Did you know that around one percent of adults stutter, while up to five percent of children go through a period of stuttering? Stuttering, also referred to as ‘fluency disorder,’ is one of the most common speech disorders and one of only a handful that often presents across the lifespan, from childhood to adolescence and into adulthood. It’s also one of the most widely misunderstood communication disorders. So, what is a stutter really? How is it caused, and what can be done to treat it?
In simple terms, a stutter is an interruption to fluent speech that occurs when a person knows exactly what they want to say but has difficulty saying it.
A person who stutters may exhibit just one or any combination of the following stutter characteristics:
- Repetitions: these may involve single sounds, parts of a word, whole words, or entire phrases. For example, “The s-s-s-s-sun is shin-shin-shining,” contains both single sound and single syllable repetitions. People who stutter often find that particular sounds cause them to stutter more and may avoid using these sounds as a compensatory strategy.
- Prolongations: stretching out a sound, as in “The sssssssun is shining.”
- Blocks: halting or pausing speech, which may be accompanied by the sensation that air is ‘stuck’ in the throat. For example, “The sun is (pause) shining.”
- Idiosyncratic behaviors: stuttering may be accompanied by tick-like behaviors, such as rapid blinking or nodding of the head.
Though everybody experiences occasional moments of dysfluency (e.g., stumbling over a word now and again), a fluency disorder occurs when the interruption to speech happens frequently enough to impact the speaker negatively. In other words, whether or not a stutter is considered a disorder requiring treatment is largely dependent on if the person who stutters experiences it as a disorder.
For example, a person with a moderate stutter (meaning that their stutter is fairly frequent and noticeable, but they are generally still able to get their message across) might find that stuttering does not affect their quality of life and, therefore, may not be interested in treatment. On the other hand, even a minor stutter that is unidentifiable to the untrained ear may cause stutter-related anxiety and be associated with poor self-image, thus warranting treatment. In such cases, a combined approach using speech therapy to treat the dysfluency and psychological support to reduce negative self-image and anxiety is recommended.
Types of stuttering and their causes
There are three different types of stuttering: developmental, psychogenic, and neurological.
Developmental stuttering is far and away the most common. It develops during early childhood, usually around the age of two or three. Though some children spontaneously recover from a developmental stutter without intervention, this type of fluency disorder can continue into adulthood.
Psychogenic stuttering may occur following a traumatic event or period of high emotional stress, while neurological stuttering is caused by a brain injury, such as a stroke or blunt force to the head. These types of stutters can occur at any age. However, they are much less common than developmental stutters.
Contrary to popular belief, a stutter is never caused by anxiety or over-excitement. However, any type of heightened emotional state, including feeling anxious or excited, may exacerbate a pre-existing stutter. Instead, developmental stutters are caused by a combination of genetics, language development, and environmental factors (we’ll cover more of what this means in the next section).
Brain imaging studies have also demonstrated that language pathways in the brains of people who stutter look and function differently than they do in the brains of people who do not stutter.
Interestingly, although stutters occur in equal measure amongst young girls and boys, they are about four times more common in adult men than women.
Demands and Capacities Model
We know that stutters are caused by some combination of genetics, language development, and environmental factors, as mentioned above. The genetics component explains why stuttering often runs in families. This is also a good opportunity for some myth-busting: children who stutter never do so because they are ‘copying’ a stuttering parent or sibling. A stutter cannot be taught and is not contagious. Instead, children with family members that stutter are more likely to stutter as well due to shared genetics.
To explain the role of language development and environmental factors, we’re going to delve into a theory known as the ‘demands and capacities model,’ which helps explain why stutters develop in early childhood and are often used as a starting point for speech-language pathologists developing treatment plans.
The basic idea is that stuttering occurs when the demand for fluent speech is greater than a child’s capacity to produce it.
Environmental factors that place demands on a child’s speech include:
- Feeling pressure to talk quickly. This may occur in large families where a child may miss their turn in a conversation if they are not quick. When parents model rapid speech to children; or when a child is not given enough time to respond to comments or questions.
- Being in a high-pressure situation, such as when asked to speak in front of the class at school.
A child may also have reduced capacity for fluency speech if:
- They are still developing their language skills (i.e., their ability to form words and sentences).
