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Medical Article on Stuttering

Stuttering is a painful symptom that interferes with a child's emotional and psychological development and deserves a serious and assertive evaluation. The pediatrician is in a crucial position to address the disorder at a curable stage. Five major points are discussed in this review: (1) Stuttering is a disorder of childhood; it begins between ages 2 and 7 years in approximately 75% of children who develop stuttering. (2) The pediatrician is often the first professional consulted by the parents of a child stutterer and therefore must assess if and when a speech pathologist or child psychiatrist should be consulted. (3) Stuttering is a painful, embarrassing symptom that causes the child much social and emotional distress. (4) Persistent stuttering greatly interferes with a child's achieving optimal development. (5) Early detection and treatment are crucial. If treated within a year of its occurrence and before a child reaches approximately age 8 years, stuttering can be cured in a great majority, with no recurrence in later life.

Dichotomy in Etiologic Views between Speech

Pathology and Psychiatry

A dichotomy exists between speech pathologists, who for the most part support the view that all child stutterers are psychologically normal, and psychiatrists, who generally support the view that all child stutterers have a psychiatric illness. However, according to this author,' 2 each position represents only a part of the truth. Child psychiatrists tend to study child stutterers who have obvious psychiatric difficulties and live in dysfunctional families; speech pathologists tend to study child stutterers who have minor emotional difficulties and live in families that are only mildly dysfunctional.

Understanding this dichotomy is crucial for the pediatrician. If a particular child stutterer needs a psychiatric evaluation but the pediatrician refers the child to a speech pathologist alone, the child may never receive the evaluation. Also, the pediatrician may refer a child with minor emotional difficulties to a child psychiatrist who may incorrectly equate stuttering with significant psychiatric illness.

There have been attempts to analyze stuttering since ancient times: Aristotle in 384 BC, Hippocrates in 370 BC, and Galen in AD 200 described stuttering as being caused by weak tongues.' Many centuries later, Francis Bacon (1627) gave stutterers hot wine to thaw their stiff tongues. Amazingly, as late as 1923, in the respected journal Lancet,' Scripture described stuttering as a "reflex neurosis with tongue spasms" and stated:

"The stutterer can be temporarily cured for a few days by making a slight but somewhat painful cut in the tongue, by burning it with a cigarette end ... the explanation for the temporary cure of stuttering is a curious one. He is now a person in pain and the human environment may go to hang."


Child and Adult Psychiatry Research

At the beginning of the twentieth century, adult psychiatrists became interested in stutterers after Sigmund Freud wrote that the etiology of stuttering was "for the most part" psychological. Later, he stated that "stammering could be caused by displacement upward of conflicts over excremental functions"' Freud felt the adult stutterer's speech mechanism was enmeshed in a conflict between the wish to defecate symbolically on his parents and authority figures by using hostile words and a concurrent fear of retaliation that caused the stutterer to hold the fecal-oriented words inside.

The early psychiatric theories about stuttering (1900-1945) generally supported Freud's anal displacement theory, and led to the recommendation that stutterers undergo psychotherapy or psychoanalysis. However, child psychiatry and child psychoanalysis did not take shape as a medical specialty until the 1940s.

Modifications to Freud's theory were seen after 1945, as in the work of the psychiatrists Kolansky and Glauber and this author, who discussed the parents' role in the etiology of stuttering. In 1960, Kolansky wrote about his treatment and cure of a 3-year-old girl who began stuttering when her mother gave birth to twins and her grandmother concurrently vigorously bowel-trained her.' In 1965, he became one of the first child psychiatrists to emphasize that the treatment of a child's stuttering should include the parents' active participation .7 His treatment of the 3-year-old involved having the mother and child together in his office playroom. This author described the treatment of two stuttering early grade school girls and the concurrent' therapy with the girls' mothers.

In 1951 and 1958, Glauber reported treating the mothers of stuttering boys. All the mothers had grown up in families in which being a girl had exposed them to parental rejection and ridicule. Later, these women experienced much anger toward and envy of their sons but kept those feelings out of conscious awareness by overprotecting the sons. However, periodically, when they became anxious about their overprotectiveness, they would abruptly withdraw from emotional involvement. In Glauber's view, by the time the son was beginning to use words around age 2 years, he was already experiencing a conflict between a wish to become independent of his mother and a desire to remain completely dependent, holding on to her before she would once again withdraw her love. In Glauber's view, stuttering developed in these sons as a means of expressing the conflict between wanting to talk and grow up and wanting not to talk and remain their mothers' babies.

