Stammering/Stuttering is a disturbance of the rhythm and fluency of speech. It may take the form of repetition of syllables or words, or block in the production of speech.

Introduction

Learning to talk is exciting, it enables children to communicate with family, friends and the world at large and provides a way of bridging the gap between self and others.

Problems with speaking can be extremely upsetting for parents and frustrating for the child. There are, however, plenty of opportunities for mistakes to occur since conversations involve listening, understanding, creative thinking, controlled movement and co-ordination of muscles.

In addition, children live very much in the present, which sometimes leads to feelings so intense that turning thoughts and experiences into words can be difficult. It is not surprising that some children stumble and get stuck when learning to talk.

Normal dysfluency in young children

Pausing, repeating words or sounds ("can, can, can I", or "mu mu mum mummy"), stopping and starting again are the sorts of dysfluencies that occur when children are learning to talk.

Mispronouncing words and muddling up sounds is natural enough but one may perhaps notice the child has difficulty getting his words out, or is unable to say certain sounds (such as ‘r’).

Don’t be too alarmed by any of this. You don’t want your child to grow up with a speech problem, but provided there’s no physical reason for his problems; most of them soon clear up. With this defect, the child talks very hesitantly, perhaps repeating the first letter or first part of a word several times. Many children in the early stages, of language association develop stammering.

Many have episodes of obvious dysfluency during the years of very rapid language development (2-5 years) and at other times during childhood when there are extra pressures to speak well.

A child who is slow in using sentences or in speaking clearly may be particularly sensitive to communication pressure.

Epidemiology

In normal situations the first production of sound is in the form of crying which is followed by babbling. In the first 2-3 months a child uses about 7-8 sounds, which by 2-3 years of age increases to about 25. In initial phases the child’s comprehension vocabulary is more than the speech vocabulary. By the age of 10 months the child starts uttering words which gradually increase, depending upon the mental state and reaching to 250 by 2 years of age.

Stammering is four times more frequent in boys than in girls.

Stammering usually begins in childhood usually between three and five and in 90 per cent of cases before the age of eight. One in 20 children will have a stammer at some time point but 4 per cent recover, with or without help, so that only 1 per cent of adults stammer.

What is Stammering/Stuttering ?

When normal dysfluencies occur so often that they interfere with talking or cause distress to either the speaker or the listener, then stammering may develop.

If relaxed repetitions or stretched out sounds become very tense and the child struggles to finish a word then he or she may be stammering. However, there are many children who experience these problems with talking who don't develop a stammer.

It is impossible to tell for sure which children will pass through a stage of stammering and which will not, so it is always best to do whatever we can to make speaking easier for the child.

There is so much variation in the rate at which children acquire speech that slow progress in language growth at the toddler stage is often within the limits of normal development.

However the situation becomes worrying if the gap in language skills between one child and others of his own age, persists beyond the age of three years. If one suspect’s that the child’s use of language is delayed- and they have had his hearing tested properly, then ask the GP to refer him to an educational psychologist, or to a speech and language therapist.

Causes

It’s really not known yet. Scientists have been working for years to try and find out whether there is a cause and whether there is a cure. So far all that has been agreed is that the problem is highly complicated.

Stammering is probably not caused by one single thing for a child- it is more likely that it is the result of very many factors. More importantly, the ingredients of stammering are probably different for every child who has a stammer. And the things that help stammering may be slightly different for every child too.

This diagram shows the four different areas which may influence the stammer:

Environment

This is linked to everything around the child - home, school, friends, enemies, etc! These don't cause the stammering, but may affect how much the child stammers.

• Is there competition to speak at home or at school?
• Are people around the child in a rush?
• Does the child get teased?

For most children it is a combination of some of these factors that, when added together, make it more likely that they will stammer.

Personality

· Does the child keep all the things to himself?

· Does the child worry a lot?

· Does the child want to be a perfectionist?

