The scope of this page includes stuttering and cluttering across the life span. Acquired neurogenic and psychogenic stuttering are not covered.
See the Fluency Disorders Evidence Map for summaries of the available research on this topic.
Fluency refers to continuity, smoothness, rate, and effort in speech production. All speakers are disfluent at times. They may hesitate when speaking, use fillers (“like” or “uh”), or repeat a word or phrase. These are called typical disfluencies or nonfluencies.
A fluency disorder is an interruption in the flow of speaking characterized by atypical rate, rhythm, and disfluencies (e.g., repetitions of sounds, syllables, words, and phrases; sound prolongations; and blocks), which may also be accompanied by excessive tension, speaking avoidance, struggle behaviors, and secondary mannerisms (American Speech-Language-Hearing Association [ASHA], 1993). People with fluency disorders also frequently experience psychological, emotional, social, and functional impacts as a result of their communication disorder (Tichenor & Yaruss, 2019a).
Stuttering, the most common fluency disorder, is an interruption in the flow of speaking characterized by specific types of disfluencies, including
These disfluencies can affect the rate and rhythm of speech and may be accompanied by
Children and adults who stutter also frequently experience psychological, emotional, social, and functional consequences from their stuttering, including social anxiety, a sense of loss of control, and negative thoughts or feelings about themselves or about communication (Boyle, 2015; Craig & Tran, 2014; Iverach et al., 2016; Iverach & Rapee, 2014).
Stuttering typically has its origins in childhood. Approximately 95% of children who stutter start to do so before the age of 4 years, and the average age of onset is approximately 33 months. Onset may be progressive or sudden. Some children go through a disfluent period of speaking. It is also not unusual for disfluencies to be apparent and then seem to go away for a period of weeks or months only to return again. Approximately 88%–91% of these children will recover spontaneously with or without intervention (Yairi & Ambrose, 2013).
Stuttering can co-occur with other disorders (Briley & Ellis, 2018), such as
Cluttering, another fluency disorder, is characterized by a perceived rapid and/or irregular speech rate, atypical pauses, maze behaviors, pragmatic issues, decreased awareness of fluency problems or moments of disfluency, excessive disfluencies, collapsing or omitting syllables, and language formulation issues, which result in breakdowns in speech clarity and/or fluency (St. Louis & Schulte, 2011; van Zaalen-Opt Hof & Reichel, 2014). Individuals may exhibit pure cluttering or cluttering with stuttering (van Zaalen-Op’t Hof et al., 2009).
Breakdowns in fluency and clarity can result from
Cluttering may have an effect on pragmatic communication skills and awareness of moments of disruption (Teigland, 1996). For example, individuals who clutter may not be aware of communication breakdowns and, therefore, do not attempt to repair them. This results in less effective social interactions.
There are limited data on the age of onset of cluttering; however, the age of onset of cluttering appears to be similar to that of stuttering (Howell & Davis, 2011). Individuals typically aren’t diagnosed or do not start treatment until 8 years of age or into adolescence/adulthood (Ward & Scaler Scott, 2011).
Cluttering can co-occur with other disorders, including
Speech clarity and fluency may temporarily improve when the person is asked to slow down or pay attention to their speech. These should be considered during differential diagnosis but should not be the sole therapeutic strategies.
The incidence of pediatric fluency disorder refers to the number of new cases identified in a specific time period. The prevalence refers to the number of individuals who are living with fluency disorders in a given time period. Estimates of incidence and prevalence vary due to a number of factors, including disparities in the sample populations (e.g., age), how stuttering was defined, and how stuttering was identified (e.g., parent report, direct observation).
Overall, the lifetime prevalence of stuttering was estimated to be 0.72% (Craig et al., 2002). Cumulative incidence estimates of stuttering in children range from 5% to 8% (Månsson, 2000; Yairi & Ambrose, 2013). Higher incidence rates of stuttering have been reported in preschool-aged children (11.2%; Reilly et al., 2013), with prevalence estimates reported as 2.2%–5.6% (Yairi & Ambrose, 2013).
A recent U.S. study estimated that approximately 2% of children ages 3–17 years stutter (Zablotsky et al., 2019). The lowest prevalence rates of stuttering were reported in adults aged 21–50 years (0.78%) and adults aged 51 years or older (0.37%; Craig et al., 2002). “Recovery” rates were estimated to be approximately 88%–91% by Yairi and Ambrose (2013).
Increased incidence of stuttering has been noted among those with a first-degree relative (e.g., parent, sibling) who stutters and an even greater likelihood if that relative is an identical twin (Kraft & Yairi, 2011). Children with a family history of stuttering were estimated to be 1.89 times more likely to persist in stuttering (Singer et al., 2020). Estimates have reported the male-to-female ratio of individuals who stutter to be as large as 4:1; however, more recent studies in preschool children suggest that a younger age of onset has smaller ratios in gender differences (Yairi & Ambrose, 2013). Males were reported to be 1.48 times more likely to persist in stuttering than females (Singer et al., 2020).
The prevalence rate of stuttering in African American children (2–5 years of age) was estimated to be 2.52%, but was not reported to not be significantly different from that reported for European American children in the same age group between 2- to 5-year-old African American children and European American children (Proctor et al., 2008). Non–English-speaking countries reported prevalence rates similar to those reported in English-speaking countries. Depending on the country and methodology used, rates were estimated to range from 1.03% (Abou et al., 2015) to 1.38% (Al-Jazi & Al-Khamra, 2015), but could be as high as 8.4% (Oyono et al., 2018).
“The presence of at least 1 disabling developmental condition was 5.5 times higher in CWS [children who stutter] when compared to children who do not stutter” (Briley & Ellis, 2018, p. 2895). For example, individuals with attention-deficit/hyperactivity disorder, autism spectrum disorder, intellectual disability, learning disability, or seizures have higher odds of stuttering. Estimates report that 1.5% of school-age children who are hard of hearing also stutter, which is similar to the estimates of older elementary students who stutter (Arenas et al., 2017).
Experts in the field of cluttering have consistently estimated that approximately one third of children and adults who stutter also present with at least some components of cluttering (Daly, 1986; Preus, 1981; Ward, 2006). It is important to note that there are more clinical anecdotes than data to support this statement; further research on the incidence and prevalence of cluttering is needed (Scaler Scott, 2013). However, a preliminary prevalence study estimated the rate of cluttering to be between 1.1% and 1.2% of school-age children (Van Zaalen & Reichel, 2017).
Signs and symptoms of stuttering include core speech behaviors, such as
The term overt stuttering is used when core speech behaviors are present.
Other observable, secondary or concomitant, stuttering behaviors can include body movements (e.g., head nodding, leg tapping, fist clenching), facial grimaces (e.g., eye blinking, jaw tightening), and distracting sounds (e.g., throat clearing). These behaviors often are used unsuccessfully to stop or avoid stuttering (Guitar, 2019; Van Riper, 1973).
Avoidance or escape behaviors may also be used and can temporarily conceal stuttering (Constantino et al., 2017; Douglass et al., 2019, 2018; B. Murphy et al., 2007; Starkweather, 1987; Tichenor et al., 2017; Tichenor & Yaruss, 2018, 2019a, 2019b, 2020).
Secondary, avoidance behaviors include
For some people, the use of these behaviors can result in little or no observable stuttering. These individuals are said to experience covert stuttering (B. Murphy et al., 2007). Efforts to conceal stuttering may adversely affect quality of life (Boyle et al., 2018). Lower levels of overt stuttering do not directly relate to lower levels of psychological, emotional, social, or functional impacts experienced by the individual (Lucey et al., 2019; Tichenor & Yaruss, 2019a, 2020).
