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doi:10.1111/jpc.12034

ANNOTATION

Management of childhood stuttering

Mark Onslow and Sue O’Brian
Australian Stuttering Research Centre, The University of Sydney, Sydney, New South Wales, Australia

Abstract: Stuttering is a speech disorder that begins during the first years of life and is among the most prevalent of developmental disorders.
It appears to be a problem with neural processing of speech involving genetics. Onset typically occurs during the first years of life, shortly after
language development begins. Clinical presentation during childhood is interrupted and effortful speech production, often with rapid onset. If
not corrected during early childhood, it becomes intractable and can cause psychological, social, educational and occupational problems. There
is evidence from replicated clinical trials to support early intervention during the pre-school years. Meta-analysis of studies indicates that children
who receive early intervention during the pre-school years are 7.7 times more likely to have resolution of their stuttering. Early intervention is
recommended with a speech pathologist. Some children who begin to stutter will recover without such intervention. However, the number of
such recoveries is currently not known, and it is not possible to predict which children are likely to recover naturally. Consequently, the current
best practice is for speech pathologists to monitor children for signs of natural recovery for up to 1 year before beginning treatment.
Key words: diagnosis; management; paediatrics; stuttering; treatment.

Stuttering disorder, autism, cerebral palsy and learning disability.2 The

Stuttering, also known as stammering in the United Kingdom,
is a speech disorder that begins during the first years of life. A
recent community cohort study of 1619 Australian children
recruited at 8 months old found that 8.5% had begun to
stutter by 3 years of age.1 The shape of the cumulative inci-
dence plot suggests that more cases will emerge as the cohort
is studied further. Onset was found to be essentially unpre-
dictable, with only 3.7% of cases explainable with case
history variables such as advanced language development,
twinning and maternal education level. A report of 3 to
17-year-olds derived from the United States National Health
Interview Surveys (n = 95,132) showed stuttering to be the
equal third most prevalent developmental disorder from
among nine, which included attention-deficit/hyperactivity
Key Points
• Stuttering is a speech disorder with genetic involvement that
begins during the first years of life and is among the most
prevalent of developmental disorders.
• Early intervention shortly after onset during the pre-school
years is recommended.
• If not corrected during early childhood, stuttering becomes
intractable and can cause psychological, social, educational
and occupational problems.
Correspondence: Professor Mark Onslow, Faculty of Health Sciences,
The University of Sydney, PO Box 170, Lidcombe, NSW 1825, Australia.
Fax: +61 2 9351 9392; email: mark.onslow@sydney.edu.au
Declaration of conflict of interest: None declared.
Accepted for publication 1 May 2012.
reported prevalence was 1.6%.
The cause of stuttering is currently unknown; however, brain
imaging data suggest that it involves a problem with neural
processing of speech,3 linked to structural and functional
anomalies at brain sites responsible for spoken language.4,5 As
these anomalies have only been investigated with school chil-
dren and adults, it is unclear whether they are a cause or an
effect of the disorder. There is genetic involvement in stuttering,
with clear evidence of vertical transmission within families.6
Around two thirds of those affected, or their parents, report a
family history. There is greater monozygotic concordance than
dizygotic concordance, which offers a genetic account of around
70% of cases.7 At present, genetic linkage studies can account
for less than one tenth of cases; however, exome sequencing
technology has yet to be applied to the study of the disorder.