Physical Factors

• Does the child have other blood relatives who stammer?
• Does the child have difficulty in concentrating or organizing himself?
• Does the child think faster than he can speak?

Speech and Language Factors

• Does the child have difficulty finding the right words?
• Did the child have trouble learning to talk or was he advanced for his age?
• Did he have difficulty making sounds for speech?
• Is he a fast talker?
• Stammering can also result from a sudden very violent shock, such as a child witnessing violence or having violence done to him, and although not a major cause of the problem this is sometimes true.

• More important are however those repeated incidents when a parent becomes angry with a child and scolds him soundly when he struggles to protest his innocence or to sob out apologies.

• Or those times when a child is pressurized into attempting speech by an impatient and unthinking adult.

• The common belief that a child can start to stammer if he is made to change from left-to right handedness probably also has some truth in it, not only because such a change may involve emotional scenes but because the areas of the brain that deal with speech and handedness are closely associated with each other.

• Of all these strong emotional disturbances are responsible for speech disorders in majority of cases. Hearing and visual defects also play some role in its production.
  
  
• Other predisposing factors resulting in stammering are organic brain disorders (like microcephaly, autism, cerebral palsy, etc).

Inheritance

As far as it is known, it is not so much the stammer that is inherited but rather particular patterns of language development and particular strengths and weakness in different areas of language skill. This means that some children need more support and fewer demands in order to develop their speaking skills in their own good time.

Once a child has developed basic language and articulation skills, it is easier to deal with more complicated ideas and communication pressures.

Development of a Stammer

· Too many demands, which the child is not mature enough to meet, can increase dysfluency which can develop into stammering, especially if the child is very sensitive to failure. There are also things that a child may think and do that can make the problem worse, for example:

A belief or feeling that speaking dysfluently is shameful or wrong.

· Concentration on the detailed mechanics of speaking may lead to self-consciousness and more mistakes.

· Trying harder to speak fluently may turn relaxed repetitions into tense stoppages as the child tries to force the word out.

· In trying to understand stammering certain words, people or situations may be blamed. Avoidance of these to reduce stammering may lead to constant scanning ahead and changing of words and so to less and less confidence in speaking abilities.

· The experience of a loss of control while speaking can be humiliating. As a society we think badly of people who are unable to control their body and its functions.

· A feeling that they are seriously different from others may make children feel isolated and lonely.

Speaking situations which can lead to more dysfluency

· Speaking to adults who talk very quickly.

· Speaking while having to look high up to see the listener's face.

· Speaking when he thinks he will be interrupted.

· Speaking to someone who is not really listening.

· Speaking when he fears the consequences of what is said.

· Speaking when he does not want to or when he has nothing to say.

· Speaking when very tired, upset, or feeling unwell.

The severity of stammering may depend on the child's surroundings. The child may have problems initiating speech, or flowing from one syllable to the next - all stammers sound different. Some deal with the problem by simply not speaking at all.

Child’s View

A child is likely to feel confident and happy when there is a balance between the demands that are made, the child's ability to meet these and the amount of support that is given. Here are some examples of the demands, abilities and supports that can affect speaking:

· Demands can arise from what people actually do or say as well as what the child thinks they want.

· People may demand: good, clear speech; answers to lots of questions; information; grown-up behaviour; quick replies.

· The child may want to: do things well; please parents and other adults; be liked by other children; talk frequently about needs, wants, hurts and pleasures.

· The situation may be: noisy, busy, frightening, exciting, tiring, competitive, there may be interruptions and lots of talking.

Communication abilities

To speak in fluent sentences children need to: know lots of words; know how to put words together (grammar); think quickly of the 'right word' or correct sentence to say what they really mean; listen and understand what others say; learn which sounds we use in our language and how they are put together to form words.

They must also develop motor or mechanical skills so that they can copy the sounds that others use in order to be understood; co-ordinate all the muscles used for breathing and speaking; control the muscles to move quickly and smoothly from one sound to the next.

