skills grow, disfluencies happen much less frequently (but most of us continue to be disfluent every so often even into adulthood).
This adorable creature is a great example of normal disfluency. Notice that she doesn’t seem to be bothered by her interruptions or even to notice them. Disfluencies seem to come at times when she is juggling the demands of forming the sentence and sequencing the story at the same time. She will even rephrase what she is saying as she isn’t satisfied with her first thought. Also notice that she is feeding off the prompting of her mother to help structure her narrative. Explaining the steps of a complex task is challenging to the language skills of a preschooler (and is a great activity to do together to help promote more advanced language skill). Many thanks to her mom for filming on demand!
Normal disfluency in childhood has certain characteristics:
- Repetition of sounds, syllables, words, or phrases are all possible, but typically most often involves word or phrase repetitions, especially after age 3. (“I want…I want…I want a cookie.”)
- Repetitions happen most frequently at the beginning of a word or phrase.
- Typically three or fewer repetitions per disfluency.
- Typically happens 10% of the time or less.
- May happen most often when asking questions, answering questions, or when excited, tired, upset, or rushed.
- The child does not appear to notice or be concerned about getting words out.
- Begins somewhere between 18 months to 7 years.
- Typically begins to fade within 6 months after it starts.
When your husband (or mom, or coworker, or second cousin) tells you it’s normal for kids to stutter in childhood, they are actually talking about normal disfluency.
Stuttering, on the other hand, is not part of the process of language development and is not common in childhood. Stuttering does not develop from normal disfluency. Let me repeat that, just so there is no question. Stuttering does not develop from normal disfluency. Stuttering in childhood is never normal. Stuttering is a neurologically based speech (not language) disorder with a strong genetic component. In February 2010, researchers discovered the first gene for stuttering, and there are certainly others yet to be discovered.
(Video example courtesy of the Stuttering Foundation. I am not affiliated with the Stuttering Foundation.) Notice here that, unlike in the previous example, these children all appear to be using great effort to produce speech. They are very aware of their disfluencies and their expressions indicate frustration. They do not appear to be searching for words but instead, appear to be interrupted in the flow and working their way through their “block” as best they can until they can get back on track. There is no evidence of effort to plan or sequence the words or sentences they are producing, in fact they appear to have a clear understanding of what they intend to say.
Like normal disfluency, stuttering begins somewhere between 18 months and 7 years. It also involves repetitions, fillers and pauses. However, given careful observation a trained ear (and eye) can hear and see a difference in the two.
Stuttering has three core or primary characteristics, and may also have some secondary characteristics. All three primary characteristics must be present to make a firm diagnosis of stuttering. These are:
- Repetitions of sounds, syllables, words, or phrases. These may sound similar to a child who is normally disfluent, but there are differences. Sound and syllable repetitions are more common (and whole word/phrase repetitions less common) than seen in normally developing children. Repetitions happen more frequently, often four or more times per disfluency (l-l-l-l-l-like this).
- Prolongations, meaning the sound is prolonged or drawn out (llllllllllllllllike this).
- Blocks, or tense pauses. The speaker may stop (possibly with visible signs of struggle) between words or even in the middle of a word (like ………….. this). This is not the result of mentally searching for the right word, but is described by adults and children who stutter as something physically preventing them from saying the word, like a car engine stalling.
Repetitions, prolongations, and blocks may happen at any point in a word, not just at the beginning of a word or sentence. Words or phrases are frequently interrupted part of the way through.
When stuttering becomes more severe it may happen much more frequently than 10% of speech, although this is not necessary to make a diagnosis.
Children who stutter are highly aware of the fact that they stutter and can be frustrated by it. In fact, it is not unusual for children who stutter to ask why they have trouble getting their words out. This is never seen in normally disfluent children. They may be well aware of words or phrases that will cause them to stutter and will avoid or talk around those words (we call this circumlocution). I have seen circumlocution in children as young as 3 years old.
Children may also show signs of physical tension when speaking. This can include blinking, twitching, jerking, tension of the muscles of the face or neck, audible gasping for breath, or other repetitive behaviors that seem uncomfortable or unnatural.
In general, the more secondary characteristics that are present and the more frequently the stuttering occurs, the more severe the stuttering (and the easier it will be to make a diagnosis).
The good news
The good news is, some children who stutter do outgrow it without treatment. We aren’t sure how many children do outgrow it, unfortunately. Different studies report anywhere from 30% to 75% of children recover without treatment. However, direct treatment of stuttering is not only possible in the preschool years, but typically has a much higher success rate when it is treated at that age. Here are some risk factors to consider:
- Children who continue to stutter after 6 months are much less likely to outgrow stuttering.
- Girls are more likely to outgrow stuttering than boys are.
- When a family member stutters into adulthood, the child is less likely to outgrow stuttering.
- Children who stutter after the preschool years are less likely to outgrow stuttering.
- When stuttering happens along with other speech-language disorders, such as delayed language development or poor articulation (pronunciation) of speech sounds, it is less likely to resolve on its own.
When to seek help
If you feel your child shows some signs of true stuttering, if your child has a blood relative who stuttered in childhood or continues to stutter, or if your child appears frustrated by the physical act of speaking, it is a good idea to have him or her evaluated. It can sometimes be difficult to distinguish normal disfluency from early-onset stuttering and a speech-language pathologist who is knowledgeable about stuttering can help.
American Speech-Language Hearing Association. (n.d.) Stuttering. Retrieved from: http://www.asha.org/public/speech/disorders/stuttering.htm
National Institutes of Health. (2010, February 10). Researchers discover first genes for stuttering. Retrieved from: http://www.nih.gov/news/health/feb2010/nidcd-10.htm
Stuttering Foundation. (n.d.). Differential Diagnosis. Retrieved from: http://www.stutteringhelp.org/Default.aspx?tabid=96