For decades, many pediatricians have reassured worried parents that children who stutter will likely outgrow it. Although that’s usually true, this approach — while statistically grounded — can miss children who would benefit from early evaluation and support.
“About 75% of the time, a child will stop stuttering,” said speech-language pathologist J. Scott Yaruss, PhD, professor of communicative sciences and disorders at Michigan State University in East Lansing, Michigan, and president/co-owner of Stuttering Therapy Resources, Inc., in McKinney, Texas. “But you can’t tell which child will continue, based only on statistics. That’s the key problem pediatricians face.”
According to Gerald A. Maguire, MD, founder and chair of the Stuttering Treatment and Research Society (STARS), pediatricians should take an active, informed role not only in identifying stuttering but also in coordinating care, screening for comorbidities, and guiding families through this frequently misunderstood condition.
Clinicians and parents should understand that stuttering, formally known as childhood-onset fluency disorder, is not typically caused by parenting style, emotional trauma, or low intelligence — misconceptions that continue to shape public perception and even clinical responses. Pediatricians should reassure parents that stuttering need not limit their child’s potential for future accomplishments, Maguire said.
“Stuttering isn’t a modern-day phenomenon. It’s been around for centuries, since the dawn of recorded history, affecting historical figures such as Moses and Demosthenes and perhaps even Alexander the Great,” Maguire, staff psychiatrist at the Maguire Neuropsychiatric Institute of Oroville Hospital in Oroville, California, told Medscape Medical News. This history is encouraging because “we see that stuttering didn’t stop them from becoming tremendous leaders and communicators.”
What Is Stuttering?
The definition of childhood-onset fluency disorder found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is “a disturbance in the normal fluency and time pattern of speech that is inappropriate for the individual’s age and persists over time.”
The age of onset is most often between 2 and 7 years, with up to 90% of affected children showing symptoms by age 6. Stuttering affects an estimated 5%-10% of preschoolers. Although it typically self-resolves, stuttering can persist into adolescence and beyond, affecting about 1% of the adult population.
“Children between ages 2 and 5 may have dysfluency or disruption in the flow of speech that improves with time as part of typical development,” said Yi Hui Liu, MD, MPH, section head of developmental-behavioral pediatrics and professor of pediatrics at the University of California, San Diego. “This developmental dysfluency occurs as the child attempts to convey their ideas in longer sentences and usually presents as repetition of words or phrases.”
Stutter-type dysfluencies include blocks, in which the child is unable to articulate; broken words; prolongations of a syllable; or part-word or single-word repetition. Other dysfluencies include frequent interjections, multisyllable repetitions, or revised/abandoned utterances.
Liu, a member of the executive committee for the American Academy of Pediatrics’ Section on Developmental and Behavioral Pediatrics, said stuttering “may occur by itself or with other speech/sound disorders, language disorders, or developmental disabilities.”
Stuttering often occurs with attention-deficit/hyperactivity disorder (ADHD), tic disorders, and obsessive-compulsive disorder. Social anxiety disorder, which affects 80% of children who stutter, can begin early and often results from the stigma and social difficulties stuttering creates.
The most common stutter-type dysfluencies are developmental, Liu added. Neurogenic stuttering, which is less common, is due to neurologic conditions or brain trauma, whereas psychogenic stuttering, which is rare, is associated with psychological trauma.
Multifactorial and Neurodevelopmental
Modern understanding of stuttering has shifted away from outdated notions like those promulgated by psychoanalytic theory, which framed stuttering as stemming from unconscious neurotic need fulfillment and unresolved oral conflict arising during early parent-child interactions, according to Maguire. “Now, we recognize stuttering as a neurologic disorder affecting the primary speech centers in the brain. We also understand that it’s multifactorial, often with a genetic basis.”
Twin studies suggest genetics may account for between 50% and 80% of stuttering cases, with as much as a threefold higher risk in those with first-degree biological relatives who stutter than in the general population.
Imaging and neurophysiologic studies have pointed to brain regions that might play a role in stuttering, including left-sided cortical sites associated with speech processing. Dysfunction in basal ganglia areas has been associated with the timing and coordination of motor function and the activity of the inner subcortical speech loop, which includes the striatum of the basal ganglia. Low function of the striatum in those who stutter is associated with an overactive presynaptic dopamine system that disrupts motor sequences necessary for speech production.