- They have reduced motor control in the muscles of the mouth or face. This is common in children with Cerebral Palsy or Down Syndrome, for example.
- They are in a heightened emotional state, such as feeling nervous, excited, or upset.
Stuttering may occur whenever the demand for fluent speech exceeds the child’s capacity.
Can a stutter resolve on its own?
For many children, stutters do resolve on their own. But that does not mean it’s a good idea to wait and see if a stutter will go away before seeking professional support. There is a critical window between the ages of four and six when stuttering therapy is most effective. Usually, it is only during this period that it is possible to resolve a stutter entirely.
Beyond the age of seven, the focus of traditional stutter therapy shifts from trying to eliminate a stutter altogether to reducing the overall frequency and duration of stuttering moments, developing strategies for stutter management, and reducing any related symptoms, such as anxiety or poor self-image.
What does treatment look like?
The decision to seek treatment for a stutter can be a complex one. As mentioned above, speech therapy has traditionally been focused on stutter elimination, reduction, and management.
More recently, holistic approaches to therapy have advocated an interdisciplinary methodology involving support from speech-language pathologists to target fluent speech, psychologists to target any associated mental health difficulties, as well as stuttering support groups to provide a safe space for people who stutter to meet with others that share their experiences.
Most recently, however, a new frontier has developed, advocating a neurodiversity-affirming approach to stutter therapy. Proponents of this approach advocate an overhaul in our historical understanding of stuttering as a disorder to be ‘cured’ or eliminated. They argue for a new framework in which we work toward acceptance of stuttering as a speech difference rather than a disorder.
I’m going to cover a little bit about how each of the latter two approaches works and concludes with a discussion of some of the relative merits of each.
1. Traditional therapy methods
Using the demands and capacities model, it makes sense that one of the first techniques used by a speech-language pathologist to improve a child’s speech is to try to reduce demand while increasing the capacity for fluent speech. This method is used primarily with children and can be thought of as an indirect treatment because it aims to modify the child’s environment rather than treating the stutter itself.
One way for parents to reduce demand for their children is to model the behavior they want to teach. It is not helpful to tell children (or adults!) who stutter to ‘slow down’ or ‘take a deep breath.’ It’s much better to show than to tell.
This is true because people tend to take on the speaking style of their interlocutors. For example, when an adult who generally speaks in a slow and languid manner goes out to dinner with a group of their fastest-talking friends, they are likely to speed up to more closely approximate the speed of everyone else. This is called linguistic mirroring, and virtually everybody does it to some degree (if you’re interested in this, you can check out my article on code-switching here).
Being surrounded by people who speak quickly may encourage a child who stutters to speed up as well, leading to an increase in stuttering moments. Consequently, it’s often helpful for the parents of children who stutter to practice slowing down themselves.
In big families where it can be hard to get a word in edgewise, it may also help to pass around an object that lets a person know when it’s their turn to speak. This may feel a bit unnatural at first, but it’s a clear method for showing children that they don’t need to rush because everybody will be given a turn.
Around sixty percent of children who stutter have a co-occurring speech, language, or non-speech-language disorder, such as ADHD, Autism Spectrum Disorder, Developmental Language Disorder, or Anxiety Disorder. Working to address these disorders can often have a remediating effect on a stutter and increase a child’s capacity for fluent speech.
For example, as previously mentioned, although anxiety does not cause stuttering, it can exacerbate a pre-existing stutter. Therefore, seeking treatment for Anxiety Disorders can help to reduce the frequency of stuttering moments that a person experiences by decreasing the frequency and severity of their anxiety.
Similarly, a child with a language delay may be unable to express themself clearly using words and sentences, reducing their capacity for fluent speech. Speech therapy focused on treating the language disorder can sometimes have the effect of improving a child’s capacity for fluent speech enough to reduce or eliminate the stutter without targeting it directly.
Thus far, we have talked about indirect treatment methods that seek to reduce or eliminate a stutter by modifying the speaking environment or addressing concurrent difficulties that may exacerbate an existing stutter. A direct intervention involves working directly on the person who stutters speech and can look quite different for young children versus adults.