These signs and symptoms are consistent with the diagnostic and associated features of childhood-onset fluency disorder (stuttering) listed in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013).
Persons who stutter also may experience psychological, emotional, social, and functional reactions to stuttering (anxiety, embarrassment, avoidance, tension and struggle, low self-esteem). Consequently, they may speak less to avoid being disfluent, and they may avoid social situations.
The frequency and severity of overt stuttering may fluctuate from day to day and in relation to the speaking situation. Stuttering is often more severe when there is increased pressure to communicate (e.g., competing for talk time, giving a report at school, talking on the telephone/during a video chat, or interviewing for a job). Factors that contribute to the perception of overt stuttering severity include frequency, duration, effort, naturalness, and the ability of the person who stutters to communicate effectively and efficiently.
Impact experienced from stuttering, or covert features of stuttering, may include
Persons who stutter may appear to have expressive language problems because of a tendency to avoid speaking or speak in a way that’s unclear to the listener. Avoidance can lead to less talking and reduced linguistic complexity. There is ongoing debate as to whether persons who stutter have language skills that are equivalent to those seen in well-matched comparison speakers. A meta-analysis did find differences in the receptive vocabulary, expressive vocabulary, and mean length of utterance between children who stutter and children who do not stutter, with children who stutter generally performing relatively weaker (Ntourou et al., 2011). Children who stutter may demonstrate poorer expressive lexical skills compared to their peers (Silverman & Bernstein Ratner, 2002). However, increased mean length of utterance, more diverse vocabulary, and greater syntactic complexity have also been noted (Wagovich & Hall, 2017).
Some persons who stutter report psychosocial benefits, including personal and relationship benefits and positive perspectives about stuttering and life. These feelings may come from having a positive perception about the ability to face challenges (Boyle et al., 2019).
Signs and symptoms of cluttering include
The speaker’s measured speech rate is not always greater than average, but the listener perceives it as rapid. This perceived rapid rate—and the resulting breakdown in speech clarity—is thought to be because speakers with cluttering speak at a rate that is too fast for their systems to handle (Myers, 1992; St. Louis et al., 2007; Ward, 2006).
Persons who clutter can experience the same affective, behavioral, and cognitive reactions as those with stuttering, including communication avoidance, anxiety, and negative attitudes toward communication (Scaler Scott & St. Louis, 2011). Although some people with cluttering are not aware of their communication difficulties, many are aware that others have difficulty understanding them.
Causes of stuttering are thought to be multifactorial and include genetic and neurophysiological factors that contribute to its emergence (Smith & Weber, 2017).
Genetics and neurophysiology appear to be related to the underlying causes of stuttering.
Environmental factors and speaking demands may exacerbate disfluency and influence a person’s negative reactions to stuttering. Environmental factors include family dynamics, fast-paced lifestyle, and stress and anxiety (J. D. Anderson et al., 2003).
Emotional problems and parenting style do not cause stuttering. However, sensitive temperament (individual behavioral characteristics or reactions) and emotion are commonly seen as traits associated with stuttering in young children. For example, emotional reactivity/regulation and behavioral disinhibition may affect the child’s ability to cope with disfluencies (Choi et al., 2013; Guttormsen et al., 2015; R. M. Jones, Conture, & Walden, 2014; Ntourou et al., 2013). For a review of temperament, emotion, and childhood stuttering, see R. M. Jones, Choi, et al. (2014).
A range of studies support a genetic predisposition for stuttering, but “no definitive findings have been made regarding which transmission model, chromosomes, genes, or sex factors are involved in the expression of stuttering in the population at large” (Kraft & Yairi, 2011, p. 34).
However, several likely gene mutations have been linked to stuttering (Frigerio-Domingues & Drayna, 2017). Specifically, mutations to GNPTAB, GNPTG, and NAGPA have been found to disrupt the signal that directs enzymes to their target location in the lysosome of the cell (Drayna & Kang, 2011). Drayna and Kang (2011) found that gene mutations were present in close to 10% of cases of familial stuttering. Genetic factors also may play a role in predicting the likelihood of persistence or recovery and, possibly, treatment outcomes (Frigerio-Domingues et al., 2019; Han et al., 2014).
Stuttering in animal models, such as zebra finches (Chakraborty et al., 2017) and mice (Barnes et al., 2016; Han et al., 2019), has also been investigated, including how the expression of stuttering influences social behaviors of mice (Han et al., 2019).
Studies have shown both structural and functional neurological differences in children who stutter (Chang, 2014; Chang et al., 2019).
Neurophysiological factors that are thought to contribute to stuttering include the following:
These neurophysiological findings should be interpreted with caution due to the small number of subjects and the heterogeneity of the methodologies used. Areas of the brain that were studied and the technologies used to conduct the research (e.g., PET, MEG, MRI, fMRI, NIRS, DCS) also varied widely. Differences between children and adults should also be considered when interpreting data from neurological studies.
There may be a relationship between stuttering and working memory. Children who stutter may demonstrate decreased performance for phonological tasks such as nonword repetition (Wagovich & Anderson, 2010). The underlying relationship between stuttering and working memory is not fully understood but may be related to interruptions in sensorimotor timing for developmental stuttering and may involve both the basal ganglia and the prefrontal cortex (Bowers et al., 2018).
It is not possible to determine with certainty which children will continue to stutter, but there are some factors that indicate a greater likelihood that stuttering will become chronic.
Risk factors that may be associated with persistent stuttering include
Limited research is available that identifies the causes of cluttering. Preliminary research suggests adults who clutter demonstrate differences in cortical and subcortical activity compared to controls (Ward et al., 2015). With regard to cluttering, research is not far enough along to identify causes. There is very little genetic information on cluttering, except for anecdotal reports that the speech characteristics have been found to be present in more than one member of a family (Drayna, 2011).
Features of cluttering are sometimes observed in conjunction with other neurological disorders (e.g., autism spectrum disorder, Tourette’s syndrome, and attention-deficit/hyperactivity disorder). Potential neurological underpinnings of cluttering include dysregulation of the anterior cingulate cortex and the supplementary motor area (Alm, 2011) as well as increased activity in the basal ganglia and premotor cortex (Ward et al., 2015).
Systems that govern self-regulation may underlie cluttering; qualitative interviews with those who clutter suggest that thoughts emerge before they are ready (Scaler Scott & St. Louis, 2011). The speaker is thought to be talking at a rate that is too fast for their system to handle, resulting in breakdowns in fluency and/or intelligibility (Bakker et al., 2011).
There is not enough epidemiological research to state specific risk factors for cluttering. Unlike stuttering, there are no data regarding age since onset and long-term outcomes of cluttering. Additionally, there is no documented recovery from cluttering; therefore, duration since onset does not seem to apply as a risk factor.
Potential risk factors for cluttering include the following:
Information is varied and conflicting regarding the exact relationship between bilingualism and disfluencies (Tellis & Tellis, 2003; Van Borsel et al., 2001).
Cultural diversity should also be considered in the discussion of stuttering, as it can have an impact on assessment and treatment of stuttering. For example, some children from bilingual or multicultural backgrounds may experience stuttering onset or a temporary increase in stuttering as result of being in new and unfamiliar situations, learning a new language, or being exposed to mixed linguistic input (Shenker, 2013). However, there is no evidence to support the idea that stuttering is caused by, or more prevalent in, bilingual or multilingual speakers or that exposure to a second language increases the risk for developing stuttering (Byrd, 2018).
Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of fluency disorders. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016b).
