ARTICLE

Predicting Stuttering Onset by the Age of 3 Years: A

Prospective, Community Cohort Study
Sheena Reilly, PhDa,b,c, Mark Onslow, PhDd, Ann Packman, PhDd, Melissa Wake, MDa,b,c, Edith L. Bavin, PhDe, Margot Prior, PhDb,f,
Patricia Eadie, PhDc, Eileen Cini, BAppScc, Catherine Bolzonello, MSpPathc, Obioha C. Ukoumunne, PhDa,c

aDepartment of Paediatrics, fSchool of Behavioural Sciences, University of Melbourne, Melbourne, Australia; bRoyal Childrens Hospital, Melbourne, Victoria, Australia;
cMurdoch Childrens Research Institute, Melbourne, Victoria, Australia; dAustralian Stuttering Research Centre, University of Sydney, Sydney, Australia; eSchool of
Psychological Science, La Trobe University, Melbourne, Victoria, Australia

The authors have indicated they have no nancial relationships relevant to this article to disclose.

Whats Known on This Subject What This Study Adds

Stuttering involves repeated movements and xed postures of the speech mechanism. The cumulative incidence of stuttering onset by age 3 years was higher than previ-
Stuttering may severely impair communication, leading to speech-related social anxiety ously reported. Risk factors for stuttering onset explained little of the variation in
and social phobia and failure to attain occupational potential. Although stuttering is a stuttering onset. Language delay and shyness were not associated with stuttering
common disorder, the cause remains unknown. onset.

ABSTRACT
OBJECTIVES. Our goals were to document (1) the onset of stuttering and (2) whether
specific child, family, or environmental factors predict stuttering onset in children
aged up to 3 years. www.pediatrics.org/cgi/doi/10.1542/
peds.2007-3219

METHODS. Participants included a community-ascertained cohort of 1619 2-year-old doi:10.1542/peds.2007-3219

Australian children recruited at 8 months of age to study the longitudinal develop- The project was initiated by Drs Reilly,
Onslow, Packman, Wake, Bavin, Prior, and
ment of early language. The main outcome measure was parental telephone report Eadie; together with Ms Bolzonello they were
of stuttering onset, verified by face-to-face expert diagnosis. Preonset continuous responsible for managing the project
measures of the childs temperament (approach/withdrawal) and language develop- including data collection and analysis. Dr
ment were available. Information on a range of predictor measures hypothesized to Ukoumunne provided statistical advice and
conducted the analyses in conjunction
be associated with stuttering onset was obtained (maternal mental health and with Ms Cini. Dr Reilly wrote the article in
education levels, gender, premature birth status, birth weight, birth order, twinning, conjunction with Drs Onslow and
socioeconomic status, family history of stuttering). Packman, and all authors contributed to
planning, reviewing, and editing the
manuscript. Dr Reilly had full access to all
RESULTS. By 3 years of age, the cumulative incidence of stuttering onset was 8.5%. of the data in the study, takes
Onset often occurred suddenly over 1 to 3 days (49.6%) and involved the use of responsibility for the integrity of the data
and the accuracy of the data analysis,
word combinations (97.1%). Children who stuttered were not more shy or with- and is the articles guarantor.
drawn. Male gender, twin birth status, higher vocabulary scores at 2 years of age, and
Key Words
high maternal education were associated with stuttering onset. The multivariable stuttering, longitudinal study, risk factors,
model, however, had low predictive strength; just 3.7% of the total variation in child, preschool, epidemiological studies
stuttering onset was accounted for. Abbreviations
ELVSEarly Language in Victoria Study
CONCLUSIONS. The cumulative incidence of stuttering onset was much higher than LGAlocal government area
SEIFASocio-economic Indexes for Areas
reported previously. The hypothesized risk factors for stuttering onset together RAresearch assistant
explained little of the variation in stuttering onset up to 3 years of age. Early onset CDIMacArthur-Bates Communicative
was not associated with language delay, social and environmental factors, or preon- Development Inventories
CSBSCommunication and Symbolic
set shyness/withdrawal. Health professionals can reassure parents that onset is not Behaviour Scales
unusual up to 3 years of age and seems to be associated with rapid growth in CI condence interval
language development. Pediatrics 2009;123:270277 IQRinterquartile range
OR odds ratio
Accepted for publication Apr 14, 2008