Until treatment of child stutterers became a significant area of interest for child psychiatrists and psychoanalysts, a void existed. In the 1930s and 1940s, another group of professionals appeared to fill the void: the American Speech Language-Hearing Association." In that period, these speech pathologists may have found the psychoanalytic literature on stuttering difficult to relate to and incorporate within their treatment frame of reference. Freud's 1901 position that the stuttering child used words as feces to be withheld from or smeared over parents or their surrogates, including us, has, interesting enough, been accepted by many speech pathology researchers as psychiatry's current position. I have been confronted with statements like "Do you expect speech pathologists to accept that child stutterers actually equate their words with feces, that they would love to smear their feces over their parents or us? It makes children sound so hedonistic and self-centered and oriented only to their own wishes and drives. " I try to explain that (1) Freud's early theory is now considered incomplete and narrow, (2) psychiatry and psychoanalysis have added to developmental theory the child's desire to control anal wishes in order to achieve self-mastery and gain the parents' love, and (3) Freud's "anal" theory was an early and partial etiological construct, a result of a study of a selected group of almost entirely adult stutterers. I also point out that it may be difficult to consider that children, stutterers or otherwise, may be carrying inside themselves intense feelings of anger toward the parents they also love. Nevertheless, the anal theory does represent a part of the truth for certain groups of child stutterers: Some children who are unresponsive to speech therapy and are referred to a child psychiatrist are often extremely angry at their parents and, in psychotherapy, are preoccupied with smearing, messing, etc. They do not verbally express their angry feelings and desires to mess, because they fear that their parents would respond quite hostility-and many of these children, as correct as they may be in that belief, suffer long and shamefully through their stuttering.

Currently, the speech pathologist is often the only professional whom most pediatricians consider consulting when evaluating a child stutterer. The child psychiatrist may receive an occasional referral by a pediatrician. However, it usually comes from a speech pathologist who has been unsuccessful in evaluation and treatment, which are usually based on behavioral modification principles, with the primary emphasis on the child's stuttering symptoms. Consequently, the child psychiatrist is usually referred a child stutterer who has one or more of the following characteristics: obvious and often quite severe psychiatric difficulties, a duration of stuttering of one or more years, and/or past participation in one or more speech therapy programs that have been unsuccessful in ameliorating or curing the stuttering. It is unfortunate but not surprising that such a prescreened and selected population has led most child psychiatrists to maintain the position expounded by Freud that all child stutterers have significant psychiatric illness and that the etiology of child stuttering is entirely psychological.

Normal Developmental Nonfluency

Normal developmental nonfluency is an aspect of speech between ages 2 and 7 years, but particularly between ages 2 and 4. It is a part of motor and cognitive development in the course of a child's learning to speak a language.

Types of developmental non. fluency in normal children:

1. Whole-word repetition ("You, you, you" )

2. Part-word repetition ("Ta-table")

3. Phrase repetition ("Can I have-can I have a cookie?")

4. Interjections ("Uh.. " "Um.. " "Er")

These nonfluencies are usually not associated with any visible tension during the normal child's verbalization and are verbalized easily and without concern. Occasionally, their frequency may increase, or the child may appear tense when he or she is seeking attention or is in a great hurry to speak. The frequency of nonfluencies is used by speech pathologists to differentiate normal nonfluency from early stuttering, but this should not be considered a hard and fast rule. Less than ten nonfluencies of all types per 100 words may be considered within the normal range; ten or more nonfluencies per 100 words may indicate that a child is developing into a stutterer. It is not yet clear whether a great degree of developmental nonfluency is continuous with or predisposes a child to stuttering.

Characteristics of Child Stuttering

Stuttering may be defined as a nonstereotyped interruption in the normal rhythm of speech manifested by symptoms of involuntary (1) repetition of words, part-words, or sounds, (2) prolongation of sounds, and (3) blocking of words, all of which are usually accompanied by tense movements of the face, jaw, and occasionally an extremity. Of particular diagnostic relevance are the obvious presence of tension while the child is manifesting stuttering symptoms, and the avoidance of certain sounds or words when experience tells the child that significant tension and physical struggle may result.