Appropriate roles for SLPs include the following:
As indicated in the ASHA Code of Ethics (ASHA, 2016a), SLPs who serve this population should be specifically educated and appropriately trained to do so. The American Board of Fluency and Fluency Disorders, under the auspices of ASHA’s specialty certification program, offers clinical specialty certification in fluency and fluency disorders. Board Certified Specialists in Fluency are individuals who hold ASHA certification and have demonstrated advanced knowledge and clinical expertise in diagnosing and treating individuals with fluency disorders.
See the Assessment section of the Fluency Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Screening is conducted whenever a fluency disorder is suspected or as part of a comprehensive speech and language assessment. The purpose of the screening is to identify individuals who require further speech-language assessment.
See ASHA’s resource on assessment tools, techniques, and data sources.
Individuals are referred to a speech-language pathologist (SLP) for a comprehensive assessment when disfluencies are noted and when one or more of the factors listed below are observed along with the disfluencies.
This list is not exhaustive, and not all factors need to be present for a referral to an SLP (e.g., Guitar, 2019; Yaruss et al., 1998).
Consistent with the World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016a; Coleman & Yaruss, 2014; Vanryckeghem & Kawai, 2015; WHO, 2001; Yaruss, 2007; Yaruss & Quesal, 2004, 2006), a comprehensive fluency assessment is conducted to identify and describe
See ASHA’s resource on assessment of fluency disorders in the context of the WHO ICF framework. See also ASHA’s resources titled Person-Centered Focus on Function: Preschool Stuttering [PDF], Person-Centered Focus on Function: School-Age Stuttering [PDF], and Person-Centered Focus on Function: Adult Stuttering [PDF] for examples of assessment data consistent with the ICF framework.
Symptoms and severity of stuttering and cluttering can vary (Davidow & Scott, 2017; St. Louis & Schulte, 2011). For example, cluttering symptoms may decrease during a formal speech evaluation—due to increased self-monitoring—but increase in more comfortable situations where the person is less likely to self-monitor. On the other hand, stuttering symptoms may decrease in more comfortable situations. In addition, some persons who stutter substitute words, omit words, or use circumlocution to hide stuttering symptoms (B. Murphy et al., 2007). Therefore, a comprehensive assessment for fluency disorders should include assessment of both overt and covert features. Additionally, the affective, behavioral, and cognitive features of stuttering are important components of the assessment (Vanryckeghem & Kawai, 2015). Clinicians need to be observant of indicators, such as stuttering avoidance or social isolation, that clients/patients/students may be internalizing negative stereotypes about stuttering (Boyle, 2013a).
For an accurate evaluation, it is ideal to collect samples of speech across various situations and tasks, both inside and outside the clinical setting (Yaruss, 1997). Audiovisual recordings of speech can provide useful information to supplement direct clinical observations. Cluttering and stuttering do not need to occur in all situations or even a majority of the time to be diagnosable disorders.
A comprehensive fluency assessment typically includes the following:
Assessment may result in
See ASHA’s resource on assessment procedures: parallel with CPT codes for a breakdown of pre-evaluation, intra-service, and post-service procedures.
The purpose of assessing fluency in a preschool child is to determine
If treatment is warranted, it is necessary to determine the timing for intervention and to set out a plan for parent education and counseling. If treatment is currently not warranted, the SLP educates the family about how to monitor the child’s fluency to determine if and when the child should be reevaluated.
For stuttering, the assessment will identify risk factors associated with stuttering, the severity of stuttering, and the presence of other speech and language concerns.
Although cluttering has been reported in children as young as 4 years of age, the diagnosis is more commonly made at about 8 years of age (Ward, 2006), when a child’s language becomes lengthy and/or complex enough for symptoms to manifest themselves.
The purpose of assessing school-age children and adolescents for fluency disorders is to determine the presence, the extent, and—most importantly—the impact of the fluency disorder and the potential benefit from treatment.
As children who stutter get older, they may become adept at word and situational avoidances that result in a low frequency of overt stuttering. However, these compensations may compound the negative experience of stuttering over time. Some children who stutter or clutter may only experience symptoms situationally. However, even when children show little observable disfluency, they may still need treatment because of the negative impact of stuttering or cluttering on their lives.
A comprehensive assessment for persistent stuttering should include a self-assessment of the experience of stuttering. However, a school-age child or adolescent who stutters may not report their experience accurately, possibly due to a lack of awareness or a desire to appease the clinician (Adriaensens et al., 2015; Erickson & Block, 2013). Therefore, clinicians may want to ask open-ended questions to assess communication across specific situations (e.g., “How do you participate in class?” “How do you talk to strangers?” “Please describe a situation when you ordered food from a restaurant.” “How did it feel?”). Clinicians also should attempt to better understand how the person experiences the moments before, during, and after stuttering. SLPs may want to relate personal experiences when asking clients to share such vulnerable information.
Adults are likely to have been living with stuttering for a long time. Therefore, as with school-age children and adolescents, the purpose of the assessment for adults typically is not to diagnose stuttering. Rather, the purpose is to determine the extent and impact of the fluency disorder on the individual, the potential benefit from treatment, and the individual’s desire and willingness to change.
Stuttering severity may vary dramatically by speaking situation. Therefore, when conducting an assessment with an adult, it is crucial to understand
Experiences with stuttering can affect an individual’s employment, job satisfaction, personal and romantic relationships, and overall quality of life (Beilby et al., 2013; Blood & Blood, 2016).
Bilingual children are assessed in both languages to determine stuttering profiles in both (Finn & Cordes, 1997). Bilingual children who stutter typically do so in both languages (Nwokah, 1988; Van Borsel et al., 2001). Empirical research on whether bilingual individuals who stutter are more disfluent in one language than the other is sparse and based on small case studies (Tellis & Tellis, 2003), but many bilingual individuals who stutter report this to be the case (Nwokah, 1988). Differences in fluency across languages may be due to the social context in which the language is used (Foote, 2013), as well as the proficiency of each language spoken.
Moments of stuttering or disfluency may be difficult to distinguish from typical disfluency or reduced language proficiency, especially for a person unfamiliar with the language (Shenker, 2011). It is helpful to know that typical bilingual or multilingual children tend to produce higher rates of monosyllabic word repetitions, sound repetitions, and syllable repetitions than monolingual speakers. The differences between disfluencies stemming from reduced language proficiency and stuttering are evident in lack of awareness, struggle, tension, blocking, and lack of self-concept as a person who stutter, which are not seen in typical second language learning profiles (Byrd, 2018).
Enlisting the help of a person familiar with the language and rating fluency in short speech intervals also may help to accurately and reliably judge unambiguous stuttering (Shenker, 2011). Parents of bilingual children easily can be trained to provide perceptual ratings of fluency in any language spoken by the child (Shenker, 2013). Parents can also report if secondary behaviors are present in both languages.
Bilingual SLPs who have the necessary clinical expertise to assess the child—and are familiar with the languages they speak—may not always be available. When a bilingual SLP is not available, using an interpreter is a viable option. See ASHA’s Practice Portal pages on Bilingual Service Delivery and Collaborating With Interpreters, Transliterators, and Translators.
As is the case with any communication disorder, language differences and family/individual values and preferences are taken into consideration during assessment. Languages differ with regard to developmental milestones, and direct comparison of scores across languages can be misleading, even if the assessments appear similar (Thordardottir, 2006). It is not appropriate to determine a standard score if the norming sample of the assessment is not representative of the individual being assessed.