The clinical presentation of chronic stuttering in adolescence
and adulthood is interrupted speech production. Symptoms
include repetitions of sounds and words, periods when speech
appears to be blocked, and excessive prolongation of sounds or
words. These features are often accompanied by extraneous,
effortful-sounding noises, and facial movements somewhat
resembling tics. The latter extraneous movements during speech
can extend to the arms and torso. The speech output of those
affected is greatly reduced, with severe cases being able to say
only a quarter as much as their peers or requiring four times as
long to say as much as their peers. Chronic stuttering is associ-
ated with clinical levels of social anxiety, with social phobia
reported for 40–60% of clinical cases.8–10 However, it is clear
that anxiety does not cause the problem. A lifetime of stuttering
can cause significant quality-of-life impairment. Adults with
chronic stuttering often fail to attain occupational potential,11
as employers can believe that those who stutter are less

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© 2012 The Authors
Journal of Paediatrics and Child Health © 2012 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

M Onslow and S O’Brian
employable and promotable.12 A linear relationship between
stuttering severity and educational attainment has been
reported.13
Clinical Presentation During
Early Childhood
Speech pathologists are responsible for the treatment of stut-
tering. In North America, they are known as speech-language
pathologists, and in the United Kingdom as speech and lan-
guage therapists. The most common presentation of early stut-
tering to a medical practitioner is soon after onset, most
commonly when the child is aged between 2 and 5 years. That
clinical presentation is often prompted by the distressing nature
of early stuttering to parents. Unlike other speech problems,
such as poor articulation or delayed language development,
stuttering appears unexpectedly after a period of normal and
uneventful speech development. It can start quite suddenly
when children begin to form simple sentences. Around half of
the cases appear within a period of 1–3 days and a third of the
cases during a single day.1,14 The severe symptoms described
previously can occur soon after onset.15 There is a general con-
sensus that the most common early sign of stuttering is repeti-
tions of sounds and words, followed by the development of
more disabling symptoms.1,16
Diagnosis of early stuttering in pre-schoolers is rarely difficult.
Its speech disturbances are distinctive from the normal dysflu-
encies and hesitations of early language development. Parents
typically initiate referrals and are rarely mistaken in their belief
that a child has begun to stutter. A recent longitudinal study1
showed no evidence of co-morbid speech, language or reading
problems close to onset. Rare diagnostic confusion may occur
with tic syndromes of early childhood. In severe cases, early
stuttering may appear to be neurological in nature. Cases of
stuttering during the school years (7–12) are less likely to
present to medical clinics, as parents typically seek speech
pathology intervention rather than medical advice.
The Effects of Stuttering During Childhood
Stuttering may cause distress to young children shortly after
onset.14 Peers recognise stuttered speech17 and may react nega-
tively to it.18 Negative attitudes to communication have been
measured in stuttering children as young as 3–6 years old.19
These signs of negative social conditioning are likely to be the
origins of the relationship between stuttering and anxiety later
in life. However, to date, no report has documented frank signs
of clinical anxiety in pre-school children.
There is also limited evidence of clinical anxiety in school
children, with only one report showing even a suggestion of
heightened anxiety levels in stuttering children aged 9–12,20
while a report of 9 to 14-year-old children showed no effects at
all.21 It is the case, however, that for these school children, the
negative social conditioning connected with stuttering intensi-
fies. From 7 years onwards, negative attitudes to communica-
tion worsen for stuttering children.22,23 Bullying is associated
with anxiety later in life, and school-age children who stutter
are bullied more often than their peers.24 Their peers have a
negative perception of them,25 and this appears linked to prob-
lems forming relationships.26
Journal of Paediatrics and Child Health 49 (2013) E112–E115
© 2012 The Authors
Journal of Paediatrics and Child Health © 2012 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
14401754, 2013, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jpc.12034 by Readcube (Labtiva Inc.), Wiley Online Library on [25/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Management of childhood stuttering
Treatment of Childhood Stuttering
It is challenging to treat chronic stuttering during adolescence
and adulthood. Speech rehabilitation at that time of life is labo-
rious, costly and relapse prone. Additionally, concomitant treat-
ment for anxiety is frequently necessary. Clearly, then, effective
childhood intervention is desirable in order to obviate the need
for speech or anxiety treatment later in life.
