Stuttering

Barry Guitar

I. Description of the problem. Stuttering is a disruption of speech, characterized by repetitions, prolongations, and/or blockages. These may be accompanied by physical struggle, frustration, and fear of speech. The term disfluency is often used synonymously with stuttering, but it also may refer to the hesitations common in the speech of typical children learning to talk.
- A. Epidemiology.
  - The prevalence of stuttering is 1% among school-aged children, slightly lower in adults, and slightly higher in preschool children. The incidence is 5%.
  - The difference between prevalence and incidence figures reflects the tendency for children who stutter to recover, usually before puberty.
  - The male-female ratio among children younger than 6 is about 2:1 and rises to 4:1 in adulthood, suggesting that females are more likely to recover.
- B. Familial transmission/genetics. Parents who stutter are more likely to have children who stutter; this is especially so for women who stutter. A multifactorial (polygenic) model has been suggested to account for the transmission.
- C. Etiology/contributing factors
  - 1. Environmental. A home or school environment that places high demands on a child’s performance can contribute to stuttering. Examples of demands include a communication environment that pressures the child to speak more rapidly, articulately, or with more advanced language than the child is easily able to. Stuttering may also be exacerbated by stressful but normal life events such as the birth of a sibling, separation from a parent, or a family move.
  - 2. Organic/transactional. Predispositions to stuttering include an inherited or acquired difficulty in speech motor coordination and a temperament, which reacts to stress with excess muscular tension and effort. Brain imaging studies of children who stutter suggest reduced gray matter volume in speech areas and abnormal white matter tracts in speech planning and speech motor areas.
  - 3. Developmental. Stuttering usually appears between the ages of 18 months and 5 years. In 70% of children who begin to stutter, early symptoms will resolve. Early onset of stuttering (between years 2-3) is associated with more likely natural recovery than later onset. In children who do not recover naturally, the signs and symptoms may worsen from (1) easy repetitions with minimal awareness to (2) rapid and physically tense repetitions with evidence of frustration to (3) blockages of speech, accompanying struggle behaviors, and avoidance of words and speaking situations.

II. Making the diagnosis.

A. Signs and symptoms/differential diagnosis. (See Table 77-1.)
B. History: key clinical questions.
- 1. “How long have you been aware of your child’s stuttering?” If the child has stuttered for more than 6 months, suspect a potential chronic problem, particularly if it has not decreased in frequency or severity since onset.
- 2. “How has the stuttering changed since it began?” If there has been an increase in effort, emotion, or avoidance associated with stuttering, it is worsening.
- 3. “What is your child’s stuttering like at its worst?” Many children who stutter will not stutter in the clinician’s office; it is important to have the parents describe the signs and symptoms that have caused them concern.
- 4. “Is the child bothered by their stuttering?” If so, the child may soon react to his stuttering with physical tension and struggle and should be referred.
C. Tests. Ask the child several direct questions (e.g., name, age, address) that must be answered without substitution or circumlocution. This is likely to elicit stuttering or avoidance if child is a stutterer.