Differentiating between typical disfluencies and stuttering (i.e., ambiguous and unambiguous moments of stuttering) is a critical piece of assessment, particularly for preschool children (see ASHA’s resource on characteristics of typical disfluency and stuttering). It is important to distinguish stuttering from other possible diagnoses (e.g., language formulation difficulties, cluttering, and reading disorders) and to distinguish cluttering from language-related difficulties (e.g., word finding and organization of discourse) and other disorders that have an impact on speech intelligibility (e.g., apraxia of speech and other speech sound disorders).
Part of the diagnostic process is also to distinguish between stuttering disfluencies and disfluencies that occur when learning a new language. For example, English language learners may have word-finding problems in the second language. Tellis and Tellis (2003) caution clinicians not to confuse these word-finding problems with stuttering.
Disfluencies noted in bilingual children and adults are similar to those found for monolingual speakers (Shenker, 2013). Mis- and overidentification of stuttering in bilingual speakers may occur due to typical disfluencies observed in development, code switching, and wording changes to maintain the grammatical integrity of the dominant language. However, these disfluencies are typical and not indicative of a disorder (Shenker, 2013).
Although cluttering and stuttering can co-occur, there are some important distinctions between the two (see Scaler Scott, 2010). Individuals who stutter are more likely to be self-aware about their disfluencies and communication, and they may exhibit more physical tension, secondary behaviors, and negative reactions to communication. Individuals who clutter may exhibit more errors related to reduced speech intelligibility secondary to rapid rate of speech.
Children who stutter typically know how to read (decode) the printed form of words, but they may not be able to speak the printed form fluently. In contrast, children with reading disorders are likely to have difficulty decoding the printed form, which, in turn, has a negative impact on oral reading fluency (Kuhn & Stahl, 2003).
When reading aloud, children who stutter
Oral reading may not be a valid measure of reading fluency for children who stutter, as fluency breakdowns will slow reading rate. Reading slowly may be perceived as a reading problem, even though the underlying cause is stuttering. The validity of reading assessment tools for children who stutter is questionable because it is difficult to differentiate the cause (decoding or stuttering) of oral reading fluency problems. Alternative measures of reading fluency—such as tests of silent reading fluency—may be more valid measures for children who stutter. See an article by ASHA’s Ad Hoc Committee on Reading Fluency For School-Age Children Who Stutter (ASHA, 2014).
It can also be challenging to assess the reading fluency of bilingual students who stutter. For example, when selecting reading passages, it may be difficult to determine the linguistic complexity of a text in a language unfamiliar to the clinician. In addition, clinicians need to avoid using religious or highly familiar texts that individuals may know by rote.
Children with language difficulties at the sentence, narrative, or conversational discourse level may exhibit increased speech disfluencies. They are likely to use interjections, repeat phrases, and revise what they are saying. However, their disfluencies are not likely to involve prolongations, blocks, physical tension, or secondary behaviors that are more typical for children who stutter (Boscolo et al., 2002).
Word-finding problems can also result in an increase in typical disfluencies that are similar to those observed in cluttering. Specific standardized tests can be used to rule out word-finding difficulties. Assessing organization of discourse also can help rule out verbal organization problems that might be mistaken for cluttering (van Zaalen-Op’t Hof et al., 2009).
Other disorders, such as apraxia of speech and/or articulation and phonological disorders, can affect speech intelligibility; assessment of speech production can be used to rule out these causes of reduced speech intelligibility. See ASHA’s Practice Portal pages on Childhood Apraxia of Speech and Speech Sound Disorders: Articulation and Phonology.
When assessing fluency, it is important to consider the impact of fluency disorders on participation in everyday activities. Fluency disorders can interfere with play, school, work, or social interactions (Yaruss & Quesal, 2004). Individuals may experience stuttering in different ways with siblings, their spouse, or other family members.
Individuals may experience the impact of fluency disorders in social and emotional, academic, and vocational domains.
Social and Emotional
Individuals who stutter may report fear or anxiety about speaking and frustration or embarrassment with the time and effort required to speak (Ezrati-Vinacour et al., 2001). Children who stutter also may be at risk for experiencing bullying (Blood & Blood, 2004; Davis et al., 2002; Langevin et al., 1998).
“For students who stutter, the impact goes beyond the communication domain. In fact, stuttering can affect all areas of academic competency, including academic learning, social-emotion functioning, and independent functioning” (Ribbler, 2006, p. 15). Fluency disorders do not necessarily affect test scores or subject grades. It is incumbent upon the SLP to help the individualized education program (IEP) team determine the academic and social impacts of stuttering on students in the school setting.
When determining eligibility for speech and language services through the public school system, SLPs need to document the “adverse educational impact” of the disability using a combination of standardized test scores when available and a portfolio-based assessment (Coleman & Yaruss, 2014; Ribbler, 2006). This includes the impact on functional communication in key school situations and on quality of life (Beilby et al., 2012b; Yaruss et al., 2012). The Present Levels of Academic Achievement and Functional Performance statement, which serves as the baseline for the IEP, refers to other areas that are not necessarily academic and can include information about communication skills, social skills, and other activities of daily living. The Present Levels of Academic Achievement and Functional Performance statements are based on objective data.
School-based SLPs and IEP teams should resist pressure to minimize the impact of stuttering on educational achievement for the purpose of disqualifying students from speech-language pathology services.
The interview process and work environment can be challenging for individuals who stutter. Stuttering may influence an individual’s perception of their career possibilities and professional limitations (Klein & Hood, 2004). Coworkers may have negative attitudes toward individuals who stutter, and the individual may feel excluded because of this. Time pressures for verbal communication and requirements to use the telephone may lead to stress and discomfort. Individuals who stutter consistently report experiencing limitations, discrimination, and glass ceiling–like effects at their jobs and within their careers (Bricker-Katz et al., 2013; Cassar & Neilson, 1997; Klein & Hood, 2004).
Helping individuals who stutter become more accepting and open about their stuttering may help them have workplace conversations about it, advocate for themselves, and build support systems within the workplace (Plexico et al., 2019).
See the Treatment section of the Fluency Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Clients often report successful stuttering therapy as a transformational experience progressing from avoidance to acceptance and openness, increasing self-confidence and self-efficacy (Plexico et al., 2005; Tichenor & Yaruss, 2019a). However during treatment and forming a new, more congruent identity, clients may progress through some of the stages of grief (e.g., 1. Shock, 2. Denial, 3. Anger/Resistance, 4. Bargaining, 5. Sadness/Depression, 6. Testing, and 7. Acceptance; Constantino et al., 2017. There are several indicators of positive therapeutic change.
Indicators of positive therapeutic change may include
Treatment for fluency disorders is highly individualized and based on a thorough assessment of speech fluency, language factors, emotional/attitudinal components, and life impact (Byrd & Donaher, 2018). The speech-language pathologist (SLP) uses linguistically and culturally appropriate stimuli and is sensitive to the unique values and preferences of each individual and their family to create a treatment plan (Sisskin, 2018).
The clinician (a) considers the degree to which the individual’s disfluent behaviors and overall communication are influenced by a coexisting disorder (e.g., other speech or language disorders, Down syndrome, autism spectrum disorder, attention-deficit/hyperactivity disorder) and (b) determines how treatment might be adjusted accordingly. Clinicians need to understand the interaction of symptoms and the strategies that are most effective for dealing with stuttering and cluttering when they occur together. The ultimate goal is for individuals to understand these interactions and how they can manage the disfluencies and their reactions.
Consider the individual’s age, preferences, and needs within the context of family and community when selecting and adapting treatment approaches and materials. For a discussion of a process for selecting evidence-based approaches based on individual needs, see Yaruss and Pelczarski (2007).