S TUTTERING INVOLVES REPEATED movements and fixed postures of the speech

mechanism and superfluous verbal and nonverbal behaviors.1 In severe cases,
fixed postures can arrest verbal communication, and associated grimacing can be
PhD, Royal Childrens Hospital, Department of
Speech Pathology, Flemington Road, Parkville,
Victoria 3086, Australia. E-mail: sheena.reilly@
Address correspondence to Sheena Reilly,

disfiguring. School-aged children who stutter suffer bullying and teasing. In later life, mcri.edu.au
stuttering can lead to speech-related social anxiety and social phobia, failure to attain PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright 2009 by the
occupational potential, and severely impaired communication.2 American Academy of Pediatrics
The cause is unknown, although it is commonly believed to be a disorder of the
neural processing underpinning spoken language, with genetic and environmental
influences.3 It is generally accepted that stuttering typically begins between 2 and 4 years of age and coincides with

270 REILLY et al
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advances in language development, particularly the de-
velopment of 2- to 3-word phrases. There are many
causal theories, but for the most part they remain un-
tested.4
To date, there have been 2 prospective, community
studies of incidence and natural recovery. Stuttering was
examined in the 1000-family study conducted in New-
castle-Upon-Tyne, England,5,6 with all children born in
that city in May and June 1947 assessed over a number
of years. Cumulative incidence up to 5 years old (ie, the
proportion of children experiencing onset by age 5) was
3.5%, and 18 (42%) of 43 children recovered naturally
by 6 years.6 Shortcomings of these data7 include the fact
that stuttering was identified by health visitors rather
than by speech pathologists, and it was not clear how
long after stuttering onset the children were assessed.
The cumulative incidence of stuttering in 1042 pre-
schoolers up to 3 years old born between 1990 and 1991
on the Danish island of Bonholm was 5%.8 By 5 years of
age, 71% were reported to have naturally recovered.
Limitations of this study included the fact that the chil-
dren were not assessed until their third birthday, and the
presence of stuttering was not established before the age
of 3 years.
Many antecedents and risk factors have been thought
to be implicated in stuttering onset. There is ongoing
debate about the relationship between language and
stuttering.9 Whereas some studies revealed that lan-
guage learning difficulties were not associated with stut-
tering,10 others demonstrated that children who stutter
have lower language proficiency than children who do
not stutter.11 In addition, they are reported to differ on
various temperament characteristics,12 including shy-
ness,13 sensitivity,14 adaptability,14 and vulnerability.15
Some have proposed that these temperament character-
istics play a role in the etiology of stuttering.13 To date,
however, no study we are aware of has measured either
language or temperament before stuttering onset. There-
fore, it is not clear whether these factors are associated
with stuttering onset and, if they are, whether they
precede or develop as a result of the stuttering.
Our review of the literature also identified several
other potential variables thought to be implicated in
stuttering onset. Included were prenatal and perinatal
factors, birth order, socioeconomic status, parent-child
relationships, traumatic experiences in early childhood,
and growth and neurologic development.5,16 Again, few
of these factors have been measured before stuttering
onset, and the reported associations are therefore not
well supported. We identified 1 exception, a study of 93
children in the Netherlands17 in which language devel-
opment measured before any of the children started to
stutter did not predict stuttering onset. The only predic-
tors associated with onset were increased child speech
rate and reduced maternal language complexity. Chil-
dren in the Dutch study were selected on the basis that
at least 1 parent stuttered, and the results may not
therefore generalize to the large numbers of children
who stutter without an overt family history.
Existing knowledge about stuttering onset has been
used to inform the development of causal pathway the-
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ories and to underpin stuttering interventions during the
preschool years.18,19 Prospective information about stut-
tering incidence, antecedents and predictors, and natural
recovery rates is urgently required to inform treatment
practices with preschoolers. Particularly pressing is the
need to identify children in whom stuttering is and is not
likely to persist, so that differing advice (watchful wait-
ing versus recommending treatment) can be correctly
targeted.
This report aims to begin to address some of these
methodologic issues by prospectively documenting the
onset of stuttering in children up to 3 years of age in a
large, community-ascertained cohort of Australian chil-
dren. Specifically, we aimed to describe the cumulative
incidence, age, and characteristics of stuttering at onset,
and to determine any child, family, or environmental
factors that might predict stuttering onset.
METHOD
Overview of the Early Language in Victoria Study
The children in this study were participants in a larger
study of early language development, the Early Lan-
guage in Victoria Study (ELVS), conducted in Mel-
bourne, Australia (population: 3.6 million), and de-
scribed in detail elsewhere.20,21 Briefly, ELVS is a
prospective observational longitudinal study commenc-
ing at 8 months, followed by repeated measures at each
birthday throughout the preschool and into the primary
school years. Infants were recruited from 6 of metropol-
itan Melbournes 31 local government areas (LGAs). The
Disadvantage Index derived from the census-based So-
cio-economic Indexes for Areas (SEIFA),22 represents
attributes such as low income, low educational attain-
ment, and high unemployment. The index was used to
stratify the 31 LGAs into 3 tiers, after which 2 noncon-
tiguous LGAs were selected from each tier to ensure the
study sampled from geographic areas across the spec-
trum of disadvantage/advantage.
Between September 2003 and April 2004, maternal
and child health nurses were asked to consecutively
approach parents of all infants at their universal
8-month visit (attended by over 80% of all Melbourne
infants), followed by a formal recruitment process. Chil-
dren were excluded if they had an obvious congenital
(eg, Down Syndrome) or developmental (eg, cerebral
palsy) problem or other serious intellectual or physical