These abilities are affected by how the child feels as well as by the demands placed upon him. When the child feels: happy, confident, listened to, sure of the content etc., then it's easier to speak well.

When the child feels: upset, tired, unwell, over-excited, unimportant etc., then speaking can be difficult.

Support

It can be difficult to offer support to others when we are anxious ourselves. However, trying to take the child's view changes our focus and makes helping possible. Then we can do those things that make the child feel loved and wanted as well as all the little things that help in particular situations, for example:

· Listening attentively

· Responding kindly and uncritically.

· Offering physical support when needed

· Helping the child to feel safe.

· Being encouraging.

· Helping others understand our child.

Speaking is easier when abilities and support balance demands.

We can help the Child

· Look at the child and get your face on the same physical level

· Speak in language that can be understood easily

· Talk about the present and things that can be seen

· Reduce the number of questions that you ask, allow the child to choose when to tell you things

· Give the child time, slow your own speech, show that you are listening and interested

· If the child is very dysfluent then reduce demands. Maybe return to some of the favourite books, rhymes, games and activities to help the child feel the security of the familiar.

Take the focus off speech

Find time to do things with your child that do not require much talking and where the activity or looking or listening is more important than speaking. Spontaneous, easy talking may occur naturally as a result of the shared experience.

Parents Should Do

· For five minutes at least 3 times a week, daily if you can manage it, arrange a time in the day when you can give your child your full attention in a calm and relaxed atmosphere.

· Try not to get stuck with responses that you know are not helping. You can experiment with ways of helping especially if you can discuss them first with a speech and language therapist.

· Try to put yourself in your child's shoes, look at speaking situations from his or her point of view and think about what may help. Slowing down your own speech when you talk to your child will make it easier for him/her to follow what you are saying and help him feel less rushed. This can be more helpful than telling the child to slow down, start again or take a deep breath.

· Avoid encouraging tricks, that is, things that we do not normally do in relaxed conversations but which improve fluency for a short while.

· It may help to pause for one second before you answer him or ask a question. This slow, less hurried way of speaking gives your child time before answering.

· Show you are interested in what s/he says, not how he is says it. Look at him/her when s/he talks, then s/he knows you are listening and won't rush his/her speech.

· Use the same sort of sentences your child does - keep them short and simple.

· Keep natural eye-contact when s/he is speaking. Do not look away when s/he stammers.

· Reduce the number of questions you ask. Always be sure that you give your child time to answer one before you ask another. Children can feel under pressure when asked a lot of questions at once.

· Encourage everyone in the family to take turns to talk. This will reduce the amount that your child is interrupted and s/he interrupts others.

· Praise your child for things s/he does well. This will help to build confidence.

· Respond to the behaviour of the child who stammers in the same way as that of a child who does not stammer. Discipline needs to be appropriate and consistent.

· Other, more usual ways of increasing fluency can be tried. If something helps then continue, if not then stop and think again. For example, you may find that slowing your own rate of speech helps whereas telling your child to slow down just increases frustration. Do not correct mispronunciations or grammatical mistakes. Just say the correct version for your child to hear.

· Do not blame yourself, you have not caused the stammer. Try to think optimistically about all the things that you can do to help your child speak more fluently.

· To say "don't worry" is unfair since it is probably impossible not to worry. However, if you can remain attentive and calm when your child gets stuck while talking, then your positive attitude may help him or her to feel confident.

· Try to put into words your child's upset and difficult feelings, this will help him or her to feel understood and supported. Do some of the things that you and your child enjoy and where speaking is not especially important.

· Be encouraging. Stammering can undermine children's confidence so that they fail to notice their achievements and everything becomes overshadowed by failures with speaking. Reduce the pressures on all members of the family including yourselves. Do not worry about 'good manners', just give a good example and your child will learn.