Treatment is sensitive to cultural and linguistic factors and addresses goals within WHO’s ICF framework (ASHA, 2016a; Coleman & Yaruss, 2014; WHO, 2001; Yaruss, 2007; Yaruss & Quesal, 2004, 2006). See ASHA’s resource on treatment goals for fluency disorders in the context of the WHO ICF framework. See also ASHA’s resources titled Person-Centered Focus on Function: Preschool Stuttering [PDF], Person-Centered Focus on Function: School-Age Stuttering [PDF], and Person-Centered Focus on Function: Adult Stuttering [PDF] for examples of treatment goals consistent with the ICF framework.
Person- and family-centered practice is a collaborative approach that fosters an alliance-style partnership among individuals, families, and clinicians. Each party is equally important in the relationship, and each party respects the knowledge, skills, and experiences that the others bring to the process. This approach to care incorporates individual and family preferences, priorities, and desired outcomes in the selection of treatment goals and treatment methods.
Person- and family-centered practice offers a range of services, including counseling and emotional support, procuring information and resources, coordinating services, teaching specific skills to facilitate communication, and advocating for or with the individual and their family. See ASHA’s resource on person- and family-centered care.
Consistent with a person- and family-centered approach to stuttering treatment, the SLP
Motivational interviewing is a person-centered approach that can be useful in developing functional goals and enhancing readiness for change (Miller & Rollnick, 2013; Rollnick & Miller, 1995). It incorporates techniques such as open-ended questions, feedback, reflective listening, affirmations, and summarizing to resolve resistance or ambivalence to therapy. Motivational interviewing may be used to help individuals who stutter better understand the thoughts and feelings associated with their stuttering and make positive changes to improve communication. When speakers are able to participate in decisions about treatment goals and select goals they consider important, they may be more motivated to take part in therapy (Finn, 2003; Sønsterud et al., 2019).
Most individuals who stutter demonstrate both observable disfluency and negative life impact (Beilby et al., 2012b; Ribbler, 2006; Tichenor & Yaruss, 2019a; Yaruss et al., 2012). When developing treatment goals, the clinician takes a holistic approach and considers the extent to which stuttering affects the individual’s entire communication experience. Goals that focus on minimizing negative reactions to stuttering and difficulties communicating in various speaking situations may help the individual reduce the effort used to hide or avoid their disfluencies and communicate with more ease. An increase in observable disfluent behaviors may occur as the individual communicates more freely.
Treatment approaches are individualized based on the child’s needs and family communication patterns. A comprehensive treatment approach for preschoolers includes both parent- and child-focused strategies. The goals of treatment may be (a) to eliminate, greatly reduce, or help the child manage their stuttering and (b) to help them not develop negative emotional reactions related to their stuttering (H. S. Arnold et al., 2011; Yaruss et al., 2006). For preschool children who stutter, parent and family involvement in the treatment process is essential, as is a home component (Kelman & Nicholas, 2020). The SLP works with parents and families to create an environment that facilitates fluency and that helps them develop healthy and appropriate communication attitudes (Onslow et al., 2003; Yaruss & Reardon-Reeves, 2017).
Young children may or may not verbalize their reactions to stuttering. Clinicians and parents also look for reactions, such as avoidance of words or speaking situations, increased physical tension or secondary behaviors, reduced utterance length, or slight changes in pitch or loudness during stuttering episodes. It is important that parents and clinicians acknowledge and respond to a child’s verbal and nonverbal reactions in a supportive manner; this helps to minimize the likelihood that the child will develop negative reactions to stuttering.
Treatment approaches for preschool children who stutter include the following.
Indirect treatment focuses on counseling families about how to make changes in their own speech and how to make changes in their child’s environment. These modifications are used to facilitate speech fluency and may include
Direct treatment focuses on changing the child’s speech, attitudes, and beliefs in order to manage stuttering or facilitate fluency (Yaruss et al., 2006). Direct treatment approaches may include speech modification (e.g., reduced rate of speech, prolonged syllables) and stuttering modification strategies (e.g., modifying a stuttered word, “pulling out” of a stuttered word) to reduce disfluency rate, physical tension, and secondary behaviors (Hill, 2003). Direct treatment approaches can also target resilience and effort control in the child and family (Caughter & Crofts, 2018; Druker et al., 2019; Kraft et al., 2019).
Operant treatment (e.g., Palin Parent–Child Interaction Therapy, Kelman & Nicholas, 2020; Lidcombe Program, Onslow et al., 2003) incorporates principles of operant conditioning and uses a response contingency to reinforce the child for fluent speech and redirect disfluent speech (the child is periodically asked for correction). With this approach, parents are trained to provide verbal contingencies based on whether a child’s speech is fluent or stuttered (M. Jones et al., 2005; Onslow et al., 2003). In this way, positive reinforcement is used to increase or strengthen the response of fluency (the desired behavior). Operant approaches operate within a framework of stuttering as a learned behavior (for a discussion, see Conture, 2001; de Sonneville-Koedoot et al., 2015, p. 334; Onslow & Yaruss, 2007).
A comprehensive treatment approach for school-age children, adolescents, and adults includes multiple goals and considers the age of the individual and their unique needs (e.g., communication in the classroom, in the community, or at work).
Treatment is focused on
Disfluent behavior becomes more complex as fear of speaking, anxiety, and resulting avoidance increase. Communication apprehension, loss of control, and shame may also develop as individuals experience greater difficulty with communication. Treatment may include strategies to reduce negative reactions to stuttering in the individual and others (Yaruss et al., 2012). For example, clinicians may use treatment strategies to reduce bullying through desensitization exercises and by educating the individual’s peers about stuttering (W. P. Murphy et al., 2007a, 2007b). Integrated treatment focused on parental involvement, self-regulation, and fluency may also be beneficial (Druker et al., 2019). Effortful control, an aspect of temperament that supports self-regulation, may be predictive of stuttering severity and may facilitate positive change in treatment (Kraft et al., 2019).
Chronic problems associated with illness, injury, or other traumatic events can have a negative impact on an individual’s emotional health and quality of life (e.g., Bonanno & Mancini, 2008). Resilience—the ability to adjust and cope in the face of adversity—can help lessen the negative impact (e.g., Coifman & Bonanno, 2010). Resilience has been examined in the stuttering literature as one factor that may protect people from the adverse effects of chronic stuttering (Craig et al., 2011; Freud & Amir, 2020).
Treatment for adolescents who stutter poses a particular challenge because of the issues related to this developmental stage. Typical adolescent experiences of emotional reactivity, resistance to authority, and social awkwardness may be exacerbated in adolescents who also experience stuttering (Daly et al., 1995; Zebrowski, 2002). Adolescents also may be particularly susceptible to peer pressure and bullying at this time. The attitudes of high school peers toward stuttering and toward persons who stutter can be improved through education in the form of classroom presentations about stuttering (Flynn & St. Louis, 2011). Students who improve their attitudes toward stuttering tend to maintain these views years later (St. Louis & Flynn, 2018).
In addition to the challenges associated with typical adolescent experiences, treatment may not be a priority for some adolescents because of other academic and social demands, denial of a speech problem, and concern about the stigma of seeking treatment. Building trust by following the student’s lead, finding out what experiences may be motivating, and bringing together peers for support are treatment options to consider (Hearne et al., 2008).
Despite these challenges, some of the therapy that applies to adults can be just as effective with teens/adolescents. They also can benefit from groups and intensive programs (Fry et al., 2014).
Adults with fluency disorders have likely experienced years of treatment with varied outcomes. They have long-held beliefs about stuttering that positively or negatively affect self-perceptions about their communication skills and their motivation for change (Daniels, 2007). Some adults lack communication confidence as a result of negative self-perceptions about their stuttering (Beilby et al., 2012a) or due to repeated exposure to people holding stereotypes about stuttering, which, in turn, may create self-stigmatization (Boyle, 2013a).