disability diagnosed by 8 months of age. Participants
were also excluded if their parents did not speak and
understand English sufficiently for recruitment and
completion of questionnaires. The final sample was 1911
children. Parents reported on early communication and
language development at each annual wave, and a broad
range of other child, family, and environmental mea-
sures was also collected.20,21
Procedure
ELVS participants were eligible for inclusion in this stut-
tering study once they had returned their 2-year-old
questionnaires. Parents were then sent a letter of invi-
tation explaining the aims and procedures of the ELVS
PEDIATRICS Volume 123, Number 1, January 2009 271
Stuttering Study, an opt-out letter, and a refridgerator
magnet defining stuttering with examples (see Appen-
dix). Reminder letters were then sent every 4 months for
12 months to all families who had not opted out. All
letters asked parents to telephone the research team if
their child displayed any of the stuttering behaviors de-
scribed (see Appendix).
When a parent telephoned, the nature of the speech
disruption was first clarified on the telephone by a re-
search assistant (RA). If the RA verified that the speech
characteristics reported resembled stuttering or was un-
sure, a 45-minute home visit was arranged as soon as
possible. All RAs were qualified speech pathologists and
consulted regularly with 2 of the authors (Drs Onslow
and Packman). At the home visit, parents were inter-
viewed to clarify the onset and characteristics of stutter-
ing and to give a detailed family history of stuttering.
This was followed by a videotaped 25-minute play ses-
sion. Parents were asked to play with their child as they
normally would, avoid asking too many questions, and
reduce 1-word utterances. A standard set of toys, pic-
tures, and questions were used to prompt verbal output.
Outcome Measure
The main outcome measure was the presence of RA-
confirmed stuttering by 3 years of age. The Lidcombe
10-point stuttering severity scale was completed, with a
score of 1 corresponding to no stuttering and 10 to very
severe stuttering.23 Where possible, home visits were
conducted within 2 weeks of the parent report. A con-
sensus panel considered all cases for whom there was
uncertainty about the presence or absence of stuttering.
The panel, comprising 2 speech pathologists experienced
in the diagnosis and rating of stuttering (Drs Onslow and
Packman), independently reviewed the videorecorded
play sessions and completed the Lidcombe stuttering
severity scale. Stuttering was determined to be present if
the parent reported stuttering and the RA and the 2
experienced raters judged stuttering to be present (ie,
scores 2 on the Lidcombe severity scale).
Predictor Measures
Predictor measures were largely drawn from the ques-
tionnaire completed by parents as children turned 2
years of age. Raw (quantitative) vocabulary scores were
calculated from the MacArthur-Bates Communicative
Development Inventories (CDI), with children below the
10th percentile for vocabulary production identified as
late talkers.24,25 The development of communicative be-
haviors up to 24 months of age was summarized using
the Communication and Symbolic Behavior Scales
(CSBS) Infant-Toddler Checklist26; standardized Total
Scores (normative mean: 100, SD: 15) were calculated
according to the manual. Parents completed the 5-item
Approach/Withdrawal scale, 1 of the 5 temperament
dimensions that comprise the Australian Temperament
Project-Short form suitable for toddlers aged 1 to 3 years
(Toddler version).27 Each item was rated on a scale from
1 (almost never) to 6 (almost always) and summed to
provide a total score (maximum score: 30).28 Shy/with-
272 REILLY et al
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drawn children receive higher, and outgoing children
lower, scores.
Maternal mental health was measured using the Non-
specific Psychological Distress Scale (Kessler-6, or K-6),29
which yields scores from a possible 0 (no distress) to 24
(maximum distress). The remaining parent-reported
predictor variables were child gender, premature birth
status, twin birth status, birth weight, existence of an
older sibling, mothers education level, and family his-
tory of speech, language, reading, and stuttering prob-
lems. Finally, the continuous SEIFA Index of Relative
Disadvantage based on the participants postcode was
used as the indicator of socioeconomic status, with lower
scores representing greater disadvantage (Australian
normative mean: 1000; SD: 100).22
Almost all of the putative risk factors identified in our
review of the literature were collected within ELVS and
in most cases before the onset of stuttering. ELVS was
designed as a study of early language development.
Therefore, data on some variables hypothesized to be
implicated in stuttering onset were not measured (eg,
traumatic experience before stuttering onset, physical
growth and neurologic development, and parent chil-
drearing skills).
Analysis
Logistic regression was used to calculate odds ratios
(ORs) for the relationship between stuttering onset by 3
years old and the predictor variables specified earlier.
Information sandwich estimates of standard error30 that
allow for the correlation between responses from twins
were obtained. Crude ORs from bivariable models, in
which each risk factor is used as a predictor on its own,
and adjusted ORs from multivariable models, in which
all the risk factors are used simultaneously as predictors,
were obtained. The squared Pearson correlation measure
was used to quantify explained variation (R2).31 Scores
on the variables of interest for children born prema-
turely, defined as 36 weeks gestation, were age-cor-
rected before analysis. All analyses were implemented
by using Stata 9.2.32
RESULTS
The Sample
Figure 1 summarizes the participant flow between ELVS
and the Stuttering Study. At 2 years of age, 57 of the
original 1911 ELVS participants were unavailable (with-
drawn, lost contact, or moved out of Victoria), and an
additional 235 parents contacted us and opted not to
participate in the study, leaving 1619 participants (85%
of the original sample). Table 1 compares the study
participants with the nonparticipants, with larger pro-
portions of children whose mothers had a degree or
postgraduate qualification among the participants than
the nonparticipants.
A total of 158 (9.8%) of 1619 parents called to report
the onset of stuttering by 3 years of age. The presence of
stuttering was then confirmed in 137 children (8.5%
[95% confidence interval (CI): 7.2%9.9%]) by a
trained research assistant during the initial home visit.
 ELVS cohort
1911 subjects