To date, the best evidence for childhood stuttering treatment
lies with a conceptually simple operant procedure conducted
by parents, with supervision from a speech pathologist. This
treatment is known as the Lidcombe Program and is available
world-wide.27 A treatment guide and brochures for parents are
downloadable from the web site of the Australian Stuttering
Research Centre.28 Parents use operant conditioning principles,
such as praise for periods when their child does not stutter, and
occasionally request their child to self-correct an utterance con-
taining stuttering. Parents also measure the child’s stuttering
severity each day with a simple scale to ensure that the child
progresses to a target of no stuttering or almost no stuttering.
When that target is attained, a maintenance phase of treatment
for around 1 year is implemented to reduce the chance of
relapse, which is known to occur.29
The efficacy of the Lidcombe Program has been demonstrated
with a series of Phase I, Phase II and Phase III clinical trials.30
To date, there have been two successful Phase III randomised
controlled trials of the treatment with a no-treatment control
group: one with New Zealand pre-schoolers and one with
German pre-schoolers.31,32 A meta-analysis (n = 136) of Lid-
combe Program clinical trials and short exposure experiments
showed an odds ratio of 7.7.30 There is evidence that children
successfully treated with this method in clinical trials are able to
produce speech that is perceptually normal.33 Of interest in
cases where parents do not have access to standard speech
pathology services is a randomised Phase II trial showing the
treatment to be efficacious in a telehealth format.34 However,
those results show that the treatment time to attain no stutter-
ing or almost no stuttering with a low-tech telehealth format is
much longer than the median of 16 h with the standard for-
mat.35 At the time of writing, a clinical trial is under way to
determine whether that problem can be solved with modern
webcam technology.
There are two other treatments for early childhood stuttering
that are in earlier phases of clinical trial development than is the
Lidcombe Program. One of these, being developed in the United
Kingdom, is a family-based treatment that seeks to alleviate
stressors within the child’s daily environment that are thought
to be responsible for a child’s continued stuttering. Such stres-
sors include a generally hurried life-style, a rapid speech rate
and having unrealistic developmental language expectations of
the child. Two non-randomised Phase I trials have been pub-
lished to date,36,37 with not particularly encouraging results,
showing overall 65% stuttering reductions.
Another recent treatment development for early stuttering,
occurring in Australia, is based on the well-known fact that
when adults who stutter speak with each syllable in time to a
rhythm, they stop stuttering, only to resume stuttering when
they stop speaking in that manner. However, three non-
randomised trials38–40 have shown that the effects of such
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Management of childhood stuttering
rhythmic speech may be more permanent with early stuttering.
The latter of those reports suggested that stuttering reduction of
96% may be attainable with this method.
When to Treat Childhood Stuttering
Considering the problems with chronic stuttering later in life,
early childhood is the best time for treatment. In light of the
evidence outlined earlier that social anxiety problems with stut-
tering may well begin during the school years, intervention
shortly after onset before beginning school is recommended.
That recommendation is supported by clinical trials data which
suggest that stuttering is clinically less tractable and relapse
following treatment is more likely during the school years than
the pre-school years.41,42
A challenge for speech pathologists is that some pre-school
children who begin to stutter will recover naturally by adult-
hood without formal treatment. There are many methodologi-
cal problems with estimating the number, but there is a
prevailing belief that it is in the range of 70–80%. A critical
review placed the natural recovery rate from childhood to ado-
lescence at 30–50%.43 The challenge here for speech patholo-
gists is to consider the need for early intervention against the
chance of early natural recovery. The accepted best practice is
for speech pathologists to monitor pre-school stuttering children
for signs of natural recovery for no longer than 1 year before
intervening. It appears that less than 5% of children will recover
naturally during that period.44 Immediate treatment is recom-
mended in cases where a child is showing signs of social distress
or avoidance. This may occur in response to negative peer
reactions to stuttering. An overarching clinical guideline is that
treatment at least needs to have begun before the child reaches
5 years of age.
