Differential Diagnosis

Normal developmental disfluency and early signs of stuttering are often difficult to differentiate. Thus, diagnosis of a stuttering problem is made tentatively. It is based upon both direct observation of the child and information from parents about the child’s speech in different situations and at different times.

Normal Disfluency

Between the ages of 18 months and 7 years, many children pass through stages of speech disfluency associated with their attempts to learn how to talk. Children with normal disfluencies between 18 months and 3 years will exhibit repetitions of sounds, syllables, and words, especially at the beginning of sentences. These occur usually about once in every ten sentences.

After 3 years of age, children with normal disfluencies are less likely to repeat sounds or syllables but will instead repeat whole words (I-I-I can’t) and phrases (I want…I want…I want to go). They will also commonly use fillers such as “uh” or “um” and sometimes switch topics in the middle of a sentence, revising and leaving sentences unfinished.

Normal children may be disfluent at any time but are likely to increase their disfluencies when they are tired, excited, upset, or being rushed to speak. They also may be more disfluent when they ask questions or when someone asks them questions.

Their disfluencies may increase in frequency for several days or weeks and then be hardly noticeable for weeks or months, only to return again.

Typically, children with normal disfluencies appear to be unaware of them, showing no signs of surprise or frustration. Parents’ reactions to normal disfluencies show a wider range of reactions than their children do. Most parents will not notice their child’s disfluencies or will treat them as normal.

Some parents, however, may be extremely sensitive to speech development and will become unnecessarily concerned about normal disfluencies. These overly concerned parents often benefit from referral to a speech clinician for an evaluation and continued reassurance.

Mild Stuttering

Mild stuttering may begin at any time between the ages of 18 months and 7 years, but most frequently begins between 3 and 5 years, when language development is particularly rapid. Some children’s stuttering first appears under conditions of normal stress, such as when a new sibling is born or when the family moves to a new home.

Children who stutter mildly may show the same sound, syllable, and word repetitions as children with normal disfluencies but may have a higher frequency of repetitions overall as well as more repetitions each time. For example, instead of one or two repetitions of a syllable, they may repeat it four or five times, as in “Ca-ca-ca-ca-can I have that?”

They may also occasionally prolong sounds, as in “MMMMMMMommy, it’s mmmmmy ball.” In addition to these speech behaviors, children with mild stuttering may show signs of reacting to their disfluency.

For example, they may blink or close their eyes, look to the side, or tense their mouths when they stutter.

Another sign of mild stuttering is the increasing persistence of disfluencies. As suggested earlier, normal disfluencies will appear for a few days and then disappear. Mild stuttering, on the other hand, tends to appear more regularly. It may occur only in specific situations, but it is more likely to occur in these  
situations, day after day. A third sign associated with mild stuttering is that the child may not be deeply concerned about the problem, but may be temporarily embarrassed or frustrated by it. Children at this stage of the disorder may even ask their parents why they have trouble talking.

Parents’ responses to mild stuttering will vary.10 Most will be at least mildly concerned about it, and wonder what they should do and whether they have caused the problem. A few will truly not notice it; still others may be quite concerned, but deny their concern at first.

Severe Stuttering

Children with severe stuttering usually show signs of physical struggle, increased physical tension, and attempts to hide their stuttering and avoid speaking. Although severe stuttering is more common in older children, it can begin anytime between ages 11/2 and 7 years. In some cases, it appears after children have been stuttering mildly for months or years. In other cases, severe stuttering may appear suddenly, without a period of mild stuttering  
preceding it.

Severe stuttering is characterized by speech disfluencies in practically every phrase or sentence; often moments of stuttering are one second or longer in  
duration. Prolongations of sounds and silent blockages of speech are common.

The severely stuttering child may, like the milder stutterer, have behaviors associated with stuttering: eye blinks, eye closing, looking away, or physical tension around the mouth and other parts of the face. Moreover, some of the struggle and tension may be heard in a rising pitch of the voice during repetitions and prolongations. The child with severe stuttering may also use extra sounds like “um,” “uh,” or “well” to begin a word on which he expects to stutter.

Severe stuttering is more likely to persist, especially in children who have been stuttering for 18 months or longer, although even some of these children will recover spontaneously. The frustration and embarrassment associated with real difficulty in talking may create a fear of speaking. Children with severe stuttering often appear anxious or guarded in situations in which they expect to be asked to talk. While the child’s stuttering will  
probably occur every day, it will probably be more apparent on some days than others.

Parents of children who stutter severely inevitably have some degree of concern about whether their child will always stutter and about how they can best help. Many parents also believe, mistakenly, that they have done something to cause the stuttering. In almost all cases, parents have not done anything to cause the stuttering. They have treated the child who stutters just like they treat their other children, yet they may still feel responsible for
the problem.

