Stuttering: A quick guide for GPs
Need to know:
- Stuttering is a multifactorial condition involving atypical neural speech processing.
- Stuttering begins suddenly and unexpectedly at a median age of 31 months and has a prevalence of 1–2%. It affects 10% of the population at some stage during life and is present in all cultures and languages.
- Intervention early in childhood is the best clinical option, taking advantage of neuroplasticity. Clinical trials of early intervention show a large effect size.
- With increasing age, stuttering becomes clinically intractable.
- The quality-of-life impairment due to stuttering is comparable to that seen with chronic diseases, such as HIV, diabetes and cardiovascular disease. This is because, unlike many affected by these other chronic conditions, stuttering is present from early childhood.
- Quality-of-life impairment includes educational and occupational disadvantage and speech-related anxiety. Social anxiety disorder (social phobia) is commonly associated with chronic stuttering.
- The Lidcombe Program has the best clinical trial evidence for treatment of early childhood stuttering. The Camperdown Program has the best clinical trial evidence for treating advanced stuttering in adolescents and adults.
- There are no effective pharmacological treatments.
Stuttering is a speech condition that interrupts verbal communication.
The symptoms include any or all of the following: words and syllables repeated, sounds prolonged or complete blocking of speech production.
Some people who stutter display physical tension and non-verbal features, such as tic-like movements of the face, head and torso.
Those who stutter know what they want to say; the issue is they experience difficulty producing speech.
Stuttering occurs in all cultures and languages. Lifetime stuttering incidence is at least 10%, with a prevalence of 1–2%. Males are more commonly affected than females, at a ratio of between 3:1 and 5:1. 1
| Resources: |
| • Australian Stuttering Research Centre • Speech Pathology Australia: Find a speech pathologist • South Western Sydney Stuttering Unit |
A multifactorial condition
Several factors are known to be associated with stuttering and its development. Brain imaging research suggests that atypical neural speech processing contributes to stuttering.1
Cortical and subcortical networks involved in the planning and production of speech have been implicated.1 This may include underdeveloped connectivity in brain regions involved in the planning and production of speech.3,4
Genetics are a factor, with around 70% of those who stutter reporting a family history of stuttering.1 Evidence to date suggests that the inheritance of stuttering is polygenic.1
The median age of onset is 31 months.5 It typically starts unexpectedly after a period of early language development — at a time when children start to use longer and more complex sentences. For some children, stuttering will begin suddenly — sometimes overnight — while for others, onset is more gradual.
Early intervention
Early intervention is essential to take advantage of neural plasticity and may prevent the potential lifelong consequences of stuttering. As soon as parents notice stuttering in a child’s speech, speech pathologist review is essential for assessment and management.
During the preschool years and, for many children, during the early school years, treatment can successfully resolve stuttering or significantly reduce its severity. While some children will recover from stuttering without any intervention, it is not possible to predict for whom this will be the case. Hence, early intervention is recommended for all children.
For young children who stutter, the treatment with the best clinical trial evidence is the Lidcombe Program: a behavioural treatment. Speech pathologists train parents to do the treatment with their child in the home environment. A Cochrane review found that the Lidcombe Program was the only childhood treatment with superiority over no-treatment controls, with a large effect size of 0.92.7
Quality-of-life impact
Stuttering is associated with significant and long-term quality-of-life impacts. The economic impact is comparable to that associated with chronic health conditions, including diabetes, cardiovascular disease and HIV.8 This is because stuttering is present from early childhood.
The onset of stuttering in young children can result in frustration, avoidance of talking and withdrawing from play and social activities.9 For children who stutter, there are many situations in the school environment that can cause anxiety, such as talking or reading aloud in front of the class. As a result, a student may try to conceal stuttering, avoid situations that require talking or avoid school.
Many children who stutter are teased and bullied because of stuttering. Teasing and bullying are known to be associated with significant negative impact on mental health and overall emotional and physical wellbeing.10
It is well documented that stuttering is associated with educational and occupational disadvantage throughout life.1 Students who stutter are less likely to complete secondary education or obtain a tertiary degree. Adults who stutter are more likely to work in jobs that are below their capabilities or to seek occupations with less emphasis on using speech to communicate.1
There is a significantly increased risk of mental health conditions for those who stutter. Social anxiety disorder (social phobia) is the most prevalent mental health condition associated with stuttering.
Primary school children who stutter have a sixfold increased likelihood of developing social anxiety disorder, and adults who stutter have up to 34-fold increased odds.11,12 For adults who stutter and are seeking speech treatment, the comorbidity of mental health conditions reduces the long-term effectiveness of that treatment.13
Persistent stuttering
During late childhood and adolescence, as cortical neuroplasticity decreases, stuttering becomes clinically more intractable and less responsive to treatment.14 Treatment approaches for persistent stuttering differ from early stuttering treatments.
With persistent stuttering, treatments focus on controlling and managing stuttering. This typically involves learning to use fluency-enhancing techniques when talking — commonly referred to as speech restructuring.
A systematic review of adult interventions reported that speech restructuring had the strongest evidence base, with benefits proven in more than 30 clinical trials.15 There is good evidence for the Camperdown Program, a speech restructuring treatment, to help adults and adolescents control stuttering.1
Those who stutter and experience associated anxiety may also benefit from clinical psychological intervention. CBT has the best evidence for treating anxiety associated with stuttering.1 CBT tailored specifically for stuttering can effectively reduce social anxiety and improve overall quality of life.16
There are no effective pharmacological treatments.17,18
Variability of stuttering severity
Severity can vary. Some people stutter mildly; others more severely. However, there are certain situations that are associated with increased stuttering, such as talking in front of a group, talking to people in authority and talking on the phone. Stuttering can also become more severe if a person is tired, anxious, stressed or unwell.
There are some activities that can reduce or temporarily eliminate stuttering. Most notable are singing and acting. When singing, the way words and sounds are produced is altered, vowels are extended and speech rate is reduced.14
Another explanation is that, when singing and acting, performers know what they are going to say. In comparison, conversational speech is a more complex task because it is spontaneous and unpredictable.1 While these conditions may reduce stuttering, they are not effective as treatments for stuttering.
Access to treatment
There is good evidence to support the use of telehealth interventions for the treatment of stuttering. Telehealth treatment outcomes are comparable to in-clinic outcomes for stutter in young children, older children and adolescents, and adults.20-22
At the time of writing, fully automated online speech and anxiety treatments are at various stages of development and clinical trials. Information about how to access these treatments or participate in clinical trials is available on the Australian Stuttering Research Centre website (see resources).
Associate Professor Robyn Lowe is a speech pathologist and researcher at the Australian Stuttering Research Centre, University of Technology Sydney, NSW.
Professor Mark Onslow is a speech pathologist, researcher and founding director of the Australian Stuttering Research Centre, University of Technology Sydney, NSW.
Acknowledgement: The authors would like to thank Damien Liu-Brennan for his scientific copyediting
contribution to this manuscript.
Declaration of interest: The authors certify the absence of any conflicts of interest, including specific financial interests, and relationships and affiliations relevant to the subject of this paper.
- References on request from Dr Kate Kelso.
