Stuttering Alexander K.C.
Leung, MBBS, FRCPC, FRCP (Edin),
Stuttering is a speech fluency disorder characterized by frequent repetitions, prolongations, hesitations , or pauses that disrupt the rhythmic flow of speech. The repetitions and prolongations may involve sounds, syllables or words. Stuttering affects approximately 5% of all preschool children and 1 % of the general population. The male to female ratio is approximately 3 to 4:1. The etiology is multifactorial. Stuttering may be due to an inappropriate response of a listener to the normal pattern of dysfluency that is observed during the early childhood years. Heredity and subtle neurophysiological dysfunction are also sugcauses. To prevent stuttering, parents should be instructed to accept dysfluent speech in early childhood. Parents should also be encouraged to change those aspects of the family environment which could be related to stuttering, to reduce the number of frustrations experienced by the child, and to build up the frustration tolerance of the child. Mild stuttering is usually a self-limited problem but severe stuttering requires treatment and counselling. The treatment plan should include tactics which will reduce or eliminate any emotional component and negative attitudes towards stuttering that are present.
gested
From the Department of Pediatrics, The University of Calgary, and the Alberta Children’sHospital, Calgary, Alberta, Canada. Correspondence to: Alexander K.C. Leung, Alberta Children’s Hospital, 1820 Richmond Road, SW, Calgary, Alberta, Canada, T2T 5C7
FRCP (Glasg), FRCPI, FAAP, DCH Wm. Lane M. Robson, MD, FRCPC
A referral to a speech therapist is warranted if the child is over the age of four years, has been stuttering for more than three months, shows consistent stuttering, demonstrates tension or struggle behavior when stuttering, or if the parents express significant concern.
Introduction Since the early medical history, stuttering has received attention than any other speech disorder. Herodotus (464-424 BC), Hippocrates (450-375 BC), and Aristotle (384-322 BC) all mentioned the problem. Moses may have been a stutterer. In Biblical times, Moses prayed, &dquo;My Lord, relieve my mind and ease my task for me, and loose the knot from my tongue that they may understand
more
my
saying.&dquo;
The International Classification of Diseases defines stuttering as &dquo;a disorder in the rhythm of speech in which the individual knows precisely what he wishes to say, but at the same time is unable to say it because of an involuntary repetition, prolongation, or cessation of sound.&dquo;2 Although the majority of children with dysfluent speech will eventually be able to speak normally, even without professional intervention, a substantial number of dysfluent children will become &dquo;full-blown&dquo; stutterers and do require professional treatment. The purpose of this article is to help health care professionals to identify those individuals who are at risk for chronic stuttering and to suggest appropriate interventions in the treatment of this condition.
498 Downloaded from cpj.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
As many as 5% of all preschool children experience periods of dysfluency that are of significant severity to cause observers to describe their speech as stuttering.3 Those children who recover without therapeutic intervention may be termed &dquo;developmentally dysfluent.&dquo; Such children experience stuttering for only brief periods, usually from the age of one to five years, and corresponding to the time between the onset of speech and school entry. Not including the period of early dysfluency, the prevalence of stuttering in the general population is about 1 %.4 The incidence varies considerably with gender. The male to female ratio is approximately 3 to 4:1.4 The available evidence indicates that the incidence of stuttering varies from culture to culture, and within a culture from one socioeconomic level to another. The incidence is higher in children from upper socioeconomic
classes.’
Etiology When children are learning to talk, speech dysfluencies Stuttering is felt by some authors to be due to an inappropriate response by the listener to normal developmental dysfluency. If a listener is not sympathetic to the dysfluency, the resulting feelings of inadequacy by the child may aggravate the dysfluency. This seems to occur particularly in an environment where the parents are perfectionistic, overanxious, and have an exaggerated concern for the welfare of their child.’ Some parents may become anxious or punitive about the normal hesitancies in the speech development of their child. When this occurs, the child, reflecting their attitude, may begin to fear, avoid, or struggle to inhibit the normal hesitancies. The problem usually begins with syllable repetitions. Later, communications become increasingly disrupted because of prolongations, and tense pauses. Once fear, frustration, avoidance, and escape are part of the problem, the disorder may become self-perpetuating. Stuttering may have a genetic predisposition. Studies of twins have shown that monozygotic twins have a higher concordance for stuttering than do dizygotic twins (77% versus 32%).5 Assuming that environmental influences are approximately the same for monozygotic and dizygotic twins, these data suggest heredity plays an important part in the development of stuttering. The risk of stuttering among first-degree relatives of stutterers is more than three times that of the general population.’ The risks vary by the sex of the proband and the sex of the relative. For are common.