Adults who stutter may be dealing with years of shame or stigma (Boyle, 2013a), and they can experience elevated levels of negative mood states (e.g., interpersonal sensitivity and depressed mood) when compared to adults who do not stutter (Tran et al., 2011).
The impact of fluency disorders often extends to social and vocational aspects of the individual’s life. For example, stuttering has been associated with higher levels of social anxiety in adults who stutter (Blumgart et al., 2010), and this can lead to fear and avoidance of social interaction (see Craig & Tran, 2006, for a review research on this topic). Adults who stutter also may experience job discrimination and occupational stereotyping, including an earnings gap, especially for females (Gerlach et al., 2018).
A clinician’s first responsibility when treating an individual of any age is to “develop a thorough understanding of the stuttering experience and a speaker’s successful and unsuccessful efforts to cope with his or her communication problem” (Manning & DiLollo, 2018, p. 370). Consistent with treatment approaches for children and adolescents, treatment for adults needs to be individualized, dynamic, and multidimensional. The clinical process for an adult involves
Often, the main reason for seeking advice from an SLP and initiating services is to eliminate or greatly reduce disfluent speech. However, the clinician needs to consider the impact of disfluency on communication and quality of life as a whole. Treatment should consider not just the overt stuttering behavior but also the affective and cognitive reactions to stuttering. Increasing fluency may not be a goal for an adult or may be only one aspect of a comprehensive and multidimensional approach (Amster & Klein, 2018).
Recurring themes of successful stuttering management in adults have been described as
Below is a list of approaches commonly used with school-age children, adolescents, and adults who stutter. All approaches should include a plan for generalization and maintenance of skills involved in activities of daily living.
Approaches may vary by therapeutic philosophy, goals and activities, duration and intensity, and age of the individual. Treatment approaches for adults should take into consideration career and workplace factors.
Many clinicians use an integration of approaches to achieve optimal outcomes. For example, counseling an individual to accept or tolerate embarrassment can facilitate desensitization. Desensitization can help decrease word avoidance and reduce fear. As fear reduces, physical tension and struggle decrease, fluency is enhanced, and the individual is better able to communicate effectively.
Not all of these approaches are appropriate for the treatment of cluttering (see Cluttering Treatment below).
Strategies for reducing impairment in body function have been separated into two categories—speech modification and stuttering modification, both of which are described below. Clinicians do not have to choose one approach or the other. A treatment plan that involves both speech and stuttering modification techniques may be necessary to achieve optimal outcomes.
Other treatment approaches described below also may be incorporated as part of a comprehensive treatment approach.
Speech modification (including fluency shaping) strategies (Bothe, 2002; Guitar, 1982, 2019) include a variety of techniques aimed at making changes to the timing and tension of speech production or altering the timing of pauses between syllables and words. These modifications are used regardless of whether a particular word is expected to be produced fluently.
Strategies aimed at changing the timing and tension of speech production include
Strategies aimed at altering the timing of pausing are used to increase the likelihood of fluent speech production and to improve overall communication skills (e.g., intelligibility, message clarity). In addition to being used for improving communication skills, pausing is also an effective method of rate control.
Just as individuals may experience feelings of shame or fear associated with showing stuttering, individuals also may experience negative feelings associated with using speech modification strategies, which often make their speech sound different from “natural” speech (Ingham & Onslow, 1985; Martin et al., 1984).
Stuttering modification strategies, originated by Van Riper (1973), have four stages: (1) identification, (2) desensitization, (3) modification, and (4) generalization and aim to reduce associated physical tension and struggle by helping individuals
These strategies help individuals learn about the speech mechanism and how it operates during both fluent and disfluent speech so they can modify it. Increasing the individual’s awareness and self-monitoring skills helps to reduce unproductive behaviors that interfere with speech, and it may allow them to alter moments of stuttering so that they have decreased tension, are shorter, and are less disruptive to communication.
Traditional stuttering modification strategies (Manning & DiLollo, 2018) include the following:
These strategies require an individual to identify a moment of disfluency before, during, or after it occurs and to make adjustments to reduce tension and struggle. The specific strategy they select will depend on when the client “catches” the disfluency—in anticipation of the moment of disfluency, in the moment, or following the moment (Van Riper, 1973).
These strategies, like speech modification strategies, are introduced along a hierarchy of speaking situations that varies both with linguistic demands and with the stressors of the environment.
Some individuals develop speech habits to escape or avoid moments of overt stuttering, such as changing words or using interjections (e.g., “um,” “uh”), and they may become so skilled at hiding stuttering that their speech appears to be fluent (covert stuttering; B. Murphy et al., 2007). The cost of such avoidance can be great because of the resulting impact on the person’s ability to say what they want to say, when they want to say it.
Such individuals may benefit from treatment strategies that focus on improving speech efficiency by reducing word avoidance and increasing spontaneity in communication. When being spontaneous and saying “all they want to say,” individuals may exhibit more surface-level stuttering. However, as they learn to reduce reactivity (see below), they develop greater comfort while speaking, they assume more positive attitudes about their ability to communicate, and they are better able to accept and manage moments of disfluency as they occur.
Numerous treatment approaches and strategies have been developed in an attempt to help speakers reduce the negative reactions associated with stuttering (e.g., W. P. Murphy et al., 2007a). These may include stuttering modification (described above) in addition to awareness, desensitization, cognitive restructuring, self-disclosure, and support.
Awareness and identification helps speakers better understand communication, speech, and stuttering along with their attitudes, beliefs, and behaviors. Clinicians may provide education about the speech systems and processes (e.g., respiratory system, phonatory, articulation/resonance, and nonverbal features) and that communication includes both verbal and nonverbal aspects, pragmatics, sender–receiver dynamics, and interpersonal relational features, which may be a target in treatment.
Some examples of these are to openly discuss experiences with stuttering (from the client and the clinician with pseudostuttering or as described by previous clients who stutter) and model pseudostuttering and techniques, attitudes, and beliefs across speaking situations (Manning & Quesal, 2016; Watson, 1988). Discussions about the physical experience of anxiety and ways to reduce it and the sense of loss of control and time pressure may be of further benefit (e.g., mindfulness and grounding; Beilby et al., 2012a; Boyle, 2011; Harley, 2018). Other identification strategies may include video or pseudostuttering analysis or tallying/freezing. Clinicians may start with the client observing videos of others who stutter (or a puppet for children) to help them identify patterns, attitudes, and beliefs about communication and stuttering. This may progress to the client analyzing the clinician’s or their own pseudostuttering, to analyzing a video of their own stuttering to real-time analysis (Bray & Kehle, 2001; Bray et al., 2003; Cream et al., 2010; Harasym et al., 2015; Prins & Ingham, 2009). Tallying has the client stop directly after a moment of stuttering to tally or bring awareness to it while not attempting to escape by continuing to talk. Freezing is similar to tallying but has the client/clinician stop, freeze, during a moment of stuttering to perform a self-scan. Both procedures help the client decrease the sense of loss of control experienced during moments of stuttering by demonstrating their ability to stop and modify moments of stuttering, anxiety, and other emotional reactivity.
Desensitization strategies are strategies that help speakers systematically desensitize themselves to their fears about speaking and stuttering by facing those fears in structured, supportive environments. One example of a desensitization activity is pseudostuttering—the use of voluntary stuttering behaviors—in different, and increasingly more difficult, situations where the individual might fear the occurrence of real moments of stuttering (e.g., Reardon-Reeves & Yaruss, 2013; J. G. Sheehan, 1970).
