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
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
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
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
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
(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
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
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).
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
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
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.