stutters has a 23% risk of being a stutterer, while the sister of a boy who stutters has only a 3% risk.’ A son of a female stutterer has a 36% risk, while a daughter of a male stutterer has only a 9% risk.’ Stuttering is found more often in males than in females.~4 Some authors speculate that stuttering may be a sex-linked genetic trait. Other authors favor an environmental explanation. According to this explanation male children are held to higher standards and explanations.6 An alternative explanation is that males are simply more vulnerable to all types of disorders than are females. Current theories of stuttering suggest that a major predisposing factor may be a difficulty in learning the precise temporal patterns required for speech and that some stutterers may have subtle neurophysiological dysfunctions which disrupt the precise timing required to produce speech. 6,1 In particular, some stutterers have difficulty coordinating airflow and voicing, with articulation and resonance.6 Even the fluent speech of a stutterer shows tiny lags and asynchronies which are reflected in slower voice onset, longer transition times between phonemes, and asymmetry between the movements of the lip and jaw. Debney and Parry-Fielder suggest that the sensory-motor reaction time of a stutterer may be slower for speech and also for some non-speech tasks than for the non-stutterer.44 The relationship between stuttering and shift of handedness is controversial.g°9 Some studies support the hypothesis that altering the handedness of a child may result in stuttering. Other studies fail to support this hypothesis.8,9 Stutterers may have varied levels of intelligence. Although several outstanding historical figures such as Charles Darwin, Edward VI, George VI, and Charles Lamb were stutterers, the mean intelligent quotient of stutterers may be slightly below the average. In one study, stutterers as a group were found to score significantly lower (half a standard deviation) on intelligence tests than
instance, the brother of a girl who
Prevalence and Incidence
non-stutterers.10°
Very rarely, stuttering may be acquired, such as when secondary to focal or diffuse damage to the central nervous system. 1 Stuttering has also been reported following the
use
of phenothiazines.
12
Clinical Manifestations The essential features of stuttering include the frequent
repetition or prolongation of sounds, syllables, or words, and frequent or unusual hesitations or pauses that disrupt the rhythmic flow of speech. The extent of the disturbance may vary from situation to situation, and is more severe
499 Downloaded from cpj.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
when the child is under pressure or emotional stress. Dams 13 suggests that the speech of a child who is either becoming or who is already an early stutterer, has the following characteristics: (a) part-word repetitions and prolongations make up in excess of 7% of all words spoken; (b) the part-word repetitions are marked by at least three unit repetitions (e.g., &dquo;bee-bee-bee-beet&dquo; versus &dquo;bee-bee-beet&dquo;); (c) the part-word repetitions are also perceived as containing the sound in place of the vowel normally found in the syllable that is being repeated (e.g., &dquo;buh-buh-buh-beet&dquo; versus &dquo;bee-bee-beet&dquo;); (d) the prolongations last longer than one second; and (e) difficulty in starting or sustaining either voicing or air flow. As more of these five signs are noted in the speech of as child, a physician can be increasingly confident that the child is a
nized sentence structure, and slurred or omitted syllables and sounds. In addition, cluttering is not associated with tensing, concern and interfering reactions that are commonly associated with stuttering. Table 1: Guidelines for abnormal dysfluency.
differentiating
normal from
stutterer.
Stutterers often use fewer words than non-stutterers and avoid difficult words or substitute an easier word for a more difficult one. As stuttering progresses, communication becomes increasingly disrupted and is associated with tense pauses, breathing irregularities, and other facial and body movements.&dquo; Most stutterers do not stutter when they sing, act in a play, speak in chorus, recite rote material, or talk to either animals or people whom they know well. When stutterers do not hear themselves speak, they are fluent. Also, they 8 are fluent when they speak while inhaling.x Van Riper et al’6 believe that children who become stutterers may be distinguished by some or all of the following: (a) a low frustration tolerance; (b) a speech environment with an excess of fluency disruption; (c) a constitutional predisposition (dysphemia) to prolonged dysfluency or to stuttering; (d) parents who misevaluate the speech of their child or for some other reason react to dysfluencies with anxiety, penalty, or both; and (e) an underlying emotional conflict.