They will benefit from reassurance that their child’s stuttering is a result of many causes and not simply the effect of something they did or didn't do. 


CASE EXAMPLES

Case Example: Sally, a child with Mild Stuttering

Sally’s mother and father were concerned because Sally, age 3, was beginning to avoid speaking. The problem had begun several months earlier when Sally was repeating parts of words, like, “Ca-ca-ca-can I ha-ha-ha-have some?” Then a few weeks ago she had difficulty getting started making the first sound of a word. She would open her mouth, quite wide at times, but nothing would come out. Once she asked her mom, “Why can’t I talk?”

Sally’s speech and language development had been normal. She began using single words at an early age—9 months—and was speaking in 2–3 word sentences by 13 months. She talked fluently and enjoyed the family’s fast-paced conversations and word games.

When Sally’s father discussed her speech with Sally’s pediatrician, she referred Sally to a speech-language pathologist in private practice who was known to have expertise in stuttering. Once-a-week treatment sessions consisted of parent counseling and play-oriented interactions between Sally and her speech clinician. Over a period of six months the clinician’s model of a relaxed, accepting style of interacting, combined with Sally’s parents’
changes in the intensity of speech and language stimulation at home, eliminated Sally’s avoidance of speaking and her inability to get sounds started. She continued to show a slightly greater than normal amount of word repetition and phrase repetition for several more years and gradually developed normal speech.

Case Example: Barbara, a child with Mild Stuttering

When Barbara was 3, her pediatrician noticed she was repeating and prolonging sounds when he talked to her. He discussed this with her mother and father and found them to be aware of it. In fact, they had been instructing her to stop and start over again when she repeated sounds. He gave them guidance about slowing their own speech rates and refraining
from criticism.

When her parents brought Barbara to his office six months later for a minor illness the pediatrician inquired about her speech. Barbara’s  parents were frustrated by the lack of change in her speech and had begun to correct her again. Barbara herself seemed reluctant to talk to him. The pediatrician referred Barbara to a speech-language pathologist and continued to counsel the parents to ease conversational pressures on Barbara and refrain from direct correction.

A month later, the pediatrician received a copy of the speech-language pathologist’s written evaluation of Barbara. This indicated that her stuttering had progressed from mild to severe, and that the parents seemed willing to change some key variables in the home speaking environment. The plan for treatment included some direct treatment of Barbara’s stuttering in the speech clinic.

Several months later, Barbara’s parents brought her to the pediatrician for treatment of an infected insect bite. The pediatrician noticed that Barbara’s speech seemed to be the same as before. The parents indicated that they didn’t see the sense in using slower speech rates themselves and have continued to try to correct Barbara’s stuttering by instructions. They had discontinued speech therapy because they were unable to afford it. At present, the pediatrician has given them a copy of If Your Child Stutters: A Guide for Parents, and Stuttering and Your Child: Questions and Answers, and is counseling them to continue changes at home.

Case Example: Jeremy, a child with Severe Stuttering

Jeremy’s speech and language developed more slowly than that of his older sister. He didn’t start to speak until he was two; until then, he would point to what he wanted. When he started to speak, he was difficult to understand. Jeremy’s parents often had to ask him to repeat what he said. His speech became a little clearer at age 3, when he was using 2–3 word sentences. But at about that time he began to repeat initial sounds of words and soon he was prolonging sounds and opening his mouth extra wide when he couldn’t get sounds started. Jeremy’s cousin had also been late in developing speech, but never stuttered, so Jeremy’s parents assumed he would just outgrow it in time. Unfortunately, the stuttering worsened. Soon Jeremy was saying “um” several times just before a word to get it started, in addition to using facial grimaces and wide mouth postures when he got stuck. When he made several attempts to get a word started without success, Jeremy would say “Oh, never mind” and give up. He was gradually becoming more and more reluctant to talk.

By this time, Jeremy’s parents became concerned enough to ask their family physician for advice. After talking to Jeremy, the physician referred them to a speech-language pathologist in a local pre-school program. The speech clinician soon determined that immediate treatment was needed and worked with Jeremy and his family in their home for a year with good initial success. Following this, Jeremy entered first grade and was seen twice a week by the school speech clinician and continues to make good progress. Although he still gets hung up on a word occasionally, his language development is normal and he participates fully in class and in social situations.

Guitar, B., & Conture, E. G. (Eds.) (2006). The child who stutters: To the pediatrician. Fourth edition, publication 0023. Memphis, TN: Stuttering Foundation of America.