Stuttering-study
FIGURE 1 Lost to follow-up participants Opted out
Flowchart of ELVS participants and relationship to the stuttering 57 subjects 1619 subjects 235 subjects
study.

Confirmed stutterers Nonstutterers

137 subjects 1482 subjects

TABLE 1 Characteristics of Participants Versus Nonparticipants 0.10

Variables Participants Nonparticipants

(N 1619)a (N 292)b 0.08

Gender

Proportion
Male, n (%) 824 (50.9) 142 (48.6) 0.06
Female, n (%) 795 (49.1) 150 (51.4)
Twin birth, n (%) 42 (2.6) 11 (3.8) 0.04
Premature birth, n (%) 47 (2.9) 12 (4.1)
Birth weight, mean (SD), kg 3.4 (0.5) 3.4 (0.6)
0.02
Birth order
First child, n (%) 820 (50.8) 134 (46.5)
Second child or more, n (%) 795 (49.2) 154 (53.5) 0.00

Family history
No problem, n (%)
Speech/language/reading problems
only, n (%)
Stuttering problem, n (%)c
SEIFA disadvantage score, mean (SD)
Mothers education level
Did not complete year 12, n (%)
Completed year 12, n (%)
Degree/postgraduate qualication, n (%)
Maternal mental health score, mean (SD)
a The number of participants ranged from 1469 to 1619.
b The
number of nonparticipants ranged from 242 to 292.
c Children with a family history of stuttering may also have reported family histories of speech/
language and/or reading problems.
The panel agreed that there were 21 borderline chil-
dren in whom stuttering reports were ambiguous, and
these children were classified as nonstuttering for the
main analyses. The median age of onset was 29.9
months (interquartile range [IQR]: 27.0 33.1; range:
12.0 36.9) and of parent telephone to report stuttering
onset was 31.8 months (IQR: 29.0 34.9; range: 24.9
42.4). The median period from reported onset to tele-
phone contact was 1.4 months (IQR: 0.6 3.2; range:
0.113.1), and between reported onset and the home
visit was 2.1 months (IQR: 1.0 3.9; range: 0.218.1).
Figure 2 plots the proportion of the ELVS cohort who
had stuttered by any age up to 3 years. The constant
slope from 25 months emphasizes that there was no
obvious shorter age window during which stuttering
characteristically commenced. Eleven parents reported
that their children started to stutter before 2 years of age.
Most parents reported that they first noticed stuttering
0 10 20 30 36
Age, mo
1213 (74.9) 222 (76.0)
312 (19.3) 60 (20.5) FIGURE 2
Proportion of study participants who stuttered by a given age. Data shown for children
94 (5.8) 10 (3.4) up to 3 years of age.
1037 (61) 1033 (60)
359 (22.4) 72 (25.2) when the child was stringing 3 or more words together
628 (39.2) 130 (45.5) (133 of 137 [97.1%]). In more than half the children,
615 (38.4) 84 (29.4) stuttering started suddenly; 51 parents (37.2%) reported
3.2 (2.9) 3.1 (2.9)
stuttering commenced during a period of 1 day, and 17
parents (12.4%) over 2 to 3 days. In some children,
stuttering was reported to emerge more slowly: 1 to 2
weeks (37 [27.0%]), 3 to 4 weeks (19 [13.9%]), and
during a period of 5 weeks in 8 children (5.8%). Four
parents (2.9%) were unsure about the time it took for
stuttering to emerge. For 1 case, the data were missing.
Family histories were obtained from all the children
in the ELVS cohort (Table 1). A more detailed family
history of stuttering and related communication prob-
lems was elicited after onset from the families of children
who stuttered, which revealed a specific family history
of stuttering in 71 (51.8%) parents of children who
started to stutter. Between 20% and 30% reported family
histories of other related conditions including speech prob-
lems, problems at school, difficulty with math, and diffi-
culty with reading and/or writing. Less than 20% reported
problems in a variety of domains including epilepsy, intel-
lectual impairment, language problems, motor difficulties,
and attention and concentration problems.
The majority of parents described the nature of their
childs stuttering as episodic (125 [91.2%]) rather than
continuous. The most commonly reported stuttering be-
havior was whole word repetition (97 [71%]). Table 2

PEDIATRICS Volume 123, Number 1, January 2009 273

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 TABLE 2 Comparison Between Stutterers and Nonstutterers on the CDI and CSBS at 2 years than children who did
Variables Stutterers Nonstutterers not stutter, but mean shyness, birth weight, and mater-
(N 137)a (N 1482)b nal mental health scores were similar (Table 2).
Table 3 summarizes the results of the logistic regres-
Male gender, n (%) 84 (61.3) 740 (49.9)
Premature birth (36 wk), n (%) 2 (1.5) 45 (3.0) sion analyses of stuttering status on the risk factors of
Twin birth, n (%) 7 (5.1) 35 (2.4) interest showing both crude (bivariable) and adjusted
Has older siblings, n (%) 62 (45.3) 733 (49.6) (multivariable) ORs. No evidence of nonlinearity in the
Family history relationships between the quantitative predictors and
No problem, n (%) 105 (76.6) 1108 (74.8) the log odds of stuttering onset by 3 years was detected
Speech/language/reading 20 (14.6) 292 (19.7) using the fractional polynomials approach.33 In the ad-
problems only, n (%) justed model male gender, twin birth status, a mother
Stuttering problem, n (%)c 12 (8.8) 82 (5.5) with a degree or postgraduate qualification, and having
Birth weight, mean (SD), kg 3.5 (0.5) 3.4 (0.5)
a high CDI raw vocabulary score at 2 years were all
SEIFA disadvantage score, mean (SD) 1047 (50) 1036 (62)
associated with stuttering. An increase of 100 words on
Mothers education level
Did not complete year 12 18 (13.3) 341 (23.2) the vocabulary score corresponds to an increase of 17%
Completed year 12 38 (28.1) 590 (40.2) in the odds of beginning to stutter. The findings for twin
Degree/postgraduate 79 (58.5) 536 (36.5) birth should be interpreted cautiously; the OR estimate for
Maternal mental health score at 2 y, 3 (1, 5) 2 (1, 4) this variable may be unstable, because the number of twins
median (IQR) who started to stutter was small. There was weak evidence
Temperament score at 2 y, mean (SD) 15.5 (4.6) 15.7 (5.0) that children with a family history of stuttering were more
CDI raw vocabulary score at 2 y, mean 299 (157) 259 (162) likely to develop stuttering in comparison to those with no
(SD) problems or those with only a history of general language/
CDI percentile rank at 2 y, mean (SD) 48.8 (27.6) 40.6 (28.3)
speech/reading problems. Overall, the multivariable model
Late talker (score 10th percentile on 11 (8.0) 268 (20.0)
had low predictive strength, accounting for only 3.7% of
CDI) at 2 y
CSBS total standardized score at 2 108 (15) 104 (15) the total variation in stuttering onset. A sensitivity analysis
years, mean (SD) in which the 21 borderline cases were classified as stut-
a Sample size ranged from 134 to 137 for stutterers.
terers rather than nonstutterers provided similar results to
b Sample size ranged from 1308 to 1482 for nonstutterers. the main adjusted analysis.
c Children with a family history of stuttering may also have reported family histories of speech/

