07 - 31.4c Child Onset Fluency Disorder (Stutterin

31.4c Child-Onset Fluency Disorder (Stuttering)

31.4c Child-Onset Fluency Disorder (Stuttering) Child-onset fluency disorder (stuttering) usually begins during the first years of life and is characterized by disruptions in the normal flow of speech by involuntary speech motor events. Stuttering can include a variety of specific disruptions of fluency, including sound or syllable repetitions, sound prolongations, dysrhythmic phonations, and complete blocking or unusual pauses between sounds and syllables of words. In severe cases, the stuttering may be accompanied by accessory or secondary attempts to compensate such as respiratory, abnormal voice phonations, or tongue clicks. Associated behaviors, such as eye blinks, facial grimacing, head jerks, and abnormal body movements, may be observed before or during the disrupted speech. Early intervention is important because children who receive early intervention have been found to be more than 7 times more likely to have full resolution of their stuttering. In severe and some untreated cases, stuttering can become an entrenched pattern that is more challenging to remediate later in life and is associated with significant psychological and social distress. When stuttering becomes chronic, persisting into adulthood, the rates of concurrent social anxiety disorder are reported to be between 40 and 60 percent. EPIDEMIOLOGY An epidemiologic survey of 3- to 17-year-olds derived from the United States National Health Interview Surveys reports that the prevalence of stuttering is approximately 1.6 percent. Stuttering tends to be most common in young children and has often resolved spontaneously by the time the child is older. The typical age of onset is 2 to 7 years of age, with 90 percent of children exhibiting symptoms by age 7 years. Approximately 65 to 80 percent of young children who stutter are likely to have a spontaneous remission over time. According to the DSM-5, the rate dips to 0.8 percent by adolescence. Stuttering affects about three to four males for every one female. The disorder is significantly more common among family members of affected children than in the general population. Reports suggest that for male persons who stutter, 20 percent of their male children and 10 percent of their female children will also stutter. COMORBIDITY Very young children who stutter typically show some delay in the development of language and articulation without additional disorders of speech and language. Preschoolers and school-age children who stutter exhibit an increased incidence of social anxiety, school refusal, and other anxiety symptoms. Older children who stutter also do not necessarily have comorbid speech and language disorders, but often manifest anxiety symptoms and disorders. When stuttering persists into adolescence, social isolation occurs at higher rates than in the general adolescent population. Stuttering is also associated with a variety of abnormal motor movements, upper body tics, and

facial grimaces. Other disorders that coexist with stuttering include phonological disorder, expressive language disorder, mixed receptive–expressive language disorder, and ADHD. ETIOLOGY Converging evidence indicates that cause of stuttering is multifactorial, including genetic, neurophysiological, and psychological factors that predispose a child to have poor speech fluency. Although research evidence does not indicate that anxiety or conflicts cause stuttering or that persons who stutter have more psychiatric disturbances than those with other forms of speech and language disorders, stuttering can be exacerbated by certain stressful situations. Other theories about the cause of stuttering include organic models and learning models. Organic models include those that focus on incomplete lateralization or abnormal cerebral dominance. Several studies using EEG found that stuttering males had right hemispheric alpha suppression across stimulus words and tasks; nonstutterers had left hemispheric suppression. Some studies of stutterers have noted an overrepresentation of left-handedness and ambidexterity. Twin studies and striking gender differences in stuttering indicate that stuttering has some genetic basis. Learning theories about the cause of stuttering include the semantogenic theory, in which stuttering is basically a learned response to normative early childhood disfluencies. Another learning model focuses on classic conditioning, in which the stuttering becomes conditioned to environmental factors. In the cybernetic model, speech is viewed as a process that depends on appropriate feedback for regulation; stuttering is hypothesized to occur because of a breakdown in the feedback loop. The observations that stuttering is reduced by white noise and that delayed auditory feedback produces stuttering in normal speakers lend support to the feedback theory. The motor functioning of some children who stutter appears to be delayed or slightly abnormal. The observation of difficulties in speech planning exhibited by some children who stutter suggests that higher-level cognitive dysfunction may contribute to stuttering. Although children who stutter do not routinely exhibit other speech and language disorders, family members of these children often exhibit an increased incidence of a variety of speech and language disorders. Stuttering is most likely to be caused by a set of interacting variables that include both genetic and environmental factors. DIAGNOSIS The diagnosis of childhood-onset fluency disorder (stuttering) is not difficult when the clinical features are apparent and well developed and each of the following four phases (described in the next section) are readily recognized. Diagnostic difficulties can arise when evaluating for stuttering in young children, because some preschool children experience transient dysfluency. It may not be clear whether the nonfluent pattern is part of normal speech and language development or whether it represents the initial stage in the development of stuttering. If incipient stuttering is suspected, referral to a