Stuttering may have an inflammatory component — specifically, in pediatric acute-onset neuropsychiatric syndrome and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. Stuttering may occur when antibodies directed against streptococcal infection attack the developing basal ganglia.
First Steps and Referrals
“Because many young children in preschool tend to have disruptions in speech when learning to talk, it’s important to differentiate between stuttering vs planning what to say, learning new words, or new sentence structures,” Yaruss said.
Liu advised pediatricians to “conduct a complete history and physical examination, with attention to the oral, auditory, and neurologic components and use validated standardized tools to screen for potential co-occurring developmental conditions, such as speech/language disorders and developmental disabilities.”
Yaruss recommended the Childhood Stuttering Screening for Physicians, a validated tool “that’s not only billable but also convenient. It can be administered by other staff members, not necessarily the physician, and is designed to prevent both under- and over-referral.”
Other medical professionals who might play a role in evaluating the child and weighing in on a treatment plan include pediatric neurologists, child psychotherapists, pediatric otolaryngologists and audiologists, and, of course, speech-language pathologists. “Stuttering is best treated multimodally and treatment should be individualized,” said Maguire.
Children can be referred for speech therapy while the broader workup is underway so intervention can be initiated as soon as possible, he added.
STARS is developing open-access multidisciplinary guidelines on stuttering management for physicians, which will be available at no cost once published in peer-reviewed literature, he said. The guidelines will include evidence-based tools for physicians and speech-language pathologists to use in screening, as well as an algorithm for diagnostic purposes and further steps to take in collaborative care.
Treatment Approaches
Speech therapy is the “most established nonpharmacologic treatment that’s supported by a large evidence base,” Maguire said. Other beneficial nonpharmacologic interventions include psychotherapy — particularly cognitive-behavioral therapy, which also addresses the social anxiety that frequently accompanies stuttering.
The FDA has yet to approve medications specifically to treat stuttering, Maguire said. Aripiprazole, approved for Tourette, has shown some efficacy in stuttering, although akathisia is a potential side effect. Newer agents investigated for stuttering include ecopipam — a dopamine D1 receptor agonist with a different mechanism of action than the dopamine D2 receptor agonists — which showed encouraging results in adults who stutter. A new category of medication under review, the vesicular monoamine transporter-2 inhibitors, have demonstrated efficacy in Tourette and tardive dyskinesia and may have utility in stuttering too.
Medications to avoid include those often prescribed for coexisting conditions, such as stimulants for ADHD, which can worsen stuttering because they can cause disturbances in the dopamine regulation pathway, Maguire said.
Be the Quarterback
Yaruss believes the “wait and see” approach, still common among clinicians, does children a disservice. “Intervention should be started as soon as possible,” he said. “We know we can decrease the likelihood that the child will struggle with stuttering. And the earlier we can provide families with ways of supporting their child, the better.”
Even if the interventions don’t completely stop the stuttering, they can diminish the adverse impact, according to Yaruss. “We can help these children know they can communicate freely without tension in their muscles and without struggle,” he said. “They may stutter a bit, but that may not necessarily be a ‘stuttering problem.’”
Parents should be advised that children with a stuttering disorder qualify as having a “disability” under Section 504 of the Rehabilitation Act of 1973 and are entitled to educational accommodations in school, including extra time when speaking in class, as well as help addressing disability-based bullying and discrimination.
The role of pediatricians doesn’t stop when children have been referred for intervention, Maguire said. “Yes, it takes a knowledgeable, collaborative, multispecialty care team, but the pediatrician is the one who needs to be the quarterback.”
Maguire reported receiving research grant support from Emalex, Noema, Johnson & Johnson, Otsuka, Biohaven, Vistagen, Bristol Myers Squibb, Eli Lilly, and Neurocrine. He reported being on the speakers bureau of Johnson & Johnson, Otsuka, Bristol Myers Squibb, Neurocrine, Teva, Alkermes, and Axsome and being the chief medical officer of AdhereTech and the principal investigator of CenExel California. Yaruss reported owning Stuttering Therapy Resources, which publishes the CSS-P screening tool. Liu reported having no relevant financial relationships.
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