Pediatric Brain Injury: Stuttering

What is stuttering?

Stuttering is a communication problem in which spoken words or sounds are involuntarily repeated, drawn out, not completed, or skipped. It affects the fluency of speech. It begins during childhood and, in some cases, lasts throughout life. The disorder is characterized by disruptions in the production of speech sounds, also called "disfluencies." Most people produce brief disfluencies from time to time. For instance, some words are repeated and others are preceded by "um" or "uh." Disfluencies are not necessarily a problem; however, they can impede communication when a person produces too many of them.

In most cases, stuttering has an impact on at least some daily activities. The specific activities that a person finds challenging to perform vary across individuals. For some people, communication difficulties only happen during specific activities, for example, talking on the telephone or talking before large groups. For most others, however, communication difficulties occur across a number of activities at home, school, or work. Some people may limit their participation in certain activities. Such "participation restrictions" often occur because the person is concerned about how others might react to disfluent speech. Other people may try to hide their disfluent speech from others by rearranging the words in their sentence (circumlocution), pretending to forget what they wanted to say, or declining to speak. Other people may find that they are excluded from participating in certain activities because of stuttering. Clearly, the impact of stuttering on daily life can be affected by how the person and others react to the disorder.

What causes stuttering?

Stuttering results when the brain is unable to transmit messages properly. The exact cause of this failure is unknown, although genetics most likely play a role in some people. About 60% of people who stutter have other family members with the disorder. Environmental factors, such as a stressful environment, or biological influences, such as a developmental delay, may trigger stuttering, especially in people who have inherited the tendency to develop the disorder.

In rare cases, stuttering develops as a result of brain damage, such as following a traumatic head injury or stroke.

What are the symptoms?

Stuttering involves irregular and interrupted speech patterns. Characteristics of typical speech patterns include:

• Repetitions of sounds, syllables, or short words. These may occur as:
  • False starts: "c-c-cold."
  • One-syllable words: "I-I hear you."
  • Entire words that have more than one syllable: "Giraffes-giraffes are tall!"
  • Phrases: "I want-I want to go, too."
• Pauses:
  • With word interruptions (interjections): "How do I-um-get up there?"
  • Within a word (broken words): "I am hun ... [pause] ... gry."
  • With lips together but no words are produced.
  • Word substitutions (circumlocution) to avoid trying to say difficult words.
  • Complete changes of words or thoughts: "I found my-Do you want to eat?"
  • Drawn-out words (prolongations), usually at the beginning of sentences: "M-m-m-m-m-mommy, you have ice cream."

You may notice your child stutters more when excited, anxious, or overwhelmed and tired. For example, talking to someone who does not appear interested or asking or answering questions may trigger or increase stuttering. In addition, stuttering often becomes worse when a child tries to explain something complex.

Stuttering may also occur with repetitive gestures or unusual mannerisms, such as exaggerated blinking or tension around the mouth. This is more likely to occur when stuttering is severe or getting worse. These symptoms often indicate that the speaker is aware of and embarrassed by his or her stuttering.

Types of stuttering

Stuttering can be categorized into three main types according to when it begins, its typical pattern, and whether or not it resolves on its own.

• Normal disfluency is stuttering that occurs during early childhood, when speech is rapidly developing, but resolves without treatment before puberty. This type of stuttering may appear sporadically and gradually decrease until it no longer occurs. The irregular speech may be infrequent, and the child usually does not notice or is not bothered by it.
• Developmental stuttering generally requires treatment to improve. Speech problems most often first appear around age 5 during the critical stages of language development but can occur any time between about 2 and 7 years of age. Symptoms range from mild to severe.
• Mild developmental stuttering and normal disfluency can be difficult to tell apart. In general, mild stuttering causes more frequent symptoms. It may also recur after a temporary improvement or become worse. Children with mild developmental stuttering often become frustrated and bothered by their speech problem
• Severe developmental stuttering affects almost every sentence of speech in all situations. Children usually become frustrated, upset, and embarrassed by their stuttering and often cover their mouths with their hands while attempting to speak. They may also develop mannerisms such as nodding the head or closing, blinking, or frequently moving the eyes in an exaggerated way. Severe stuttering most often affects older children, but it can develop in very young children as well. Speech therapy and other forms of treatment are needed to improve severe stuttering, especially if it has lasted 18 months or longer.
• Acquired stuttering may result from an injury or condition that damages the brain, such as a stroke or Alzheimer's disease. Less often, stuttering begins after experiencing an emotional trauma. Typically, a person with acquired stuttering repeats or draws out sounds, syllables, or word patterns. The speaker maintains normal eye contact, does not seem anxious or bothered by his or her speech problems, and doesn't have unusual mannerisms, such as grimacing or eye-blinking.

How is stuttering diagnosed?

Your health professional or a speech-language pathologist diagnoses stuttering by asking questions about your child's speech irregularities and assessing his or her risk factors for stuttering.