language and/or reading problems. DISCUSSION

shows the stuttering group had higher proportions of
children with each of the following characteristics than
the nonstuttering group: boys, twins, and parents edu-
cated at or above degree level. The stuttering group had
a lower proportion of late-talkers and higher total scores
The cumulative incidence of stuttering onset by 3 years
old was 8.5%, which is almost twice the percentage
previously reported in other studies. Although we con-
firmed several of the hypothesized predictive associa-
tions, very little of the variation in stuttering onset
(3.7%) could be explained by the 12 risk factors we
investigated.

TABLE 3 Logistic Regression of Stuttering Status (Stuttering Versus not Stuttering)

Variable Crude Adjusted
OR 95% CI P OR 95% CI P
Male gender 1.59 1.102.29 .01 1.64 1.102.45 .02
Premature birth (36 wk) 0.47 0.111.98 .31 0.54 0.122.45 .43
Twin birth 2.23 0.816.09 .12 3.28 1.208.99 .02
Birth weight, kg 1.21 0.861.70 .28 1.08 0.721.63 .71
Has older siblings 0.84 0.591.19 .33 0.89 0.601.32 .56
Family history .14 .06
No problem Reference Reference
Speech/language/reading problems only 0.72 0.441.19 0.82 0.481.41
Stuttering problema 1.54 0.812.93 2.15 1.064.37
SEIFA disadvantage score (per 100-unit increase) 1.45 1.052.00 .03 1.10 0.781.54 .59
Mothers education level .001 .001
Did not complete year 12 Reference Reference
Completed year 12 1.22 0.692.17 1.06 0.581.95
Degree/postgraduate 2.79 1.644.74 2.17 1.233.81
Maternal mental health score 0.99 0.931.05 .81 1.02 0.951.09 .67
Temperament score of child at 2 y 0.99 0.961.03 .70 1.01 0.971.04 .64
CSBS total score at 2 y (per 15-unit increase) 1.30 1.081.56 .005 1.17 0.931.48 0.19
CDI raw vocabulary score at 2 y (per 100-unit increase) 1.16 1.051.29 .005 1.17 1.021.34 .02
The number ranges from 1442 to 1619 for unadjusted analyses and is 1335 for adjusted analysis.
a Children with a family history of stuttering may also have reported family histories of speech/language and/or reading problems.