Parents of young children who stutter will generally be involved in parent training programs with a speech-language pathologist in which they learn to identify stuttering moments and provide positive feedback for ‘smooth talking.’ This helps children tune into the way they are speaking and start working toward using smooth, fluent speech more consistently.
For teenagers and adults, a speech-language pathologist will often implement a speech restructuring program, in which a new speech pattern is taught and then practiced until the person who stutters feels confident implementing the technique across a variety of speaking situations in their daily lives.
Speech restructuring programs ultimately aim to reduce the frequency and duration of stuttering moments and help the person who stutters gain more control over their speech rather than eliminating the stutter altogether.
How does stuttering affect the quality of life?
Stuttering doesn’t only affect the way that a person speaks. Research shows that Anxiety Disorder is six to seven times more common in people who stutter than in the general population (with up to fifty percent of people who stutter affected). Social Anxiety Disorder is at least sixteen times more common, with some research estimating that it’s up to thirty-four times more common.
And yet, it seems apparent that anxiety disorders in people who stutter often develop as a reaction to how stuttering is viewed and treated by society at large. Children who stutter are at increased risk of being bullied. Adults who stutter are often stereotyped as excessively nervous, self-conscious, or intellectually weak. It is these negative attitudes toward stuttering that cause people to go to great lengths to try to hide their stuttering, either by speaking less or avoiding words or phrases that might bring on a stuttering moment.
As John Hendrickson, a senior editor at the Atlantic, described in a recent New York Times Article, “As a kid, every time you stutter, you feel like you’re letting people down. Then you’re trapped in this vicious feedback loop of avoidance, shame, and low self-esteem. Those feelings breed anxiety, which can make your stutter more pronounced and can make you want to talk even less. We have to start breaking that toxic pattern during childhood.”
2. Neurodiversity-affirming approaches to stuttering
Over the past few years, there have been great strides forward in the conversation around neurodiversity, particularly with regard to Autism. Medical approaches to disability have a long history of pathologizing differences, with interventions generally aimed toward making people with disabilities seem more ‘normal.’
While the intentions of such therapies are often to help people achieve better life outcomes by fitting into mainstream society, disability advocates argue that this burdens and shames people who are different and creates a value-based system in which being neurodivergent is seen as ‘wrong,’ and being neurotypical is seen as ‘right.’ Instead, they argue, we should focus our energy on building a society that is more accepting of all kinds of people.
Suppose we recall that people who stutter present with physiological differences in the brain, stuttering can be understood as a kind of neurodiversity. Using the neurodiversity-affirming model might therefore mean shifting away from the idea that fluent speech is superior to stuttered speech. Instead, speech therapy might be focused on unlearning value-based attitudes toward speech that many in the stuttering community say is harmful to mental health and incentivize shame and avoidance. It might instead be focused on accepting and embracing different kinds of speech patterns.
Though the merits of the neurodiversity-affirming approach are largely self-evident, there are arguments to be made for traditional approaches to stuttering therapy as well. Stutter severity falls along a continuum from mild to severe, a scale that reflects the frequency and duration of stuttering moments. A severe stutter can make it virtually impossible for the speaker to get their message out. It can also be physically exhausting and uncomfortable, interrupting rhythmic breathing and making it difficult for the body to be at rest. For this type of stutter, therapy aimed toward improving speech fluency can be paramount to self-expression and quality of life.
In some cases, a person with a mild stutter may feel more motivated by a traditional therapy approach, or a person with a severe stutter may find that they prefer a neurodiversity-affirming approach. As we move toward new frontiers in speech therapy, many speech-language pathologists are working to integrate the tenets of a neurodiversity-affirming approach into their practice while providing their clients the liberty to decide what treatment methodology works best for them.
What’s clear in any case, however, is that change has to come from the wider world as well. We can all work harder to educate ourselves and dispel any stereotypes we might unwittingly hold about stuttering or other types of differences. If you know or meet somebody who stutters, be sure to treat, talk to, and listen to them in the same way you would treat, talk to, or listen to anybody else. Don’t finish their sentences for them. Don’t congratulate them for getting their thoughts out. Don’t try to rush the conversation along or make any assumptions. Just wait, listen, and engage with kindness and respect.