There are activities of the stuttering child that are usually associated with the development of temporary fluency: singing, choral reading, repeated readings of the same passage, and, during speech, when the introduction of background noise interferes with the child's hearing his or her own voice.

Speech Pathology Research

The amount of speech pathology literature on stuttering since the 1930s is staggering. Froeschels 12 hypothesized that the cause of stuttering was in the ear of the child, that children begin to stutter when they become tense upon hearing their normal developmental nonfluencies. This eventually gave way to Johnson's more widely publicized theory" that the cause of stuttering was in the ear of anxious and perfectionistically oriented parents. Johnson strongly advised speech pathologists and pediatricians to ignore the early symptoms of stuttering in children and work only with the parents to help them become less perfectionistic. His theory had a profound influence on pediatricians and family practitioners, and to this day some medical professionals still advise the parents of a child stutterer to "Ignore it, he'll outgrow it' "

Other theories included the popular belief, disproved by later research, that stuttering can be caused by changing a child's hand preference. Recent research has focused on stutterers showing (1) slowness in initiating speech, (2) a delay in language acquisition, or (3) a disturbance in the child's auditory feedback response to his or her spoken words. However, although small groups of stutterers have been identified as having one of these disturbances, the majority of child stutterers do not manifest any of them.

Sex Ratio and Familial Data

There is a 1% incidence of stuttering worldwide, and a higher incidence in male than in female children, with a range reported from 4:1 to 2.3: 1. Studies of familial incidence of stuttering have reported a positive family history in 25% to 60% of cases. Concordance rates for stuttering in monozygotic twins have been reported as high as 60%, but Farber 14 reported a 0% concordance for six sets of monozygotic twins reared apart.

Child Stutterers: A Heterogeneous Population

Based on my study of approximately 50 child and adolescent stutterers referred in a pediatric clinic setting, it appears that child stutterers are a heterogeneous population. Other researcher have emphasized that child stutterer can no longer be viewed as homogeneous by the speech pathologist or child psychiatrist.

Longitudinal data" suggest that genetic or physiologic-constitutional pre disposition may exist in child stutterers rendering their speech mechanism vulnerable to stress. This necessary predisposing factor is hypothesized to interact with sufficient psychological and environmental stressors to produce stuttering symptoms; however, it most likely has a quantitatively different effect among individual child stutterers. What constitutes the genetic or physiologic-constitutional predisposition and whether it is necessary or only contributory is still unknown. Its mode of transmission is also unclear. Van Riper states, "At present we cannot say with certainty whether the tendency to stutter is carried by a dominant or recessive gene or whether polygenesis is involved.

It is also difficult to explain symptom selection on the basis of psychological and environmental variables, because these variables produce differing symptomatic expression among children. For example, Glauber's theory documented the fact that the mothers of a selected group of stuttering boys alternately encouraged dependence and independence. However, this same pathologic maternal pattern also can be found in the case histories of boys who develop other symptoms, such as encopresis and enuresis.

Risk Factors to Assess in the

Pediatric Evaluation

The following list represents risk factors the pediatrician may be able to assess in the evaluation of a child stutterer. They would be difficult to elicit in taking a history from any group of parents and, therefore, the pediatrician must be skillful, empathetic, and nonjudgmental. The presence of one or more tends to increase the probability that the child's stuttering will not be a transient developmental event, and hence dictates that the pediatrician refers the child for separate psychiatry and s child speech pathology evaluations.

1. The degree to which parents view stuttering as unrelated to childhood stress; i.e., they avoid associating stuttering with a environmental, developmental, family interactional, or speech stress. Nelson found a successful treatment of stuttering for a certain group of children by working almost exclusively with their parents, who were able to view the child's stuttering as a communication of stress." In being open to the consideration that the child's stuttering was indicative of some stress in the family or environment, they could become aware of their excessive ambition and how it influenced the manner in which they spoke to the child, e.g., talking to their child in language more advanced than their child could understand.

2. The degree to which a child's parents are unable to allow the child to use speech to express the truth, i.e., the degree to which they refuse to let the child talk about frustrations, worries, feelings, and conflicts. In a family in which a child faces rejection as a result of saying how he or she feels, it may be very difficult for the child to accept the aid of a speech therapist if stuttering develops.