274 REILLY et al
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 To our knowledge, this is the largest epidemiological
study of early stuttering onset to date, and the first to
recruit a cohort and measure putative risk factors before
onset and to incorporate reliable, expert diagnoses.
Some of our findings confirm previous reports about
early stuttering. For example, boys were more likely to
stutter than girls. In addition, we confirmed the reported
rapid onset of stuttering, its episodic nature, and the
prominence of repeated words at onset. Consistent with
existing retrospective evidence, the majority of parents
reported that stuttering onset occurred during the 2- or
3-word stage of language development.
Reports of a family history of stuttering varied accord-
ing to when the information was obtained. Before stut-
tering onset, 12 (8.8%) of 137 families with stuttering
children reported a family history of stuttering. When
family history data were collected after stuttering onset,
many more of these families recalled a family history (71
of 137 [51.8%]). Similar findings have been reported in
studies involving screening for hearing impairment,34
and the finding may simply reflect parents being un-
aware of the risk factor at the time of questioning (eg,
before onset). The finding, however, does raise concern
about using a potential risk factor such as family history
to identify children at risk of stuttering onset.
The high cumulative incidence of stuttering onset of
8.5% by 3 years old may seem surprising. We are con-
fident about the estimate, because the 95% CIs were
narrow (7.2%9.9%). The response rate was high (85%
of parents in the original ELVS cohort), and stuttering
was rigorously verified by experts using strict criteria, so
we can be reasonably confident that both the majority of
children in the population who started to stutter before
age 3 were identified and that the high rate was not
because of false-positives. Finally, the high incidence is
plausible: it is likely we have identified stuttering that
would have been missed in previous studies, either be-
cause it was mild or because it was short-lived. In the
Newcastle-Upon-Tyne study,5 for example, stuttering
sometimes seemed to last only a few months.
Whenever a major study reports more extreme
findings than previous research, the possibility of bias
must be considered. We acknowledge that our cumula-
tive incidence estimate may be somewhat inflated, be-
cause disadvantaged parents and infants were underrep-
resented in this cohort (a common limitation in
longitudinal population studies), whereas children of
highly educated mothers were both more likely to stut-
ter and to be included in the study. However, this does
not alter our conclusions. Australian census data on
mothers of children born in 2001 indicate that 43.8%
did not complete school, compared with only 22.4% in
our stuttering study. When we applied inverse probabil-
ity weights accordingly as a sensitivity check, the esti-
mated cumulative incidence fell from 8.5% to 7.5%
(95% CI: 6.2% 8.8%), which is still considerably higher
than previously reported. Other contributors to selection
bias seem unlikely: the ELVS cohort was not originally
recruited to a study of stuttering, recruitment occurred
well before any concern about stuttering onset might
have arisen, and our findings indicate that the great
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majority of those with a family history of stuttering were
unaware of it (ie, this could not have been the reason for
self-selection into either ELVS or the stuttering study).
Finally, the study successfully captured families from
across the entire socioeconomic spectrum to quantify
internal predictor-outcome relationships, for which a
representative sample is not essential.
This report includes onset only up to 3 years. The
cumulative incidence of stuttering onset by 4 years will
be higher. We may have missed some cases because
parents elected not to call or stuttering duration was so
brief that it did not elicit a parent report. As we continue
our observation of this cohort into the preschool years,
we will be able to ascertain any missed cases of persistent
stuttering that were not notified by parents.
Four factors were significantly associated with stut-
tering onset at the 5% level. The association with gender
is the best-recognized factor in the literature, but the
associations with both twinning and maternal education
were surprising and, as noted earlier, should be inter-
preted cautiously. Mothers with a degree or postgradu-
ate qualification were more likely to have children that
stuttered by 3 years. It could be that well-educated
