Identification and Treatment

of Childhood Stuttering
J. Scott Yaruss, Ph.D., CCC-SLP
Stuttering Center of Western Pennsylvania
University of Pittsburgh
Children’s Hospital of Pittsburgh

Pediatric Grand Rounds

Mercy 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 Primary
Symptoms 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
 R e a c tio n s

A f f e c t iv e

P re s u m e d
Im p a i r m e n t B e h a v io r a l D is a b ili t y H a n d ic a p
E t i o lo g y

C o g n it iv e

E n v ir o n m e n t a l
In flu e n c e s a n d
After Yaruss (1998) O th e r F a c to rs
 What Causes Stuttering?
• NO single factor has been shown to be
THE 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 may
be largely determined by the child’s environment
 Doesn’t Everybody
Stutter 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 Children
Outgrow 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 for
Recovery 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 Risk
for 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 Referred
for 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
 Who Should Evaluate
and Treat Stuttering?
• 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
 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 Pittsburgh
4033 Forbes Tower
Pittsburgh, PA 15260
Phone: (412) 647-1367
Fax: (412) 647-1370
Email: jsyaruss@csd.upmc.edu
S tuttering

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A 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