Differential
Diagnosis
The differentiation between stuttering and normal dysfluency is not difficult when the disorder is severe. The difficulty is greatest when the disorder is mild or in the early stages of development. The guidelines suggested by
Dams 13
are
useful to differentiate the two conditions
(vide supra). Table 1 shows a modified checklist devised by Van Riper for differentiating normal from abnormal
dysfluency. 14 Cluttering may be confused with stuttering since repetitions are common in both disorders. The major features of cluttering are an excessive speed of speaking, a disorga-
Modified from Van
Riper.14
Complications Stuttering children are more likely to have difficulties in other areas of speech and language development.’° Their
500 Downloaded from cpj.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
development is slower than that of their and fluent peers, they are more likely to have other unrelated articulation disorders.’° Children who stutter are often the target of abuse by peers, and may be teased and ridiculed. They are often unable to participate fully in school activities, particularly those that necessitate speaking in front of a group. They may be discriminated against when they apply for college acceptance. Stuttering children are often involved in disturbed family interactions. The children may have a poor self image, a sense of failure, and a passive external approach to life situations. As well, children who stutter
rate of language
Prevention
Physicians should encourage parents to accept early developmental dysfluency. This will relieve not only the
may express feelings of inferiority and rejection. Stuttering limits career choices, seriously affects personal relationships, and may lead to the development of psychological difficulties that impair the quality of life of an individual. Stuttering is not merely a speech impediment, it is an impediment to social living. Lemert15 remarked that &dquo;the stutterer finds himself at a distinct loss in a culture where such a large proportion of adjustments are predominantly verbal and where competitive success in many areas depends upon the ability of the person to manipulate others through verbal controls. The stutterer simply does not possess the effective speech through which the more important roles are implemented...&dquo;
pressures that the parents may feel, but also the pressures they may otherwise bring to bear on their child. Parents should be encouraged to change those aspects of the environment which may be related to the stuttering. To set a good example, the parents and other family members should talk slowly and in a relaxed manner. Family conversations should be structured so that each child feels he or she can talk at his or her own pace. The child should not be told to speak more slowly or to repeat words that are said indistinctly. Correction or criticism of the speech of the child should be eliminated. Parents should be counselled to reduce the number of frustrations experienced by the child and to build up the frustration tolerance of the child. Children who stutter should be given an opportunity, through play or creative dramatics, to release their feelings. If the home life is excessively busy and hurried, a calmer style should be introduced. Parents should insure that the child has individual attention. Instituting bedtime reading allows the parent to provide a model of slow, calm speech and also to foster closeness and intimacy.
Clinical Evaluation
Treatment
An adequate appraisal of the symptoms is necessary to confirm that stuttering is the correct diagnosis. At least two interviews should be held for children who are evaluated as potential stutterers. The first interview should be a minimum ten minute conversation between the child and the parent. The second interview should be another ten minute conversation between the child and the physician. It is important to assess the degree of dysfluency that the child exhibits and the type of speech interruptions that the child shows. Generally, if the child has more than five or more speech breaks per hundred words, there is cause for concern. It is especially important to identify the type of dysfluency, since this may indicate how far the disorder
has progressed. It is important to obtain historical data relative to the course of the stuttering and specifically to the circumstances and events associated with changes in the frequency and the extent of the stuttering. It is also helpful to inquire about the attitude toward the problem maintained by the stutterer and, in the case of children, by the parents. A complete assessment should include an evaluation of the motor and auditory skills of the stutterer as well as the administration of a screening test of language abilities.
-
cases of stuttering are self-limiting but severe require specific treatment and counselling. In order achieve a lasting result, the treatment plan should
Mild cases
to
include tactics which reduce or eliminate any emotional component and negative parental attitudes, as well as the abnormal speech behavior. The therapy should be individually tailored to fit each child. Parental education is critical to the treatment of the young stutterer. Anxious and punitive reactions to stuttering should be eliminated. The therapy should be directed at increasing the confidence of the child and reducing the fear of stuttering. The child should be encouraged to discuss the problem openly with family and friends, explore his or her feelings and attitudes about the disorder and generally try to diminish the fear. Specific speech therapy is now widely recommended4.7, s~’6 and may be accomplished in the following ways: ( 1 ) The stutterer is induced to decrease the speech rate, either with the direction of the speech therapist, or with the use of a mechanical device, such as a metronome.’ (2) The stutterer is taught an altered way of producing
501
Downloaded from cpj.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
An example is the &dquo;timed syllabic speech,&dquo; in which the child is taught to speak syllable by syllable, with each syllable stressed evenly, said in time to a regular even rhythm, and separated equidistantly from the next syllable.’6 In the &dquo;shadowing&dquo; method, the stutterer follows the words spoken by the therapist. In the &dquo;delayed auditory feedback&dquo; method, a tape recording and reproducing device allows the voice to be returned by ear phones after a few milliseconds.8,16 In an effort to overcome the distorted feedback the patient slows down his speech. Since stutterers speak fluently when they cannot heart their own voice, one method of treatment consists of masking their voice so they cannot hear it. The Edinburgh Masker (Findlay, Irvine Ltd; Penicuik, Scotland) involves strapping a small apparatus acrosss the larynx and then attaching it through a stethoscopelike system. When a stutterer begins to talk, they
speech.