Summary
Stuttering is one of the most prevalent developmental disorders
of early childhood. It can appear suddenly after a period of
normal speech and language development. It is known to
involve genetics and is currently thought to be a problem with
neural processing of speech. Effective early intervention from a
speech pathologist is critical to avoid long-term quality-of-life
problems, which may include educational and occupational
limitations and mental health problems. There is a good reason
to believe that such mental health problems may begin shortly
after onset during the pre-school years. There is replicated,
randomised, clinical evidence for effective early intervention.
Many children may recover without intervention, but the exact
number is not known, and it is not possible to know which
children will recover. The best practice is for speech pathologists
to monitor children for signs of natural recovery for up to 1 year
before beginning treatment.
Multiple Choice Questions
1. Stuttering is a
A. Non-genetic disorder
B. A disorder caused by psychological problems
C. A speech disorder
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M Onslow and S O’Brian
D. Now known with certainty to be a problem with neural
speech processing
E. A language disorder
A is incorrect, because there is evidence of genetic involvement
in stuttering.
B is incorrect, because anxiety occurs after onset and does not
cause stuttering.
C is correct, because current evidence suggests it to be a problem
with neural speech processing.
D is incorrect, because current evidence suggests, rather than
proves, that to be the case.
E is incorrect, because stuttering is a speech disorder.
2. The recommended treatment practice is to
A. Always delay intervention for 1 year after onset, in the
hope that natural recovery will occur
B. Intervene after monitoring for natural recovery for up to
1 year
C. Reassure parents that the disorder is innocuous
D. Consider genetic testing
E. Refer for psychological assessment
A is incorrect, because the accepted best practice is to delay
intervention for up to 1 year after onset, unless the disorder is
causing excessive distress to the child or family.
B is correct, because this is the current recommended best
practice.
C is incorrect, because the disorder is not innocuous; if it
persists and becomes intractable, it may impair the quality of
life.
D is incorrect, because genetic testing is not necessary for
diagnosis.
E is incorrect, because psychological problems develop only if
stuttering persists during the pre-school years.
3. Diagnosis of stuttering in pre-school children
A. Can be difficult, because it is indistinguishable from tics
B. Can be difficult, because it is difficult to distinguish from
the normal hesitations and dysfluencies of language
development
C. Can be difficult, because it is a psychological problem
D. Is rarely difficult, because parents are usually correct in
their report of stuttering onset
E. Is rarely difficult, because early stuttering is always severe
soon after onset
A is incorrect, because stuttering only somewhat resembles tics.
B is incorrect, because it is easy to distinguish from these aspects
of normal language development.
C is incorrect, because it is a speech problem, and psychological
problems do not emerge until later in life.
D is correct, because parents are rarely mistaken about this.
E is incorrect, because stuttering symptoms are severe soon after
onset only in some cases.
References
1 Reilly S, Onslow M, Packman A et al. Predicting stuttering onset by
the age of 3 years: a prospective, community cohort study. Pediatrics
2009; 123: 270–7.
2 Boulet SL, Boyle CA, Schieve LA. Health care use and health and
functional impact of developmental disabilities among US children,
1997–2005. Arch. Pediatr. Adolesc. Med. 2009; 163: 19–26.
Journal of Paediatrics and Child Health 49 (2013) E112–E115
© 2012 The Authors

M Onslow and S O’Brian
3 Packman A, Onslow M. Searching for the cause of stuttering. Lancet
2002; 360: 655–6.
4 Sommer M, Koch MA, Paulus W, Weiller C, Buchel C. Disconnection of
speech-relevant brain areas in persistent developmental stuttering.
Lancet 2002; 360: 380–3.
5 Chang SE, Erickson KI, Ambrose NG, Hasegawa-Johnson MA, Ludlow
CL. Brain anatomy differences in childhood stuttering. Neuroimage
[Article] 2008; 39: 1333–44.
6 Bloodstein O, Bernstein Ratner N. A Handbook on Stuttering, 6th edn.
Clifton Park, NY: Delmar, 2008.