3. The degree to which the child's parents need to hold on to the child and thereby prevent his growth and development. In investigating this risk factor, we must await the results of further research on very young stutterers, particularly whether there is a statistical correlation between prior parental inhibition of a child's normal development and the subsequent development of stuttering. Nevertheless, regardless of the etiology of the child's stuttering, a mother or father's need to inhibit a child's independence, can, without realizing it, "welcome" the onset of stuttering.

4. The degree to which the following family events and parental behaviors are present:

(a) The child has had frequent separations from primary caretakers, with a lack of concern by them for the effect of the separations on the child's feelings.

(b) The child has had repeated losses of significant people during early childhood (age I to 7 years), such as by death, divorce, or abandonment.

(c) The child has suffered ongoing lack of appreciation and rejection by primary caretakers.

(d) One or both parents are depressed (especially noteworthy is depression in the parent in a single household).

Factors (a) through (d) represent the risk factors found most often in children who, regardless of the etiology of their stuttering, tend to have a poor response to speech therapy and a concurrent psychiatric disturbance. Neither speech therapy nor psychotherapeutic treatment of child stuttering has been studied independently for efficacy. Therefore, it cannot be assumed that successful speech therapy indicates the absence of child psychopathology; nor can it be assumed that failure of speech therapy indicates its presence.

Obtaining a Child's Speech Sample

During Stress

The pediatrician should attempt to obtain a sample of the child's speech during varied situations of stress, which can include the following activities:

1. Ask the child questions about himself, his day, his friends, etc.

2. Show pictures and ask the child to tell a story about each picture.

3. Have another pediatrician or a nurse enter the examination room while the child is responding to pictures or a storybook.

4, Interrupt the child while he is engrossed in speaking about himself, a picture, a favorite story, a TV show, or a recent movie.

5. Show loss of attention for what the child is saying and then ask the child to repeat it.

6. Have the parents enter the examination room and interrupt the child by asking you a question while ignoring him. Then ask the child what he was saying when his parents interrupted.

A New Classification of Child Stuttering_

I. Transient Developmental Stuttering

Phenomenologic and longitudinal data" reveal that approximately 75% of children who begin stuttering between ages 2 and 7 are stutter-free by age 12 years. Data are not available as to what percentage of children recover from stuttering without professional treatment, speech therapy, and/or psychotherapy, nor does a review of the literature demonstrate a study of the psychological and emotional developmental state of children after recovery from stuttering. The assumption that recovered stutterers are not psychologically normal is not borne out by the clinical experience of most pediatricians and speech pathologists. Undoubtedly, some of these children are psychologically normal and others are not so well adjusted. Current research in our clinic is addressing this issue.

Parents of the child with transient developmental stuttering. These parents are relieved when the pediatrician tells them that the stuttering is partially due to a predisposition in the child's speech mechanism but are willing to consider that the predisposition is not sufficient by itself to cause the stuttering. They are willing to discuss the possibility that there may be family stressors that cause the child to experience anxiety. Hence, they can view the child's stuttering as communicating that he or she is under stress. They readily take interest in learning and using fluency-building strategies with the child (Table 2).

Table 2. Parental Fluency-Enhancing Strategies*

1. Reduction in parents' rate of talking. Child will model slower speech rate. Avoid telling child "to slow down;" this suggests child is doing something wrong,

2. Reduction in parents' questioning of child. Do more "commenting" on child's play, activities; child then can choose to speak or remain silent.

3. Parental avoidance of show and tell. Avoid beginning a verbal interchange with a question that requires a child to remember, for example: "Tell Daddy what you saw at the zoo. " Better to comment to Dad in child's presence, "We went to the zoo today and saw elephants and tigers" Child can then comment if he chooses to.

4. Parents increasing their listening and looking at their child when he is talking. When engaged in an activity, ask child to wait before he talks, then give undivided attention as much as possible.

5. Parents talking in shorter sentences and less focused on teaching vocabulary. Allow child to choose to speak when engaged more in shared physical play; be less concerned with teaching vocabulary for a while.

6. Parental response to stuttering should be varied. For children under age 3, simply repeating slowly the child's statement calms the child, reassuring him that the parent understood his message. For children over age 3, repeating the child's statement could cause anxiety. Parents should show patience and acknowledge severe stuttering with something like, I know it was hard for you to say that, and I understand what you said "

*Adapted from material presented by Nelson."