· Do anything that makes talking and listening enjoyable. If your child seems aware of stammering then talk gently to him about it. Some adults who stammer felt during childhood that there was a 'conspiracy of silence' which made them feel ashamed of their stammering. Uncritical and open discussion can help.

· Try to be consistent in your handling of all your children. Being clear about family rules helps everyone to feel secure. Consistency with bedtimes, eating, discipline, etc., can reduce battles and also help to avoid excessive tiredness and irritability.

Do seek the help of a speech and language therapist at your local health centre. In most districts you can make direct contact, there is no need to go to a doctor or health visitor first.

It does not matter how young your child is, most therapists like to see a family as soon as they are worried rather than wait until the stammering is developed and so harder to deal with. Therapists are careful not to increase a child's awareness of stammering so they often work mainly with the parents, though an older child may be more directly involved in therapy.

Coping with Teasing

Lots of children have problems with teasing. Here are some problem solving ideas which the children can use:

• Write in a school "problem box"
• Tell a friend
• Call a hotline (e.g. BSA hotline)
• Ask them to stop
• Walk away
• Tell the mother of the person who is teasing you
• Ignore them
• Punch the person
• Make an excuse and leave the situation
• Tell your mum and dad
• Tell your teacher
• Tease back
• Cry
• Avoid them
• Talk to someone else
• Stick with your friends

Stammering and the Bilingual Child

During the pre-school years, virtually all children learn to speak one language well. Across the world there are millions of children who grow up learning to understand and speak more than one language. Research has shown that young children are easily able to learn at least two languages simultaneously.

Between the ages of two and five years, some children repeat words and phrases and hesitate with "em's" and "er's". This is normal when a child is sorting out what to say next.

About five in every hundred children stammer for a time when they are learning to talk. Given that it is considered that about 50% of the world's population is bilingual, there is a large number of children who are showing signs of stammering whilst learning to speak more than one language. However, this does not mean that there is a link between stammering and being bilingual.

There is no evidence to suggest that learning more than one language causes Stammering.

Exposing a child to one or more languages at this early stage is giving him or her opportunity to become competent in both languages.

Managing early dysfluency in a bilingual child is really very similar to the guidelines for a child who speaks one language:

· Continue using two languages at home.

· Show your child how to speak languages well by speaking them one at a time and not mixing up vocabulary.

· Let your child mix up the two languages, as this is a natural stage for bilingual children. Continue to speak the languages properly yourselves but don't ask him or her to repeat it correctly.

If stammering continues for more than a few weeks or seems to be getting worse, one should arrange to see a speech and language therapist.

Treatment

Stammering can make many people feel desperate. Some will go to just about any lengths to experiment with claims of cure, many of which are very expensive. These can take the form of drug therapies or private intensive courses, which may claim to cure a lifelong stammer in a matter of days and, naturally, this is an attractive prospect!

People who claim to have found the cure for stammering often passionately believe they have something to offer those who stammer.

Evidence shows that speech and language therapy can make a positive difference to stammering, especially in the under 5 age group.

By the time children are older, in teenage years, and in adulthood, stammering has generally become more complex. At this later stage psychological issues (including anxiety, fear and self consciousness) have begun to impinge and become intrinsically linked with the stammer itself. While this makes lasting speech change more difficult to achieve, and habitual patterns harder to 'unlearn', older children and adults can still benefit enormously from speech and language therapy and achieve many very positive results.

There is sadly no evidence of a universal cure for stammering, and 'universal' is an important aspect of this notion of cure.

Cure is a medical term and by definition suggests something that is universally effective.

Stammering on the other hand, by teens and adulthood, is a complex disorder with characteristics unique to each individual. It may sound similar to that of another person but differences become evident when factors that trigger the stammering, and reactions to the onset of stammering (both physical and emotional) are considered. These aspects are highly personal and make it important to consider individual needs in any course of therapy.

While there are techniques which can be helpful, these almost always