Diagnosing stuttering usually also includes:

A history of your child's development. This includes identifying when developmental milestones were reached and whether overall physical and thinking (cognitive) skills are normal for your child's age.

Hearing tests. Hearing problems can affect how well a child pronounces words and uses language to communicate.

Speech and language tests. These are useful in helping a speech-language pathologist identify and assess the severity of irregular speech patterns. A child's speech is evaluated while he or she reads a prepared sample or engages in conversation. A child may also be videotaped talking in different settings.

Your child may also have a physical examination to determine whether another condition is causing or occurring along with stuttering.

This process helps your health professional determine whether irregular speech is a type of normal disfluency, which usually resolves on its own, or a form of developmental stuttering, which requires treatment.

Speech problems that are not normal for your child's age may be diagnosed as developmental stuttering. General indications of developmental stuttering include:

Having three or more speech-related problems (such as trouble starting words; repeating parts of words, sounds, or syllables; prolonging parts of a word; or visibly attempting to speak but producing no sound).

Avoiding or escaping certain words or sounds. This may include pauses or interjections such as "uh" and "um."

Appearing tense and uncomfortable when speaking. This may include grimacing, eye-blinking, head-nodding, and other nervous mannerisms.

Stuttering in adulthood

If you begin to stutter for the first time as an adult, visit your health professional. Be ready to answer questions about your general health and whether you have recently been injured. Your health professional will try to determine whether brain injury is present, such as from an accident or a stroke. If there is a possible relationship, you will be referred to a neurologist.

You may also be referred to a psychiatrist if a recent emotional trauma or other mental health problems may be affecting your speech.

How is it treated?

Stuttering that develops between ages 2 and 7 years is not uncommon and usually resolves on its own. Regardless of whether stuttering is expected to be a temporary condition, treatment can be helpful.

Treatment usually includes parent counseling and speech therapy. Specific treatment varies depending on when and whether a child's stuttering is specifically diagnosed as:

• Normal disfluency, which likely will resolve on its own.
• Developmental stuttering, which most often first appears around age 5 and generally requires treatment to improve.
• Acquired stuttering, which develops as the result of brain injury (usually from an accidental injury or a disease that affects the brain, such as Alzheimer's) or less often, from severe emotional trauma.

Counseling

Parents of children with suspected normal disfluency may benefit from counseling. This therapy strives to educate parents about speech development and how to respond to their child's stuttering in positive ways. Appropriate responses to your child's stuttering can help the child avoid social and emotional problems that can develop. Being supportive of your child also helps prevent stuttering from becoming a more permanent condition.

Speech therapy

Speech therapy for stuttering has a number of different approaches depending on factors such as the person's age, whether stuttering is likely to resolve on its own, and the severity of the problem. Usually, a speech-language pathologist also combines and expands on elements of parent counseling techniques.

The two basic speech therapy methods used for treating stuttering are called indirect treatment and direct treatment.

Indirect treatment focuses on creating a comfortable and relaxing environment in which the child's speech can improve naturally. A speech-language pathologist evaluates and monitors progress while observing the child and parents.

Direct treatment is one-on-one personal interaction between a speech-language pathologist and a child who stutters. The speech-language pathologist teaches the child how to form words, speak slowly, and relax even while stuttering. The child can also practice these exercises outside of instruction time. The child also learns ways to eliminate the physical symptoms of stuttering, such as eye-blinking, and how to deal with the emotional difficulties that may result from speech problems

Other treatments for stuttering are also sometimes used.

Counseling for the child is often recommended when stuttering is complicated by additional problems, such as anxiety. It is also sometimes used when speech therapy has failed. Counseling and speech therapy are often used together for teenagers and adults who have developmental stuttering. The longer stuttering is left untreated, the more difficult it is to manage because additional problems frequently develop, such as low self-esteem. Speech therapy alone is unlikely to resolve these problems. Treatment of teens and adults takes longer and is generally less successful than for children.

Medications are sometimes used as part of treatment for other conditions, such as depression or anxiety, that can make stuttering worse. Talk to your health professional if you have questions about when medications may be appropriate.

Specialized therapies are needed for acquired stuttering, which develops as the result of brain injury (usually from an accidental injury or a disease that affects the brain, such as Alzheimer's) or less often, from severe emotional trauma. After a thorough evaluation, a treatment program is specifically designed that often includes some combination of speech therapy, physical rehabilitation, and medication.

• Concussion
• Craniosynostosis
• Labyrinthitis
• Stuttering

General Brain Injury Topics

• General Brain Injury Verdicts
• Pediatric Brain Injury
• Types of Brain Injuries

General Brain Injury Videos

General Brain Injury Links

• General Brain Injury - Brain Injury Association of America
Official website for the Brain Injury Association of America - includes symptoms, treatments, contacts, etc.
• General Brain Injury - Medline Plus- Brain Injury
General information on head injuries including types, symptoms, treatment, and other resources.