These parents allow the child to talk about how he or she feels without being critical or withdrawing. Their marital relationship is a good one, with each parent showing the child that they respect each other. Neither parent is in great conflict about allowing the child to separate; however, one parent may, for example, be unaware that a recent life event has made the parent cling to the child.

The child with transient develop. mental stuttering. This child most often separates easily from the parents and wants to engage with the pediatrician in the evaluation procedures. The child is often aware that lie has a problem talking and is able to say he is unhappy with how he talks. The child does not usually feel excessive guilt about stuttering, nor does the stuttering make the child feel lie is unloved, worthless, or bad.

Making the diagnosis of transient developmental stuttering. This diagnosis is made retrospectively when (1) the child and family demonstrate the profiles described above and (2) the child's stuttering ceases. However, when these risk factors are not present to any significant degree but the child's stuttering persists for three months after the pediatrician's initial evaluation (and teaching the parents the fluency-enhancing strategies), the child should be referred for separate speech pathology and child psychiatry evaluations.

II. Stuttering Caused by a Developmental Interference

In my clinical experience with a group of unscreened child stutterers, I have identified a category of children that Nelson" independently identified. The parents of these children, for the most part, show most of the characteristics described in the section on parents of a child with transient developmental stuttering. However, in these children, identification of a stressor, with consequent change in a parent-child interaction or environmental manipulation, and the use of fluency-enhancing strategies, does not eradicate the stuttering. It will most often be more severe than that of a child with transient developmental stuttering, showing more tension, more blocking of words and prolongation of the initial sounds of words, and more physical struggle behaviors.

The child with this type of stuttering may possess a greater quantitative degree of the physiologic-constitutional predisposition to stuttering. The pediatrician also must consider the possibility that there may be a greater degree of one or more of the various risk factors, which would tend to increase the probability that the child will not manifest simply a transient developmental form of stuttering.

Such a child should be referred for separate speech pathology and child psychiatry evaluations. With an understanding of the heterogeneity of child stuttering and through collaboration, the speech pathologist and child psychiatrist will be able to identify the nature and quantitative level of the developmental interference to which the child is exposed.

The developmental interference will, in general, fall into one of the following two categories:

1. A hidden, anxiety-producing abnormal family interaction of fairly recent onset that has disturbed the previously usually good family interaction and cohesion.

The child psychiatrist, as a member of a multidisciplinary team, is usually best trained to discover the presence of a family interactional stressor that impinges on the child, causing anxiety. Despite its presence, the recommendation may still be that the child undergo speech therapy.

2. The presence of a quantitatively higher level of the physiologic-constitutional predisposition to stuttering than is present in the child with transient developmental stuttering.

A family history will reveal normal psychological health. The child's high degree of predisposition will make normal stressors of development (e.g., a family move or the death of a pet) become triggering events for the development of stuttering. Hence, the child may appear at first to have transient developmental stuttering, which should resolve, but the stuttering persists. (Interestingly, these children are often documented by speech pathologists as doing well in a speech therapy program and at times used incorrectly to support the view that all stutterers are psychologically normal.)

The pediatrician must be cognizant that a child who has parents such as those described in the section on transient developmental stuttering, but whose stuttering does not resolve, is the type of child who requires the concurrent evaluations of a speech pathologist and a child psychiatrist. The therapy that best addresses the child's stuttering will evolve eventually from a new and better collaboration among pediatrician, speech pathologist, and child psychiatrist.

Some years ago, in collaborative work with speech pathology colleagues, I gave psychotherapy to children who were also in speech therapy. This clinical experience has made me pessimistic about recommending such concurrent therapy. Many children became confused and anxious because of their inability to understand the difference between the speech therapist and the child psychiatrist. (This is especially true of children younger than age 12. When children are older than 12, they understand the difference intellectually but often become confused about the different feelings stimulated by seeing two "doctors" for the same symptom.) As one 7-year-old boy in both speech and psychotherapy commented, "I can't think about speech stuff with my speech doctor and then worry stuff with you, it's too hard" Consequently, in a multidisciplinary treatment conference, it is best to decide on one treatment approach, either speech therapy or psychotherapy/psychoanalysis. In an active collaborative process, if the chosen treatment is ineffective, the child can begin the other treatment.