mothers were more likely to be aware of (and therefore
to report) stuttering onset. It is also possible that the
association with maternal education may be an artifact;
stuttering onset typically occurs with the development of
3-word combinations, and such combinations may sim-
ply occur earlier in children of more highly educated
mothers. Against this, vocabulary scores at 2 years were
significantly associated with onset of stuttering but not
with maternal education,21 and clearly this unexpected
association requires additional elucidation as the chil-
dren mature. Our results do not support the premise that
language problems are associated with stuttering onset
but that communication skills and vocabulary are more
highly developed in children who start to stutter by 3
years of age.
Of clinical and theoretical interest is our finding that
the dimension of temperament we measured did not
predict stuttering onset children who started to stutter
were neither more shy nor more outgoing than their
peers who did not stutter. Importantly, our measures
were taken before stuttering onset by using a well-vali-
dated parent report instrument normed on Australian
children.27 Temperament is regarded as a relatively sta-
ble trait, but is nonetheless receptive to environmental
experiences.27,35,36 It is possible that when children begin
to stutter they become more vigilant and more reticent,
as described by Anderson et al.12 Alternatively, it may be
that parents, who are the ones that typically fill out
temperament questionnaires, perceive their children to
be so simply because they stutter. Regardless, our results
do not suggest that innate shyness has a causal role in
stuttering.
Additional study of this cohort will enable estimation
of the cumulative incidence of stuttering onset during
the preschool years and identify whether stronger pre-
dictors emerge with stuttering onset after 3 years of age.
We will also be able to estimate the natural recovery rate
during the preschool years and provide a much-needed
PEDIATRICS Volume 123, Number 1, January 2009 275
evidence base regarding symptom clusters that are likely
to persist and resolve with time. The study did not iden-
tify risk factors or antecedents that could be used by
health professionals in the clinical case history to reliably
predict children at risk of stuttering onset. The known
prevalence of stuttering in adults is around 1%,37 so one
significant implication of our high incidence is that nat-
ural recovery could be much higher than previously
thought. Parents presenting to health professionals with
concerns about stuttering onset should be reassured
about the following points: first, stuttering onset is not
unusual in children up to 3 years of age. Second, stut-
tering onset was associated with rapid growth in lan-
guage development, most noticeably the combining of
words into phrases and short sentences. Third, children
who start to stutter do not seem to be more shy or
withdrawn compared with other children of the same
age who do not stutter. Finally, parents should be reas-
sured that there is no strong evidence that the social and
environmental factors measured in this study are related
to stuttering onset.
APPENDIX: INFORMATION PROVIDED TO PARENTS ABOUT
THE ONSET OF STUTTERING
Children who stutter have trouble getting their words
out. Stuttering is when children:
Repeat words or syllables over and over (eg, can
can canI go)
Make long prolonged sounds (eg, caaaaaaaaaaaaaan I
go)
Have speech stoppages or blocks where no sounds
come out
Stuttering can start quite suddenly or it can begin
gradually over days, weeks, or months.
If you think your child is stuttering please contact the
ELVS team as soon as you notice it.
ACKNOWLEDGMENTS
This study was funded by Australian Research Council
grant DP0557291. The ELVS was funded by Australian
National Health and Medical Research Council
(NHMRC) grant 237106. The project was supplemented
by an NHMRC program grant held by Professors Onslow
and Packman (402763) and additional grants from the
Murdoch Childrens Research Institute and the Faculty of
Healthy Sciences at La Trobe University. Drs Onslow and
Wake were funded by NHMRC Research Fellowship
302101 and NHMRC Population Health Career Develop-
ment Award 284556, respectively. Dr Okoumunnes
postdoctoral position is funded by NHMRC Population
Health Capacity Building grant 436914. Ethical ap-
proval was obtained from the Royal Childrens Hospi-
tal Melbourne (23018) and La Trobe University Hu-
man Ethics Committee (03-32).
We sincerely thank all the participating children and
parents.
276 REILLY et al
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HEALTH CLINICS INSIDE STORES LIKELY TO SLOW THEIR GROWTH