One example of a treatment approach that incorporates desensitization is Avoidance Reduction Therapy for Stuttering (Sisskin, 2018). The goal of Avoidance Reduction Therapy for Stuttering is to decrease fear of stuttering that leads to “struggle.” Disfluencies are not directly targeted; however, the frequency and intensity of disfluencies decrease as struggle is reduced. The individual who stutters becomes desensitized to their fears by performing activities (e.g., self-disclosing, going to a place where they fear speaking) using a “fear hierarchy.” This hierarchy represents situations or activities that range from low risk to high risk. The individual learns strategies for generalization of skills to the classroom, workplace, and community.
Cognitive restructuring is a strategy designed to help speakers change the way they think about themselves and their speaking situations. Individuals learn to identify the thoughts underlying their negative attitudes and emotional reactions and examine the link between these thoughts, attitudes, and emotional reactions and their speech. Through a process of identifying the assumptions underlying their thoughts, they can evaluate whether those thoughts are helpful (or valid) and ultimately adopt different assumptions or thoughts. Cognitive restructuring can be combined with the desensitization strategies described above (W. P. Murphy et al., 2007a).
One example of an approach that incorporates cognitive restructuring is Acceptance and Commitment Therapy (ACT; Beilby & Brynes, 2012; Beilby et al., 2012a; Palasik & Hannan, 2013). ACT is a holistic, person-centered approach that allows individuals to alter the relationships they have with their emotions and thoughts. One of the core principles of ACT is mindfulness. Mindfulness is an intentional awareness of the present moment (e.g., through meditation) to help disengage from automatic thoughts and redirect attention, de-escalate emotions, and increase self-acceptance (Boyle, 2011; Harley, 2018).
Another example is Cognitive Behavior Therapy (CBT; Menzies et al., 2019, 2009). The purpose of CBT is to modify current negative thoughts, emotions, and/or behaviors and replace them with positive ones through identification of thought patterns and challenging cognitive distortions in real time. More recently, CBT and mindfulness have been applied to stuttering therapy and may support that CBT+mindfulness is more beneficial to clients who stutter than CBT alone (Gupta et al., 2016; Harley, 2018).
Self-disclosure involves communicating to others information that reveals one’s identity as a person who stutters. Often referred to as “advertising” in the stuttering community, self-disclosure can involve
Disclosing a fluency disorder has many benefits on both the speaker (Boyle & Gabel, 2020; Boyle et al., 2018; Mancinelli, 2019) and the listener (Byrd, Croft, et al., 2017; Byrd, McGill, et al., 2017; Ferguson et al., 2019; Healey et al., 2007). Persons who stutter may appear “friendlier” when they self-disclose their stuttering, and self-disclosure may help put listeners more at ease (Healey et al., 2007). Disclosing a fluency disorder may be done a number of ways, such as verbally stating “I stutter/have a speech disorder” or by pseudostuttering or openly stuttering, while doing so confidently (McGill et al., 2018).
Support (both giving and receiving) can be valuable for improving attitudes, boosting self-confidence, and reducing feelings of isolation (Yaruss et al., 2007). Partners may be sources of support for treatment of stuttering (Beilby et al., 2013).
Treatment approaches that incorporate support activities also can provide venues to practice learned strategies in a safe environment and help promote generalization. Support activities can be incorporated into group treatment and through participation in self-help groups (Trichon & Raj, 2018), attendance at self-help conferences (Boyle et al., 2018; Gerlach et al., 2019; Trichon & Tetnowski, 2011), and participation in summer camp programs (Byrd et al., 2016).
Examples of support groups and activities include FRIENDS: The National Association of Young People Who Stutter, the National Stuttering Association, and SAY: The Stuttering Association for the Young; online groups (e.g., online chats); and social media (e.g., blogs; Reeves, 2006).
Technological advances and the expansion of social media outlets have increased opportunities for adults who stutter to connect, share, and gain information through the Internet (Fuse & Lanham, 2016; Raj & Daniels, 2017) and stuttering-related podcasts (Dignazio et al., 2020). It is important for clinicians to verify online sites and virtual support groups recommended to clients and their families. SLPs also need to discuss with persons who stutter and their families how to evaluate the veracity and trustworthiness of sites claiming to “cure” stuttering that they may find on their own. See What To Ask When Evaluating Any Procedure, Product, or Program.
The ability to use speech strategies; to make choices to speak and participate, regardless of the level of fluency; and to take risks is greatly reduced outside of the treatment setting when time pressure and conditioned negative feelings may trigger fear and old behaviors. To facilitate generalization of skills, the clinician can help the individual use a variety of therapeutic activities outside of the treatment room, such as
The SLP can use audio- or videoconferencing to augment this type of treatment.
Prior to developing generalization activities, the SLP needs to consider the individual’s profile.
To foster generalization, assignments adhere to a hierarchy of linguistic skills and environmental stressors. The assignments begin in supportive, low-fear situations and slowly evolve to more challenging situations and settings as the individual demonstrates the ability to accept or tolerate potential negative reactions.
Children and adolescents with fluency disorders may qualify for accommodations whether or not they have an active individualized education program (IEP). Section 504 of the Rehabilitation Act of 1973 (United States Department of Labor, n.d.) protects qualified individuals from discrimination based on their disability via a 504 plan. The plan outlines reasonable accommodations for speaking or reading activities to help ensure a student’s academic success and access to the learning environment in school. This law also applies to organizations that receive financial assistance from any federal department or agency.
Reasonable accommodations include
Section 504 of the Rehabilitation Act of 1973 also applies to individuals with disabilities in a work setting. It applies protections to ensure that programs and employment environments are accessible and to provide aids and services necessary for effective communication in these settings. Reasonable accommodations would vary by work setting and type of work.
See ASHA’s Practice Portal resource on Transitioning Youth.
Because the theory behind cluttering is that speakers are talking at a rate that is too fast for their systems to handle, techniques that help regulate speech rate, such as increased pausing, often are helpful. In fact, increased pausing alone may increase speech fluency and intelligibility for those who clutter (Scaler Scott & Ward, 2013). However, fluency shaping approaches, such as easy onset or continuous phonation, may not be appropriate for the treatment of cluttering.
There has been some documentation of the use of stuttering modification strategies to help those who clutter (Ward, 2006). Such strategies include simulating a fast rate of speech and applying pausing and/or simulating overarticulated speech and applying increased emphasis to increase intelligibility. These simulations and applications of strategies might be most likened to cancellation and pull-out techniques used in stuttering.
Other strategies for treating cluttering include overemphasizing multisyllabic words and word endings, increasing awareness of when a communication breakdown occurs (e.g., through observation of listener reactions), and increasing self-regulation of rate and clarity of speech.
Some people who clutter tend to decrease volume at the ends of sentences or phrases and, therefore, can benefit from learning to keep a steady volume throughout their utterances.
Individuals and families may have a wide range of beliefs about the best way to treat fluency disorders, ranging from medical and therapeutic intervention to prayer. Some families may decide to send children to live with relatives or ask children not to speak in public (Shenker, 2013). Clinicians need to be mindful of different beliefs and the stress imposed on the individual and family during treatment. See ASHA’s Practice Portal page on Cultural Competence.
Behavioral treatments that address improved speech fluency appear to be effective across a range of cultures and languages (Finn & Cordes, 1997). Improvements in fluency may generalize spontaneously from a treated language to an untreated language in bilingual speakers (Roberts & Shenker, 2007).
