II. Definitions

  1. Stuttering
    1. Involuntary dysfluency in verbal expression
  2. Persistent Stuttering
    1. Stuttering that lasts beyond age 7 years

III. Epidemiology

  1. Genetic component (from twin studies)
  2. Prevalence
    1. Childhood-Onset Fluency Disorder: 5-10% of preschoolers
    2. Children under age 10 years: 1.4% (66% are boys)
    3. Adults: <1% (80% are men)

IV. Pathophysiology

  1. Fluent speech requires CNS complex coordination of respiratory, laryngeal and articulatory Muscles
  2. Preschool children normally display speech disfluency as they are learning to speak
  3. Those with Childhood-Onset Fluency Disorder display CNS imaging changes affecting speech related pathways
    1. Requires concious monitoring by those who Stutter, in contrast to unconscious fluent speech

V. Signs

  1. Involuntary dysfluency
    1. Repeated sounds, syllables or words
    2. Speech blocks
    3. Prolonged pauses between words
  2. Associated compensatory behaviors
    1. Eye blinking
    2. Jaw jerking
  3. Provocative Factors
    1. Stressful circumstances
    2. Public speaking

VI. Types

  1. Developmental Stuttering (80% of cases)
    1. Stuttering occurs at begining of words
    2. Prominent secondary behaviors
    3. Onset at age 3-8 years and resolves within 4 years in 75% of cases
  2. Neurogenic Stuttering
    1. Acquired Stuttering due to neurologic Trauma (e.g. Cerebrovascular Accident, Head Trauma)
  3. Psychogenic Stuttering (rare)

VII. Differential Diagnosis

  1. Stutter-like Dysfluency
    1. Dysthymic phonation
      1. Blocks (unable to articulate)
      2. Broken words ("I am sp.....eaking")
      3. Prolonged sounds ("ssssssugar")
    2. Partial word repetition ("my ddddd dad is here.")
    3. Single word repetitions ("I think I think..." or "she she she")
  2. Interjections (e.g. "um")
  3. Incomplete phrase ("He is - oh where is he")

VIII. Grading

  1. Normal Stuttering
    1. Onset age 1.5 to 3 years old
    2. Repeated syllables and sounds at the begining of sentences
    3. Children have no awareness of their Stuttering
  2. Mild Stuttering
    1. Onset age 3 to 5 years old
    2. Similar to normal Stuttering but more frequent, associated with secondary behaviors
  3. Severe Stuttering
    1. Onset age 1-7 years
    2. Stuttering occurs in most phrases and sentences

IX. Management

  1. Refer Mild and Severe Stuttering to Speech Pathology
    1. Early interventions are most effective (plastic brain) and less likely to develop complications (see below)
    2. Stutter-like Dysfluency (see differential diagnosis above)
    3. Parental concerns regarding child's speech
    4. Persistent dysfluency >12 months
    5. Worsening dysfluency
  2. Best therapies focus on reducing, not eliminating Stuttering
    1. Decrease Stuttering to less than half the prior events (and ideally to where the child and others do not notice)
    2. Decrease secondary behaviors and mannerisms (e.g. facial expressions, word avoidance)
    3. Speech pathology sessions are typically with both parent and child
      1. Parent learns interventions to practice with their child
  3. Medications are ineffective in Stuttering
    1. Bothe (2006) Am J Speech Lang Pathol 15(4): 342-52 [PubMed]
  4. Devices (Contremporary Stuttering devices, Fluency-shaping mechanisms)
    1. Example: Delayed auditory feedback device (slows speaking rate)
  5. Behavioral Techniques
    1. Provide relaxed environment that allows child enough time to speak without hurrying
    2. Parents and teachers praise fluent speech
    3. Ocasionally acknowledge and correct Stuttering in a gentle non-judgemental way
      1. Examples of feedback: Noting either bumpy or fluid speech

X. Complications

  1. Decreased self esteem and negative Perception by others
  2. Word avoidance and mannerisms (e.g. facial expressions during Stuttering)
  3. Social withdrawal
  4. School difficulties and difficulty completing education
  5. Unemployment or impeded career advancement
  6. Anxiety Disorder (including social anxiety)

XI. Prognosis

  1. Most Stuttering (65-87%) resolves by age 7 years with or without treatment

XII. Resources

  1. American Board of Fluency and Fluency Disorders
    1. https://www.stutteringspecialists.org/
  2. American Speech-Language-Hearing Association (ASHA)
    1. https://www.asha.org/
  3. National Stuttering Association
    1. https://westutter.org/
  4. Stuttering Foundation of America
    1. http://www.stutteringhelp.org

XIII. References

  1. Moore and Jefferson (2004) Handbook Psychiatry , 2nd ed, Chap. 20
  2. Simms in Kliegman (2007) Nelson Pediatrics, 18th ed., Chap. 32
  3. Prasse (2008) Am Fam Physician 77(9): 1271-8 [PubMed]
  4. Sander(2019) Am Fam Physician 100(9): 556-60 [PubMed]
  5. Costa (2000) CMAJ 162(13):1849-55 [PubMed]

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