7 Felsenfeld S, Kirk KM, Zhu G, Statham DJ, Neale MC, Martin NG. A
study of the genetic and environmental etiology of stuttering in a
selected twin sample. Behav. Genet. 2000; 30: 359–66.
8 Iverach L, O’Brian S, Jones M et al. Prevalence of anxiety disorders
among adults seeking speech therapy for stuttering. J. Anxiety
Disord. 2009; 23: 928–34.
9 Blumgart E, Tran Y, Craig A. Social anxiety disorder in adults who
stutter. Depress. Anxiety 2010; 27: 687–92.
10 Stein MB, Baird A, Walker JR. Social phobia in adults with stuttering.
Am. J. Psychiatry 1996; 153: 278–80.
11 Klein JF, Hood SB. The impact of stuttering on employment
opportunities and job performance. J. Fluency Disord. 2004; 29:
255–73.
12 Hurst MI, Cooper EB. Employer attitudes toward stuttering. J. Fluency
Disord. 1983; 8: 1–12.
13 O’Brian S, Jones M, Packman A, Menzies R, Onslow M. Stuttering
severity and educational attainment. J. Fluency Disord. 2011; 36:
86–92.
14 Yairi E. The onset of stuttering in two- and three-year-old children: a
preliminary report. J. Speech Hear. Disord. 1983; 48: 171–7.
15 Conture EG, Kelly EM. Young stutterers’ nonspeech behaviors during
stuttering. J. Speech Hear. Res. 1991; 34: 1041–56.
16 Yairi E, Ambrose NG. Early Childhood Stuttering. Austin: Pro-Ed, 2005.
17 Ezrati-Vinacour R, Platzky R, Yairi E. The young child’s awareness of
stuttering-like disfluency. J. Speech Lang. Hear. Res. 2001; 44:
368–80.
18 Langevin M, Packman A, Onslow M. Peer responses to stuttering in
the preschool setting. Am. J. Speech Lang. Pathol. 2009; 18: 264–76.
19 Vanryckeghem M, Brutten GJ, Hernandez LM. A comparative
investigation of the speech-associated attitude of preschool and
kindergarten children who do and do not stutter. J. Fluency Disord.
2005; 30: 307–18.
20 Blood GW, Blood IM. Preliminary study of self-reported experience of
physical aggression and bullying of boys who stutter: relation to
increased anxiety. Percept. Mot. Skills 2007; 104: 1060–6.
21 Craig A, Hancock K. Anxiety in children and young adolescents who
stutter. Aust. J. Human Commun. Disord. 1996; 24: 28–38.
22 De Nil LF, Brutten GJ. Speech-associated attitudes of stuttering and
nonstuttering children. J. Speech Hear. Res. 1991; 34: 60–66.
23 Vanryckeghem M, Brutten GJ. The speech-associated attitude of
children who do and do not stutter and the differential effect of age.
Am. J. Speech Lang. Pathol. 1997; 6: 67–73.
24 Langevin M, Bortnick K, Hammer T, Wiebe E. Teasing/bullying
experienced by children who stutter: toward development of a
questionnaire. Contemp Issues Commun Sc Disord. 1998; 25: 12–24.
25 Langevin M, Hagler P. Development of a scale to measure peer
attitudes toward children who stutter. In: Bothe AK, ed.
Evidence-Based Treatment of Stuttering: Empirical Issues and Clinical
Implications. Mahwah, NJ: L. Erlbaum, 2004; 139–70.
Journal of Paediatrics and Child Health 49 (2013) E112–E115
© 2012 The Authors
Journal of Paediatrics and Child Health © 2012 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
14401754, 2013, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jpc.12034 by Readcube (Labtiva Inc.), Wiley Online Library on [25/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Management of childhood stuttering
26 Davis S, Howell P, Cooke F. Sociodynamic relationships between
children who stutter and their non-stuttering classmates. J. Child
Psychol. Psychiatry. 2002; 43: 939–47.