(3)
literally cannot hear anything that they say. (4) To teach the stutterer to relearn normal speech, the various component speech gestures are taught first individually and then in combination. A speech language pathologist should be consulted as early as possible. In general, a referral to a speechlanguage pathologist is indicated if the child is over the age of 4 years, has been stuttering for more than three months, shows consistent stuttering, demonstrates tension or struggle behavior when stuttering, or if the parents show
3.
Although numerous drugs have been tried for stuttering, only haloperidol has produced improvement, 17 but often at the cost of unacceptable side effects. 18 Haloperidol should not be routinely used in the treatment of stuttering.
Etiology and treatment of stuttering.
6.
7. 8. 9.
10. 11.
eds. Processes and Disorders of Human Communication. New York: Harper and Row, 1978:175-204. Van Riper C, Emerick L. Speech correction: an introduction to speech pathology and audiology. New Jersey: Prentice-Hall Inc, 1984:266-8. Guitar BE. Stuttering and stammering. PIR 1985;7:163-8. Rosenfield DB. Stuttering. Curr Probl Pediatr 1982;12:1-27. Chase RA. Neurological aspects of language disorders in children. In: Irwin JV, Marge M, eds. Principles of Childhood Language Disabilities. New York: Appleton-Century-Crofts, 1972:99-135. Editorial. Speech dysfluency. Lancet 1989;1:530-2. Helm NA, Butler RB, Benson DF. Acquired stuttering. Neurology
1978;28:1159-65. 12.
Nurnberg HG, Greenwald B. Stuttering: an unusual side effect of phenothiazines. Am J Psychiatr 1981;138:386-7.
13.
Adams MR. The differential assessment and direct treatment of stuttering. In: Costello JM, ed. Speech Disorders in Children: Recent Advances. San Diego: College Hill Press 1984:261-90. Van Riper C. The nature of stuttering. Englewood Cliffs: PrenticeHall, Inc., 1971:28. Lemert EM. Social Pathology. New York: McGraw, 1951:171. Illingworth RS. The normal child: some problems of the early years and their treatment. New York: Churchill Livingstone, 1987:336-8. Murray TJ, Kelly P, Campbell, et al. Haloperidol in the treatment of stuttering. Br J Psychiatr1977;130:370-3. Leung AK, Fagan JE. Tic disorders in childhood ( and beyond). Postgrad Med 1989;86:251-61. Riley G, Riley J. Evaluation as a basis for intervention. In: Prins D, Ingham R, Treatment of Stuttering in Early Childhood. California: College Hill Press, 1983:43-7.
14. 15.
16.
17. 18.
Prognosis Without specific treatment, approximately 80% of children who have mild stuttering will &dquo;outgrow&dquo; the disorder. In the majority of children, the stutter lasts for only a few months. Even for those children whose stutter is more than mild, the chances of a favorable outcome are excellent provided that treatment is initiated early enough. Riley et al reported that one year after treatment, 84% of the stutterers were either stutter-free or had only a mild residual stutter and two to four years later, the figure was
81%.19
References 1.
Overstake CP.
2.
World Health Organization. International Classification of Diseases.
Ear Nose Throat
J 1980;59:60-81. 4. Debney SJ, Parry-Fielder BR. The child who stutters: theory and therapy in the 1980s. Aust Paediatr J 1988;24:273-4. 5. Williams DE. Stuttering. In: Curtis JF, Davis, JM, Hardy JC, et al,
19.
great concern.’
1977:202. Cooper EB.
Stuttering: a new look at an old problem based on neurophysiological aspects. Springfield: Charles C. Thomas, 1979:3, 14-34.