III. Stuttering Associated with Disturbed Family Relationships: Stuttering as a Symptom of a Child's Psychiatric Illness

There is one type of child stutterer whom an intuitive pediatrician will be able to identify as manifesting symptoms of psychiatric illness without necessarily viewing the stuttering as the main symptom. These children are often referred by pediatricians directly to child psychiatrists because of obvious emotional difficulties in addition to stuttering; however, on occasion, some parents may be very adept at hiding significant pathologic child-parent interactions.

A child also may present stuttering as the only manifest symptom of distress. Such a child is often an overachiever and overly self-critical. The child's parents will not report any stressors in the child's life, either in the present or in the past. They tend to talk like the typical "psychosomatic family," i.e., reporting that everything is perfect in the family, with the only problem being their child's physical symptom, in this case, stuttering. They are often unaware of how ambivalently they behave toward the child, giving love and involvement but then withdrawing both when the child does not perform at the high levels of expectation set by one or, often, both parents.

The more the parents need to deny and thereby become adept in hiding their intense ambition and perfectionism toward the child, the more likely it is that the pediatrician will view the family as fairly healthy and make a referral to a speech pathologist, bypassing the child psychiatrist.

The pediatrician can more easily identify this type of child by noticing the unwillingness of parents to view stuttering as an indication of stress. Also, both parents will describe a packed schedule for the child-sports, music lessons, extra school courses, etc.-and yet be unaware of how unwilling they are to address their excessive ambition for the child. When the pediatrician indicates that they may be too ambitious for the child, they usually respond with anger or condescending politeness. These parents also expect the pediatrician to refer the child to a speech therapist or child psychiatrist who will quickly "fix" the stuttering. (This author has described in detail the parental patterns and psychological variables that must be addressed in the psychotherapeutic treatment of this type of child and his or her parents.' 2 ) The treatment of choice for this child or one with more obvious and prevalent symptoms indicative of psychopathology in addition to stuttering is child psychotherapy or psychoanalysis. Without it, the child will most likely carry the burden of stuttering into adulthood.

IV. Neurogenic Acquired Stuttering

Neurogenic acquired (organic) stuttering' is associated with degenerative brain disease, as a sequela to acute brain damage or meningitis, and is associated with metastatic brain tumor, severe mental retardation, and cerebral vascular infarction. Neurogenic acquired stuttering differs from the three types of stuttering described above in that reading in unison, singing, and delayed auditory feedback do not reduce its frequency and intensity, although they significantly modify stuttering in physically healthy children between ages 2 and 7 years.

The Need for Early Prevention

and Treatment of Child Stutterers

In reviewing Glasner's speech therapy experience with young stutterers, Kernan" encouraged speech pathologists to evaluate child stutterers as early as possible after the onset of stuttering symptoms.

A multitude of behavioral speech modification approaches are being utilized with varying degrees of success. 'A child in speech therapy is often taught various techniques that replace stuttering with controlled, slow rates of talking that help the child focus on (1) connecting words with no breaks or pauses between words, and (2) decreasing the intensity of all vocalizations. The child says words "lightly" instead of making "hard contacts" on all the sounds he verbalizes. The goal is that these new and somewhat artificial ways of talking will, in time, lead to a greater frequency of normal-sounding speech. The child must be willing to monitor his speech so that if he notices an increase in stuttering, he will decrease his rate of talking, etc. Sadly enough, as long as the child continues to use behavioral techniques, he remains "a stutterer." The mental set that eventually the child internalizes is: "I accept it, I am a stutterer, but through using my therapy I can talk better most of the time"

Some children who receive treatment for stuttering before age 7 years, and especially before age 5 years, are cured with no recurrence or further need to use speech techniques. A physiologic-constitutional predisposition is thought always to be present. Its weight in the genesis of the different types of stuttering, and its meaning in the response to treatment have not yet been rigorously researched.

Speech pathologists often have difficulty modifying stuttering in children younger than age 7 years. Children younger than 7 often lack the degree of motivation and concentration needed to use the speech techniques. They find it difficult to think about how they are talking, and they tend to talk before they think. Hence, speech therapy with a child under age 7 years often employs play therapy techniques while de-emphasizing speech techniques. However, play therapy, more within the domain of the child psychiatrist, requires more professional training than most speech pathologists usually receive. Further research by the speech pathologist and the child psychiatrist must address the optimal way to treat the young child stutterer, since effective therapy before age 7 and especially before age 5, is most often associated with a total cure.

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