27 Lidcombe Program Trainers Consortium. Available from: http://www.
sydney.edu.au/health-sciences/asrc/health_professionals/lptc.shtml
[accessed 10 December 2011].
28 Australian Stuttering Research Centre home page. Available from:
http://www.sydney.edu.au/health-sciences/asrc/ [accessed 10
December 2011].
29 Jones M, Onslow M, Packman A et al. Extended follow-up of a
randomised controlled trial of the Lidcombe Program of early
stuttering intervention. Int. J. Lang. Commun. Disord. 2008; 43:
649–61.
30 Onslow M, Jones M, Menzies R, O’Brian S, Packman A. Stuttering. In:
Sturmey P, Hersen M, eds. Handbook of Evidence-Based Practice in
Clinical Psychology. Hoboken, NJ: Wiley, 2012; 185–207.
31 Lattermann C, Euler HA, Neumann K. A randomized control trial to
investigate the impact of the Lidcombe Program on early stuttering
in German-speaking preschoolers. J. Fluency Disord. 2008; 33:
52–65.
32 Jones M, Onslow M, Packman A et al. Randomised controlled trial of
the Lidcombe Programme of early stuttering intervention. BMJ
[Article] 2005; 331: 659–61.
33 Lincoln M, Onslow M, Reed V. Social validity in the treatment
outcomes of an early intervention for stuttering: the Lidcombe
Program. Am. J. Speech Lang. Pathol. 1997; 6: 77–84.
34 Lewis C, Packman A, Onslow M, Simpson JM, Jones M. A phase II trial
of telehealth delivery of the Lidcombe Program of early stuttering
intervention. Am. J. Speech Lang. Pathol. 2008; 17: 139–49.
35 Kingston M, Huber A, Onslow M, Jones M, Packman A. Predicting
treatment time with the Lidcombe Program: replication and
meta-analysis. Int. J. Lang. Commun. Disord. 2003; 38: 165–77.
36 Millard SK, Nicholas A, Cook FM. Is parent–child interaction therapy
effective in reducing stuttering? J. Speech Hear. Res. 2008; 51:
636–50.
37 Millard S, Edwards SI, Cook FM. Parent–child interaction therapy:
adding to the evidence. Int. J. Speech Lang. Pathol. 2009; 11:
61–7.
38 Trajkovski N, Andrews C, O’Brian S, Onslow M, Packman A. Treating
stuttering in a preschool child with syllable timed speech: a case
report. Behav. Change 2006; 23: 270–7.
39 Trajkovski N, Andrews C, Onslow M et al. A Phase II trial of the
Westmead Program: syllable-timed speech treatment for preschool
children who stutter. Int. J. Speech Lang. Pathol. 2011; 13: 500–9.
40 Trajkovski N, Andrews C, Onslow M et al. Using syllable-timed speech
to treat preschool children who stutter: a multiple baseline
experiment. J. Fluency Disord. 2009; 34: 1–10.
41 Lincoln M, Onslow M, Lewis C, Wilson L. A clinical trial of an operant
treatment for school-age children who stutter. Am. J. Speech Lang.
Pathol. 1996; 5: 73–85.
42 Koushik S, Shenker R, Onslow M. Follow-up of 6–10-year-old stuttering
children after Lidcombe Program treatment: a Phase I trial. J. Fluency
Disord. 2009; 34: 279–90.
43 Ingham R. Spontaneous remission of stuttering: when will the
emperor realize he has no clothes on? In: Prins D, Ingham R, eds.
Treatment of Stuttering in Early Childhood: Methods and Issues. San
Diego: College-Hill Press, 1983; 113–40.
44 Yairi E, Ambrose NG. Early childhood stuttering I: persistency and
recovery rates. J. Speech Lang. Hear. Res. 1999; 42: 1097–112.
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