502
Downloaded from cpj.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
Leung, MBBS, FRCPC, FRCP (Edin),
Stuttering is a speech fluency disorder characterized by frequent repetitions, prolongations, hesitations , or pauses that disrupt the rhythmic flow of speech. The repetitions and prolongations may involve sounds, syllables or words. Stuttering affects approximately 5% of all preschool children and 1 % of the general population. The male to female ratio is approximately 3 to 4:1. The etiology is multifactorial. Stuttering may be due to an inappropriate response of a listener to the normal pattern of dysfluency that is observed during the early childhood years. Heredity and subtle neurophysiological dysfunction are also sugcauses. To prevent stuttering, parents should be instructed to accept dysfluent speech in early childhood. Parents should also be encouraged to change those aspects of the family environment which could be related to stuttering, to reduce the number of frustrations experienced by the child, and to build up the frustration tolerance of the child. Mild stuttering is usually a self-limited problem but severe stuttering requires treatment and counselling. The treatment plan should include tactics which will reduce or eliminate any emotional component and negative attitudes towards stuttering that are present.
gested
From the Department of Pediatrics, The University of Calgary, and the Alberta Children’sHospital, Calgary, Alberta, Canada. Correspondence to: Alexander K.C. Leung, Alberta Children’s Hospital, 1820 Richmond Road, SW, Calgary, Alberta, Canada, T2T 5C7
FRCP (Glasg), FRCPI, FAAP, DCH Wm. Lane M. Robson, MD, FRCPC
A referral to a speech therapist is warranted if the child is over the age of four years, has been stuttering for more than three months, shows consistent stuttering, demonstrates tension or struggle behavior when stuttering, or if the parents express significant concern.
Introduction Since the early medical history, stuttering has received attention than any other speech disorder. Herodotus (464-424 BC), Hippocrates (450-375 BC), and Aristotle (384-322 BC) all mentioned the problem. Moses may have been a stutterer. In Biblical times, Moses prayed, &dquo;My Lord, relieve my mind and ease my task for me, and loose the knot from my tongue that they may understand
more
my
saying.&dquo;
The International Classification of Diseases defines stuttering as &dquo;a disorder in the rhythm of speech in which the individual knows precisely what he wishes to say, but at the same time is unable to say it because of an involuntary repetition, prolongation, or cessation of sound.&dquo;2 Although the majority of children with dysfluent speech will eventually be able to speak normally, even without professional intervention, a substantial number of dysfluent children will become &dquo;full-blown&dquo; stutterers and do require professional treatment. The purpose of this article is to help health care professionals to identify those individuals who are at risk for chronic stuttering and to suggest appropriate interventions in the treatment of this condition.
498 Downloaded from cpj.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
As many as 5% of all preschool children experience periods of dysfluency that are of significant severity to cause observers to describe their speech as stuttering.3 Those children who recover without therapeutic intervention may be termed &dquo;developmentally dysfluent.&dquo; Such children experience stuttering for only brief periods, usually from the age of one to five years, and corresponding to the time between the onset of speech and school entry. Not including the period of early dysfluency, the prevalence of stuttering in the general population is about 1 %.4 The incidence varies considerably with gender. The male to female ratio is approximately 3 to 4:1.4 The available evidence indicates that the incidence of stuttering varies from culture to culture, and within a culture from one socioeconomic level to another. The incidence is higher in children from upper socioeconomic
classes.’
Etiology When children are learning to talk, speech dysfluencies Stuttering is felt by some authors to be due to an inappropriate response by the listener to normal developmental dysfluency. If a listener is not sympathetic to the dysfluency, the resulting feelings of inadequacy by the child may aggravate the dysfluency. This seems to occur particularly in an environment where the parents are perfectionistic, overanxious, and have an exaggerated concern for the welfare of their child.’ Some parents may become anxious or punitive about the normal hesitancies in the speech development of their child. When this occurs, the child, reflecting their attitude, may begin to fear, avoid, or struggle to inhibit the normal hesitancies. The problem usually begins with syllable repetitions. Later, communications become increasingly disrupted because of prolongations, and tense pauses. Once fear, frustration, avoidance, and escape are part of the problem, the disorder may become self-perpetuating. Stuttering may have a genetic predisposition. Studies of twins have shown that monozygotic twins have a higher concordance for stuttering than do dizygotic twins (77% versus 32%).5 Assuming that environmental influences are approximately the same for monozygotic and dizygotic twins, these data suggest heredity plays an important part in the development of stuttering. The risk of stuttering among first-degree relatives of stutterers is more than three times that of the general population.’ The risks vary by the sex of the proband and the sex of the relative. For are common.