The boom in walk-in health clinics located inside pharmacies, supermarkets

and big-box retailers is showing signs of slowing. Hailed as an inexpensive
option for treating minor health ailments like sore throats and rashes, the
retail clinics have grown in number to 963 as of May 1 from just 125 three
years ago. The clinics typically feature nurse practitioners who can prescribe
basic drugs, and the price for a visit ranges from $50 to $75. But in recent
months, retail health-clinic operators based in New York, Nevada, Indiana
and Alabama have closed their doors, shuttering 69 clinics in 15 states. Now,
the biggest retail-clinic operator, CVS Caremark Corp., says it is scaling back
expansion plans for its MinuteClinic brand. The cost of setting up an in-store
clinic runs about $500 000. That is one reason why much of the future
growth in walk-in health centers is expected to come from big companies
with deep pockets and from hospital systems that are already well-known
within a community and dont have to spend so much on marketing.
Armstrong D. Wall Street Journal. May 7, 2008
Noted by JFL, MD

PEDIATRICS Volume 123, Number 1, January 2009 277

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Predicting Stuttering Onset by the Age of 3 Years: A Prospective, Community
Cohort Study
Sheena Reilly, Mark Onslow, Ann Packman, Melissa Wake, Edith L. Bavin, Margot
Prior, Patricia Eadie, Eileen Cini, Catherine Bolzonello and Obioha C. Ukoumunne
Pediatrics 2009;123;270
DOI: 10.1542/peds.2007-3219
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2009 by the American Academy of Pediatrics. All
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Predicting Stuttering Onset by the Age of 3 Years: A Prospective, Community
Cohort Study
Sheena Reilly, Mark Onslow, Ann Packman, Melissa Wake, Edith L. Bavin, Margot
Prior, Patricia Eadie, Eileen Cini, Catherine Bolzonello and Obioha C. Ukoumunne
Pediatrics 2009;123;270
DOI: 10.1542/peds.2007-3219

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/123/1/270.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2009 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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