speech pathologist is indicated. CLINICAL FEATURES Stuttering usually appears between the ages of 18 months and 9 years, with two sharp peaks of onset between the ages of 2 to 3.5 years and 5 to 7 years. Some, but not all, stutterers have other speech and language problems, such as phonological disorder and expressive language disorder. Stuttering does not begin suddenly; it typically develops over weeks or months with a repetition of initial consonants, whole words that are usually the first words of a phrase, or long words. As the disorder progresses, the repetitions become more frequent, with consistent stuttering on the most important words or phrases. Even after it develops, stuttering may be absent during oral readings, singing, and talking to pets or inanimate objects. Four gradually evolving phases in the development of stuttering have been identified: Phase 1 occurs during the preschool period. Initially, the difficulty tends to be episodic and appears for weeks or months between long interludes of normal speech. A high percentage of recovery from these periods of stuttering occurs. During this phase, children stutter most often when excited or upset, when they seem to have a great deal to say, and under other conditions of communicative pressure. Phase 2 usually occurs in the elementary school years. The disorder is chronic, with few if any intervals of normal speech. Affected children become aware of their speech difficulties and regard themselves as stutterers. In phase 2, the stuttering occurs mainly with the major parts of speech—nouns, verbs, adjectives, and adverbs. Phase 3 usually appears after the age of 8 years and up to adulthood, most often in late childhood and early adolescence. During phase 3, stuttering comes and goes largely in response to specific situations, such as reciting in class, speaking to strangers, making purchases in stores, and using the telephone. Some words and sounds are regarded as more difficult than others. Phase 4 typically appears in late adolescence and adulthood. Stutterers show a vivid, fearful anticipation of stuttering. They fear words, sounds, and situations. Word substitutions and circumlocutions are common. Stutterers avoid situations requiring speech and show other evidence of fear and embarrassment. Stutterers may have associated clinical features: vivid, fearful anticipation of stuttering, with avoidance of particular words, sounds, or situations in which stuttering is anticipated; and eye blinks, tics, and tremors of the lips or jaw. Frustration, anxiety, and depression are common among those with chronic stuttering. DIFFERENTIAL DIAGNOSIS Normal speech dysfluency in preschool years is difficult to differentiate from incipient stuttering. In stuttering occurs more nonfluencies, part-word repetitions, sound prolongations, and disruptions in voice airflow through the vocal track. Children who

stutter appear to be tense and uncomfortable with their speech pattern, in contrast to young children who are nonfluent in their speech but seem to be at ease. Spastic dysphonia is a stuttering-like speech disorder distinguished from stuttering by the presence of an abnormal breathing pattern. Cluttering is a speech disorder characterized by erratic and dysrhythmic speech patterns of rapid and jerky spurts of words and phrases. In cluttering, those affected are usually unaware of the disturbance, whereas, after the initial phase of the disorder, stutterers are aware of their speech difficulties. Cluttering is often an associated feature of expressive language disturbance. COURSE AND PROGNOSIS The course of stuttering is often long term, with periods of partial remission lasting for weeks or months and exacerbations occurring most frequently when a child is under pressure to communicate. In children with mild cases, 50 to 80 percent recover spontaneously. School-age children who stutter chronically may have impaired peer relationships as a result of teasing and social rejection. These children may face academic difficulties, especially if they persistently avoid speaking in class. Stuttering is associated with anxiety disorders in chronic cases, and approximately half of individuals with persistent stuttering have social anxiety disorder. TREATMENT Evidence-based treatments for stuttering are emerging in the literature. One such treatment is the Lidcombe Program, which is based on an operant conditioning model in which parents use praise for periods of time in which the child does not stutter, and intervene when the child does stutter to request the child to self-correct the stuttered word. This treatment program is largely administered at home by parents, under the supervision of a speech and language therapist. A second treatment program being investigated in clinical trials is a family-based, parent-child interaction therapy that identifies stressors possibly associated with increased stuttering and aims to diminish these stressors. A third treatment currently under investigation in clinical trials is based on the knowledge that speaking each syllable in time to a particular rhythm has led to diminished stuttering in adults. This treatment program appears to be promising when administered early on, to preschoolers. Distinct forms of interventions have historically been used in the treatment of stuttering. The first approach, direct speech therapy, targets modification of the stuttering response to fluent-sounding speech by systematic steps and rules of speech mechanics that the person can practice. The other form of therapy for stuttering targets diminishing tension and anxiety during speech. These treatments may utilize breathing exercises and relaxation techniques, to help children slow the rate of speaking and modulate speech volume. Relaxation techniques are based on the premise that it is nearly impossible to be relaxed and stutter in the usual manner at the same time. Current interventions for stuttering use individualized combinations of behavioral