stutters has a 23% risk of being a stutterer, while the sister of a boy who stutters has only a 3% risk.’ A son of a female stutterer has a 36% risk, while a daughter of a male stutterer has only a 9% risk.’ Stuttering is found more often in males than in females.~4 Some authors speculate that stuttering may be a sex-linked genetic trait. Other authors favor an environmental explanation. According to this explanation male children are held to higher standards and explanations.6 An alternative explanation is that males are simply more vulnerable to all types of disorders than are females. Current theories of stuttering suggest that a major predisposing factor may be a difficulty in learning the precise temporal patterns required for speech and that some stutterers may have subtle neurophysiological dysfunctions which disrupt the precise timing required to produce speech. 6,1 In particular, some stutterers have difficulty coordinating airflow and voicing, with articulation and resonance.6 Even the fluent speech of a stutterer shows tiny lags and asynchronies which are reflected in slower voice onset, longer transition times between phonemes, and asymmetry between the movements of the lip and jaw. Debney and Parry-Fielder suggest that the sensory-motor reaction time of a stutterer may be slower for speech and also for some non-speech tasks than for the non-stutterer.44 The relationship between stuttering and shift of handedness is controversial.g°9 Some studies support the hypothesis that altering the handedness of a child may result in stuttering. Other studies fail to support this hypothesis.8,9 Stutterers may have varied levels of intelligence. Although several outstanding historical figures such as Charles Darwin, Edward VI, George VI, and Charles Lamb were stutterers, the mean intelligent quotient of stutterers may be slightly below the average. In one study, stutterers as a group were found to score significantly lower (half a standard deviation) on intelligence tests than
instance, the brother of a girl who
Prevalence and Incidence
non-stutterers.10°
Very rarely, stuttering may be acquired, such as when secondary to focal or diffuse damage to the central nervous system. 1 Stuttering has also been reported following the
use
of phenothiazines.
12
Clinical Manifestations The essential features of stuttering include the frequent
repetition or prolongation of sounds, syllables, or words, and frequent or unusual hesitations or pauses that disrupt the rhythmic flow of speech. The extent of the disturbance may vary from situation to situation, and is more severe
499 Downloaded from cpj.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
when the child is under pressure or emotional stress. Dams 13 suggests that the speech of a child who is either becoming or who is already an early stutterer, has the following characteristics: (a) part-word repetitions and prolongations make up in excess of 7% of all words spoken; (b) the part-word repetitions are marked by at least three unit repetitions (e.g., &dquo;bee-bee-bee-beet&dquo; versus &dquo;bee-bee-beet&dquo;); (c) the part-word repetitions are also perceived as containing the sound in place of the vowel normally found in the syllable that is being repeated (e.g., &dquo;buh-buh-buh-beet&dquo; versus &dquo;bee-bee-beet&dquo;); (d) the prolongations last longer than one second; and (e) difficulty in starting or sustaining either voicing or air flow. As more of these five signs are noted in the speech of as child, a physician can be increasingly confident that the child is a
nized sentence structure, and slurred or omitted syllables and sounds. In addition, cluttering is not associated with tensing, concern and interfering reactions that are commonly associated with stuttering. Table 1: Guidelines for abnormal dysfluency.
differentiating
normal from
stutterer.
Stutterers often use fewer words than non-stutterers and avoid difficult words or substitute an easier word for a more difficult one. As stuttering progresses, communication becomes increasingly disrupted and is associated with tense pauses, breathing irregularities, and other facial and body movements.&dquo; Most stutterers do not stutter when they sing, act in a play, speak in chorus, recite rote material, or talk to either animals or people whom they know well. When stutterers do not hear themselves speak, they are fluent. Also, they 8 are fluent when they speak while inhaling.x Van Riper et al’6 believe that children who become stutterers may be distinguished by some or all of the following: (a) a low frustration tolerance; (b) a speech environment with an excess of fluency disruption; (c) a constitutional predisposition (dysphemia) to prolonged dysfluency or to stuttering; (d) parents who misevaluate the speech of their child or for some other reason react to dysfluencies with anxiety, penalty, or both; and (e) an underlying emotional conflict.
