Patient Presentation
A 6-year-old female came to clinic with sore throat and fever for 1 day. She had had 3 days of rhinorrhea. She was drinking and urinating well and denied other pain, rash, nausea or emesis. The past medical history revealed a history of stuttering that began around age 3 and started causing social problems when she entered kindergarten as peers starting to make fun of her. She had started private speech therapy about 1 year before the visit.
The pertinent physical exam showed a slightly tired appearing female with a temperature of 38.2°C, respiratory rate of 20/minute, and heart rate of 106/minute. HEENT revealed a reddened pharynx with white patches on her tonsils bilaterally. There was small anterior cervical adenopathy. The rest of her examination was normal. The laboratory evaluation of a rapid strep test was positive. The diagnosis of strep throat was made and penicillin was prescribed. During the visit, the pediatrician had remarked to the mother how much she thought the child’s stuttering had improved. The mother responded that it had “really improved” and they were probably going to stop the therapy soon.
Discussion
Stuttering is defined as to utter with involuntary repetition of sounds. This commonly occurs in young children especially of initial sounds (Li-li-li-like he can’t do that!) but it can be whole word repetition (Like-like-like he can’t do that!). Stuttering as a normal utterance markedly decreases by age 6, so by age 7 if the child has stuttering the child should be evaluated by a professional speech and language pathologist (SLP). Indications for referral to a SLP for stuttering and other problems can be found here.
A recent review of stuttering epidemiology found:
- Initiation of stuttering occurs usually before age 5, most often around 3 years of age
- Females are more affected than males
- Higher socio-economic status has been shown to occur in some studies, but there are methodological problems with some of the studies
- Overall life incidence of 7-8%, and prevalence of <1%
- Genetic studies have found that ~70% of stuttering may be due to genetics and have found a variety of candidate genes on numerous chromosomes depending on the type of study.
Treatment for stuttering in the past has tried a variety of pharmacological treatments with conflicting results as to efficacy and potentially serious negative side effects. Behavioral interventions with SLPs are the mainstay of treatment for patients and families. Behavioral treatment is defined as “…interventions that involve a change in speech behavior through (a) the direct modification of the person stuttering, (b) operant procedures, or (c) in integration of both approaches.” Some examples of behavioral treatments includes:
- Speech motor training where language is broken into smaller parts and relearned through several methods. These parts are then used in word and sentence formation that becomes increasing complex over time
- Delayed auditory feedback where the patient hears their own speech but with a slight delay which hopefully helps them to slow their speech rate. The feedback delay is then decreased over time to no delay, with hopefully retained normal speech rate over time.
- Gradual increase in speech complexity is where one word fluency is achieved with a slow rate of speech, and gradually the words are combined into longer and more complex sentences.
- Extended utterance length is similar to gradual increase in speech complexity but fluency is initially at the syllable level
- Smooth speech is based on prolonged speech treatment where fluency is improved by smooth initiation of words and transitions between words
Many studies have evaluated the % of syllables stuttered as an efficacy measure. In a recent systematic review and meta-analysis, behavioral interventions (N=9 of 4 different behavioral treatments) decreased syllables stuttered by 1 standard deviation usually which was clinically significant for the patients. Five of the studies evaluated the Lidcombe Program developed at the University of Sydney and found it to provide consistent improvement. In this program where the premise is that the parent provides therapy to the child on a daily basis in their own home, the patient and family sees a SLP weekly to provide direct therapy. The SLP also works with the parent in particular to provide feedback to their child daily in their own home and evaluate the stuttering daily. The information is reviewed at the next weekly session. This continues for approximately 1 year until particular ends points are reached. The direct SLP sessions become less frequent but still occur to “maintain” the previous level of improvement, and hopefully have continued improvement.
Learning Point
Rates of stuttering recovery are very high and newer data may indicate even better recovery. Traditionally 85% stuttering recovery has been cited, but newer data cites recovery as closer to 90% and maybe even higher.
Questions for Further Discussion
1. What type of speech and language therapy is available in your location?
2. What are indications for a hearing test?
Related Cases
- Symptom/Presentation
- Specialty
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Stuttering and Speech and Communication Disorders.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
University of Sydney. Lidcombe Program. Available from the Internet at http://sydney.edu.au/health-sciences/asrc/clinic/parents/lidcombe.shtml (rev. 09/24/12, cited 9/21/15)
Ward D. Risk factors and stuttering: evaluating the evidence for clinicians. J Fluency Disord. 2013 Jun;38(2):134-40.
Yairi E, Ambrose N. Epidemiology of stuttering: 21st century advances. J Fluency Disord. 2013 Jun;38(2):66-87.
Nye C, Vanryckeghem M, Schwartz JB, Herder C, Turner HM 3rd, Howard C. Behavioral stuttering interventions for children and adolescents: a systematic review and meta-analysis. J Speech Lang Hear Res. 2013 Jun;56(3):921-32.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 