This Child Isn’t Fluent — Is It Stuttering Or Something Else?

By Nan Ratner, Ed.D., University of Maryland, College Park
I will start this column by telling a story. 
Because I have specialization in child language disorders, I am often approached by therapists who have school-aged children on their caseloads who seem to need both fluency and language services. A number of years ago, I was struck by how many children appeared to have these dual diagnoses, and also by a common theme that emerged when the child’s therapist (SLP) approached me for input: that the majority of these cases didn’t seem upset by their fluency “problem,” which frustrated a number of approaches that the SLP wished to take with the child. 
Given my experience working in the area of childhood stuttering, I was somewhat dubious that an older child would in fact be oblivious to the stuttering, so I started to ask additional questions, including asking the SLP to imitate the behavior that concerned them and/or the child’s parents.
That turned out to be very informative. 
Almost without exception, SLPs imitated repetitions of sounds, words and phrases, some “drawling” or lengthening of segments, lots of hesitations, and numerous revisions. Blocks, the most canonical of stuttering behaviors, were never imitated, nor was struggle, nor any evidence of self-concept as a child who has difficulty talking. 
Struck by this, I began to think that what the therapists were hearing was certainly not fluent enough to qualify as normal disfluency, but nor did it seem representative of stuttering. 
After reviewing the literature, we found that some others had noted this problem (notably, Penelope Hall in 1977 and Nancy Hall and colleagues; see Hall (1996), and began to take a closer look. It turns out that children with a number of types of language delay and disorder are quite disfluent, far more so than typical children of the same age (see references below from our own lab and the work of other researchers). Critically, however, while these children DO repeat sounds, syllables and words, hesitate, prolong and revise, they don’t demonstrate audible or visible struggle, or awareness, in any of these studies. They appear to have what I will call language formulation disfluency.
Language formulation disfluency: Why does this happen? Well, one approach is to consider how the term “fluency” is used in other fields, such as second language learning, to define mastery of the language. Language fluency is the ability to quickly and accurately assemble sentences, without undue stops to plan the rest of the utterance, retrieve vocabulary, or repair mistakes in production. This is what appears to be happening in children who have a variety of language delays and disorders. Each year, the literature on this topic grows, and production fluency is now being considered as a potentially universal feature of pediatric expressive language disorder, regardless of language being learned (Bernstein Ratner, 2013).
How should one treat these profiles, which do appear atypical? 
This is a tough question, because there is substantial evidence that children with developmental language problems never really fully catch up to peers, implying that many will never be quite as fluent as their typical school-mates. However, that also demonstrates why it may be quite important NOT to treat these children as children who stutter for two separate reasons: first, it is hard to imagine how traditional approaches to stuttering (those that either change the child’s speech motor patterns, or help the child identify and move through moments of struggled stuttering) will be effective in these cases – the cause of the fluency breakdown seems to stem from language formulation problems, and the child is unaware of the problem. Second, any time taken to address the fluency problem will take valuable time away from working on the language problem, which has the potential to seriously impair the child’s educational and vocational potential.
Clearly, there are children who both stutter and have language problems. These children need carefully planned therapy goals so that each gets addressed properly, and the goals of one treatment do not interfere with the goals of the other. For instance, we know that stressing a child’s linguistic abilities can adversely affect the ability to maintain fluency (see summary of this body of research in Hall, et al., 2007).
I turn next to a related term that is often used by SLPs and parents to discuss pre-school children’s fluency: developmental disfluency. This term has been used since the 1930’s (Davis, 1939)  to describe a stage in toddler development during which the child appears to try to say more than s/he can handle without stopping to think or revise or repeat parts of words or phrases. Crucially, this term is only meant to apply to cases where the fluency pattern does not contain hallmarks of stuttering, such as struggle, blocking and awareness.  Developmental disfluency is believed to be a normal phase of language learning that will resolve over the time course of toddlerhood. 
Despite early conjecture that something might operate to change developmental disfluency INTO stuttering (either parental responses, life experiences, etc.), it now seems fairly evident from longitudinal studies of typical pre-schoolers and age-matched peers referred for concerns about stuttering (e.g., the Illinois Project; Yairi & Ambrose, 2005) that these children’s speech behaviors are different from the earliest points in time, and that stuttering does not develop out of developmental disfluency. Despite this, I often see diagnostic reports of young children who go on to specify the characteristics of the child’s stuttering, including Stuttering Severity Instrument scores well within or above the moderate range, with awareness, struggle and secondary behaviors, but the therapist then evaluates family history and other factors that suggest a positive prognosis (we do know that roughly 80% of early stuttering spontaneously resolves without intervention and that some factors can aid in predicting risk for persistence), and diagnose the child with developmental disfluency – because it is likely to go away. In my opinion, this is inaccurate. Stuttering, language formulation disfluency and developmental disfluency have different features, not just likely different outcomes. 
A child who sounds like she is stuttering but who has good prognostic indicators for recovery is a child who stutters but is likely to recover, not a child with developmental disfluency.
Finally, SLPs and parents alike are often confused when children show atypical patterns of disfluency, such as complex repetitions of the ends of words and phrases, that are clearly not normal… but are they stuttering?  In an upcoming column, Vivian Sisskin and I will discuss these more complicated cases, and some possible approaches to treating them.
Boscolo, B., Bernstein Ratner, N. & Rescorla, L. (2002). Fluency characteristics of children with a history of Specific Expressive Language Impairment (SLI-E). American Journal of Speech-Language Pathology, 11, 41-49.
Bernstein Ratner, Nan (2013). Fluency in late talkers. In L. Rescorla & P. Dale (eds.) Late talkers: from theory to practice. Baltimore: Brookes (pp 129-144).
Davis, D. M. (1939). The relation of repetitions in the speech of young children to certain measures of language maturity and situational factors: Part I. Journal of Speech Disorders, 4, 303-318.
Finneran, D. A., Leonard, L. B., & Miller, C. A. (2009). Speech disruptions in the sentence formulation of school-age children with specific language impairment. International Journal of Language & Communication Disorders, 44, 271–286.
Guo, L., Tomblin, J. B., & Samelson, V. (2008). Speech disruptions in the narratives of English-speaking children with specific language impairment. Journal of Speech, Language, and Hearing Research, 51, 722–738.
Hall, N. E. (1996). Language and fluency in child language disorders: Changes over time. Journal of Fluency Disorders, 21, 1-32. 
Hall, N. E., & Yamashita, T. S. (1993). Relationship between language and fluency in children with developmental language disorders. Journal of Speech & Hearing Research, 36, 568-580. 
Hall, Nancy, Wagovich, Stacy & Bernstein Ratner, Nan (2007). Language considerations in childhood stuttering. In E. Conture & R. Curlee (eds.) Stuttering and related disorders of fluency (3rd ed). NY: Thieme.(pp.153-167)
Hall, P. K. (1977). Occurrence of disfluencies in language-disordered school-age children. Journal of Speech & Hearing Disorders, 42364-369. 
Wagovich, S. A., Hall, N. E., & Clifford, B. A. (2009). Speech disruptions in relation to language growth in children who stutter: An exploratory study. Journal of Fluency Disorders, 34(4), 242-256. 
Yairi, E. and Ambrose, N. (2005). Early Childhood Stuttering. Austin: Pro Ed.
From the Winter 2015 Newsletter