Differential
Diagnosis
The differentiation between stuttering and normal dysfluency is not difficult when the disorder is severe. The difficulty is greatest when the disorder is mild or in the early stages of development. The guidelines suggested by
Dams 13
are
useful to differentiate the two conditions
(vide supra). Table 1 shows a modified checklist devised by Van Riper for differentiating normal from abnormal
dysfluency. 14 Cluttering may be confused with stuttering since repetitions are common in both disorders. The major features of cluttering are an excessive speed of speaking, a disorga-
Modified from Van
Riper.14
Complications Stuttering children are more likely to have difficulties in other areas of speech and language development.’° Their
500 Downloaded from cpj.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
development is slower than that of their and fluent peers, they are more likely to have other unrelated articulation disorders.’° Children who stutter are often the target of abuse by peers, and may be teased and ridiculed. They are often unable to participate fully in school activities, particularly those that necessitate speaking in front of a group. They may be discriminated against when they apply for college acceptance. Stuttering children are often involved in disturbed family interactions. The children may have a poor self image, a sense of failure, and a passive external approach to life situations. As well, children who stutter
rate of language
Prevention
Physicians should encourage parents to accept early developmental dysfluency. This will relieve not only the
may express feelings of inferiority and rejection. Stuttering limits career choices, seriously affects personal relationships, and may lead to the development of psychological difficulties that impair the quality of life of an individual. Stuttering is not merely a speech impediment, it is an impediment to social living. Lemert15 remarked that &dquo;the stutterer finds himself at a distinct loss in a culture where such a large proportion of adjustments are predominantly verbal and where competitive success in many areas depends upon the ability of the person to manipulate others through verbal controls. The stutterer simply does not possess the effective speech through which the more important roles are implemented...&dquo;
pressures that the parents may feel, but also the pressures they may otherwise bring to bear on their child. Parents should be encouraged to change those aspects of the environment which may be related to the stuttering. To set a good example, the parents and other family members should talk slowly and in a relaxed manner. Family conversations should be structured so that each child feels he or she can talk at his or her own pace. The child should not be told to speak more slowly or to repeat words that are said indistinctly. Correction or criticism of the speech of the child should be eliminated. Parents should be counselled to reduce the number of frustrations experienced by the child and to build up the frustration tolerance of the child. Children who stutter should be given an opportunity, through play or creative dramatics, to release their feelings. If the home life is excessively busy and hurried, a calmer style should be introduced. Parents should insure that the child has individual attention. Instituting bedtime reading allows the parent to provide a model of slow, calm speech and also to foster closeness and intimacy.
Clinical Evaluation
Treatment
An adequate appraisal of the symptoms is necessary to confirm that stuttering is the correct diagnosis. At least two interviews should be held for children who are evaluated as potential stutterers. The first interview should be a minimum ten minute conversation between the child and the parent. The second interview should be another ten minute conversation between the child and the physician. It is important to assess the degree of dysfluency that the child exhibits and the type of speech interruptions that the child shows. Generally, if the child has more than five or more speech breaks per hundred words, there is cause for concern. It is especially important to identify the type of dysfluency, since this may indicate how far the disorder
has progressed. It is important to obtain historical data relative to the course of the stuttering and specifically to the circumstances and events associated with changes in the frequency and the extent of the stuttering. It is also helpful to inquire about the attitude toward the problem maintained by the stutterer and, in the case of children, by the parents. A complete assessment should include an evaluation of the motor and auditory skills of the stutterer as well as the administration of a screening test of language abilities.
-
cases of stuttering are self-limiting but severe require specific treatment and counselling. In order achieve a lasting result, the treatment plan should
Mild cases
to
include tactics which reduce or eliminate any emotional component and negative parental attitudes, as well as the abnormal speech behavior. The therapy should be individually tailored to fit each child. Parental education is critical to the treatment of the young stutterer. Anxious and punitive reactions to stuttering should be eliminated. The therapy should be directed at increasing the confidence of the child and reducing the fear of stuttering. The child should be encouraged to discuss the problem openly with family and friends, explore his or her feelings and attitudes about the disorder and generally try to diminish the fear. Specific speech therapy is now widely recommended4.7, s~’6 and may be accomplished in the following ways: ( 1 ) The stutterer is induced to decrease the speech rate, either with the direction of the speech therapist, or with the use of a mechanical device, such as a metronome.’ (2) The stutterer is taught an altered way of producing
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An example is the &dquo;timed syllabic speech,&dquo; in which the child is taught to speak syllable by syllable, with each syllable stressed evenly, said in time to a regular even rhythm, and separated equidistantly from the next syllable.’6 In the &dquo;shadowing&dquo; method, the stutterer follows the words spoken by the therapist. In the &dquo;delayed auditory feedback&dquo; method, a tape recording and reproducing device allows the voice to be returned by ear phones after a few milliseconds.8,16 In an effort to overcome the distorted feedback the patient slows down his speech. Since stutterers speak fluently when they cannot heart their own voice, one method of treatment consists of masking their voice so they cannot hear it. The Edinburgh Masker (Findlay, Irvine Ltd; Penicuik, Scotland) involves strapping a small apparatus acrosss the larynx and then attaching it through a stethoscopelike system. When a stutterer begins to talk, they
speech.