Treatment outcomes for bilingual children who stutter do not appear to be different from those of monolingual children who stutter (Shenker, 2011). Parent involvement may be a beneficial approach for addressing fluency issues in a bilingual child. Engaging parents in treatment helps to achieve carryover in the home environment and helps with treatment across languages (Shenker, 2013).
Treatment for all communication disorders, including fluency disorders, may necessitate adjustments to protocols, processes, and approaches for bilingual individuals. Adjustments can include
For bilingual individuals, it is important for the clinician to consider the language or languages used during intervention. As indicated in the ASHA Code of Ethics (ASHA, 2016a), SLPs are obligated to provide culturally and linguistically appropriate services, regardless of the clinician’s personal culture, practice setting, or caseload demographics. Bilingual clinicians who have the necessary clinical expertise to treat the individual may not always be available. When a bilingual clinician is not available, using an interpreter is a viable option. See ASHA’s Practice Portal pages on Collaborating With Interpreters, Transliterators, and Translators and Bilingual Service Delivery.
Counseling is an integral part of the assessment and treatment of individuals who stutter or clutter. SLPs’ counseling skills should be used specifically to help speakers improve their quality of life by minimizing the burden of their communication disorder. The use of counseling in other areas of the speaker’s life—that is, those not directly related to communication—is outside the scope of practice for SLPs (ASHA, 2016b). Referral to another helping professional should be made if a condition or situation falls outside of the SLP’s scope of practice.
Counseling allows the clinician who works with those who stutter or clutter to practice within the ICF framework by targeting all aspects of the disorder—not just the surface behaviors. Effective counseling is important for encouraging individuals with a fluency disorder to share information in the affective, cognitive, and social domains.
Counseling helps an individual, a family member, or a caregiver of a person of any age who stutters move from the current scenario to a preferred scenario through an agreed-upon action plan (Egan, 2013). An effective client–clinician relationship facilitates the identification of potential roadblocks (Plexico et al., 2010). This relationship is recognized as one of the common factors that account for the effectiveness of counseling (common factors theory; Wampold, 2001).
Clinicians need to be familiar with various counseling principles and approaches (Luterman, 2006; Zebrowski & Schum, 1993). Counseling begins with active listening and continues with microskills (Egan, 2013) that emphasize attending, showing empathy, demonstrating shared interest in the individual/family, and working to build trust.
Treatment for fluency disorders helps the individual make changes that will facilitate communication in a variety of settings. One of the most widely used models of change is the transtheoretical or “stages of change” model (Prochaska & DiClemente, 2005). This model describes stages in the process of behavioral change, and it can be used to determine an individual’s readiness to make a change.
The model describes the following stages of behavioral change:
See Manning and DiLollo (2018) and Floyd et al. (2007) for a description of how the “stages of change” model can be applied to fluency therapy. Their description details the characteristics of each stage, along with treatment goals and processes appropriate for each stage.
Clinicians can help clients progress to active stages through building self-efficacy. Self-efficacy is a positive belief in one’s own ability to successfully accomplish a set goal that is task dependent, which comes from (a) past experiences of mastery, (b) vicarious experiences, (c) verbal persuasion, and (d) emotional/physical states (Boyle, 2013a, 2013b, 2015; Boyle et al., 2018; Carter et al., 2017).
Often, there are pivotal points during treatment that indicate progress (T. K. Anderson & Felsenfeld, 2003; Plexico et al., 2005).
These include when the individual who stutters
Overall, these indicators demonstrate progression from avoidance and negative impact to acceptance, openness, and increased socialization (V. M. Sheehan & Sisskin, 2001).
See the Service Delivery section of the Fluency Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Service delivery for fluency disorders encompasses, among other factors, treatment format, provider(s), dosage, timing, and setting. Fluency treatment is a dynamic process; service delivery may change over time as the individual’s needs change.
Format refers to the manner in which a client receives treatment—individually, as part of a group, or both. There are benefits of both individual and group treatment.
Individual treatment allows for
Group treatment allows the individual to
Provider refers to the person providing treatment (e.g., SLP, trained volunteer, family member, or caregiver). The primary provider of fluency treatment is the SLP.
Parental involvement is an integral part of any treatment plan for children who stutter. The SLP can instruct parents in how to modify the environment to enhance fluency and reduce communication pressure. Parents can also learn about how to help their child generalize skills from the treatment room to different settings and with different people. SLPs can include teachers in the treatment process by educating them about fluency disorders, involving them in treatment sessions, and having them assist with assignments outside of treatment sessions.
Adults also may want to involve family members, friends, or coworkers as part of a treatment plan. For example, an individual might elect to self-disclose in a workplace and educate coworkers about fluency disorders via a group presentation followed by a question-and-answer period.
Dosage refers to the frequency, intensity, and duration of treatment.
Dosage depends largely on the nature of the treatment (e.g., direct, indirect), age group, and the task level (e.g., learning basic skills requires more clinic room practice than does generalization).
Short-term intensive treatment programs have been used for some individuals to reduce disfluency and address negative attitudes. Time and expense are considerations along with attention to generalization and treatment needs following an intensive program (Cooper, 1979).
Scheduling concerns, cost, and insurance reimbursement also are likely to be factors affecting dosage. Given these potential issues, determining dosage often comes down to the professional opinion of the SLP and the needs of the individual.
Timing refers to the initiation of treatment relative to the diagnosis.
Fluency treatment can occur at any point after the diagnosis. In general, the earlier preschool stuttering is addressed (relative to its onset), the easier it is to manage (Onslow & O’Brian, 2012).
For school-age children and adolescents, initiation of treatment depends, in large part, on their motivation, which, in turn, is dependent on factors such as their perceived needs, the degree of adverse impact they experience, and their previous treatment experiences.
With adults, initiation of treatment depends on the individual’s previous positive or negative intervention experiences and current needs pertaining to their fluency and the impact of their fluency disorder on communication in day-to-day activities and participation in various settings (e.g., community or work).
Setting refers to the location of treatment (e.g., home, community-based [including work settings], school environments, clinic room).
Individuals with disfluencies are seen in all of the typical speech-language pathology service settings, including private practices, university clinics, hospitals, and schools.
Technology has been incorporated into the delivery of services for fluency, including the use of telepractice to deliver face-to-face services remotely. See ASHA’s Practice Portal page on Telepractice.
Information About Stuttering
Oral Reading and Fluency
Billing and Coding
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
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Adriaensens, S., Beyers, W., & Struyf, E. (2015). Impact of stuttering severity on adolescents’ domain-specific and general self-esteem through cognitive and emotional mediating processes. Journal of Communication Disorders, 58, 43–57. https://doi.org/10.1016/j.jcomdis.2015.10.003
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Content for ASHA’s Fluency Disorders Practice Portal page was developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA thanks the following individuals, who, in 2014, made significant contributions to the development of this content.
ASHA also extends its gratitude to the following subject matter experts who were involved in the review and development of this page:
In addition, ASHA thanks the members of the Steering Committee of ASHA’s Special Interest Division on Fluency and Fluency Disorders (Division 4) whose work preceded this content. Members were Gordon Blood, Eugene Cooper, Hugo Gregory, John Hanley, Charles Healey, Stephen Hood, Kenneth S. Louis, Theodore Peters, C.W. Starkweather, Janice Westbrook. Lyn Goldberg and Michelle Ferketic served as ex officios. Crystal Cooper, Diane L. Eger, and Nancy Creaghead served as monitoring vice presidents.
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association (n.d.). Fluency Disorders in Childhood (Practice Portal). Retrieved month, day, year, from www.asha.org/practice-portal/clinical-topics/fluency-disorders/.