(3)
literally cannot hear anything that they say. (4) To teach the stutterer to relearn normal speech, the various component speech gestures are taught first individually and then in combination. A speech language pathologist should be consulted as early as possible. In general, a referral to a speechlanguage pathologist is indicated if the child is over the age of 4 years, has been stuttering for more than three months, shows consistent stuttering, demonstrates tension or struggle behavior when stuttering, or if the parents show
3.
Although numerous drugs have been tried for stuttering, only haloperidol has produced improvement, 17 but often at the cost of unacceptable side effects. 18 Haloperidol should not be routinely used in the treatment of stuttering.
Etiology and treatment of stuttering.
6.
7. 8. 9.
10. 11.
eds. Processes and Disorders of Human Communication. New York: Harper and Row, 1978:175-204. Van Riper C, Emerick L. Speech correction: an introduction to speech pathology and audiology. New Jersey: Prentice-Hall Inc, 1984:266-8. Guitar BE. Stuttering and stammering. PIR 1985;7:163-8. Rosenfield DB. Stuttering. Curr Probl Pediatr 1982;12:1-27. Chase RA. Neurological aspects of language disorders in children. In: Irwin JV, Marge M, eds. Principles of Childhood Language Disabilities. New York: Appleton-Century-Crofts, 1972:99-135. Editorial. Speech dysfluency. Lancet 1989;1:530-2. Helm NA, Butler RB, Benson DF. Acquired stuttering. Neurology
1978;28:1159-65. 12.
Nurnberg HG, Greenwald B. Stuttering: an unusual side effect of phenothiazines. Am J Psychiatr 1981;138:386-7.
13.
Adams MR. The differential assessment and direct treatment of stuttering. In: Costello JM, ed. Speech Disorders in Children: Recent Advances. San Diego: College Hill Press 1984:261-90. Van Riper C. The nature of stuttering. Englewood Cliffs: PrenticeHall, Inc., 1971:28. Lemert EM. Social Pathology. New York: McGraw, 1951:171. Illingworth RS. The normal child: some problems of the early years and their treatment. New York: Churchill Livingstone, 1987:336-8. Murray TJ, Kelly P, Campbell, et al. Haloperidol in the treatment of stuttering. Br J Psychiatr1977;130:370-3. Leung AK, Fagan JE. Tic disorders in childhood ( and beyond). Postgrad Med 1989;86:251-61. Riley G, Riley J. Evaluation as a basis for intervention. In: Prins D, Ingham R, Treatment of Stuttering in Early Childhood. California: College Hill Press, 1983:43-7.
14. 15.
16.
17. 18.
Prognosis Without specific treatment, approximately 80% of children who have mild stuttering will &dquo;outgrow&dquo; the disorder. In the majority of children, the stutter lasts for only a few months. Even for those children whose stutter is more than mild, the chances of a favorable outcome are excellent provided that treatment is initiated early enough. Riley et al reported that one year after treatment, 84% of the stutterers were either stutter-free or had only a mild residual stutter and two to four years later, the figure was
81%.19
References 1.
Overstake CP.
2.
World Health Organization. International Classification of Diseases.
Ear Nose Throat
J 1980;59:60-81. 4. Debney SJ, Parry-Fielder BR. The child who stutters: theory and therapy in the 1980s. Aust Paediatr J 1988;24:273-4. 5. Williams DE. Stuttering. In: Curtis JF, Davis, JM, Hardy JC, et al,
19.
great concern.’
1977:202. Cooper EB.
Stuttering: a new look at an old problem based on neurophysiological aspects. Springfield: Charles C. Thomas, 1979:3, 14-34.
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