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Normal developmental disfluency and early signs of stuttering are often difficult to differentiate. Thus, diagnosis of a stuttering problem is made tentatively. It is based upon both direct observation of the child and information from parents about the child's speech in different situations and at different times. The following section and Tables 1 and 2 should help the physician distinguish between normal disfluency, mild stuttering, and severe stuttering, so that appropriate referral can be made.
Normal Disfluency
Between the ages of 18 months and 7 years, many children pass through stages of speech disfluency associated with their attempts to learn how to talk. Children with normal disfluencies between 18 months and 3 years will exhibit repetitions of sounds, syllables, and words, especially at the beginning of sentences. These occur usually about once in every ten sentences.
After 3 years of age, children with normal disfluencies are less likely to repeat sounds or syllables but will instead repeat whole words (I-I-I can't) and phrases (I want I want I want to go). They will also commonly use fillers such as "uh" or "um" and sometimes switch topics in the middle of a sentence, revising and leaving sentences unfinished.
Normal children may be disfluent at any time but are likely to increase their disfluencies when they are tired, excited, upset, or being rushed to speak. They also may be more disfluent when they ask questions or when someone asks them questions.
Their disfluencies may increase in frequency for several days or weeks and then be hardly noticeable for weeks or months, only to return again.
Typically, children with normal disfluencies appear to be unaware of them, showing no signs of surprise or frustration. Parents' reactions to normal disfluencies show a wider range of reactions than their children do. Most parents will not notice their child's disfluencies or will treat them as normal.
Some parents, however, may be extremely sensitive to speech development and will become unnecessarily concerned about normal disfluencies. These overly concerned parents often benefit from referral to a speech clinician for an evaluation and continued reassurance.
Mild Stuttering
Like normal disfluency, mild stuttering may become more noticeable when the child is beginning to talk in 2-word sentences. Children who stutter mildly may show the same sound, syllable, and word repetitions as children with normal disfluencies but may have a higher frequency of repetitions overall as well as more repetitions each time.
For example, instead of one or two repetitions of a syllable, they may repeat it four or five times, as in "Ca-ca-ca-ca-can I have that?"
They may also occasionally prolong sounds, as in "MMMMMMMommy, it's mmmmmy ball." In addition to these speech behaviors, children with mild stuttering may show signs of reacting to their disfluency.
For example, they may blink or close their eyes, look to the side, or tense their mouths when they stutter. Another sign of mild stuttering is the increasing persistence of disfluencies. As suggested earlier, normal disfluencies will appear for a few days and then disappear.
Mild stuttering, on the other hand, tends to appear more regularly. It may occur only in specific situations, but it is more likely to occur in these situations, day after day. A third sign associated with mild stuttering is that the child may not be deeply concerned about the problem, but may be temporarily embarrassed or frustrated by it. Children at this stage of the disorder may even ask their parents why they have so much trouble talking.
Parents' responses to mild stuttering will vary.5 Most will be at least mildly concerned about it, and wonder what they should do and whether they have caused the problem. A few will truly not notice it; still others may be quite concerned, but deny their concern at first.
Severe Stuttering
Children with severe stuttering usually show signs of physical struggle, increased physical tension, and attempts to hide their stuttering and avoid speaking. Although severe stuttering is more common in older children, it can begin anytime between ages 1½ and 7 years. In some cases, it appears after children have been stuttering mildly for months or years. In other cases, severe stuttering may appear suddenly, without a period of mild stuttering preceding it.
Severe stuttering is characterized by speech disfluencies in practically every phrase or sentence; often moments of stuttering are one second or longer in duration. Prolongations of sounds and silent blockages of speech are common.
The severely stuttering child may, like the milder stutterer, have behaviors associated with stuttering: eye blinks, eye closing, looking away, or physical tension around the mouth and other parts of the face. Moreover, some of the struggle and tension may be heard in a rising pitch of the voice during repetitions and prolongations. The child with severe stuttering may also use extra sounds like "um," "uh," or "well" to begin a word on which he expects to stutter.
Severe stuttering is more likely to persist, especially in children who have been stuttering for 18 months or longer, although some of these children will recover spontaneously. The frustration and embarrassment associated with real difficulty in talking may create a fear of speaking. Children with severe stuttering often appear anxious or guarded in situations in which they expect to be asked to talk. While the child's stuttering will probably occur every day, it will probably be more apparent on some days than others.
Parents of children who stutter severely inevitably have some degree of concern about whether their child will always stutter and about how they can best help. Many parents also believe, mistakenly, that they have done something to cause the stuttering. In almost all cases, parents have not done anything to cause the stuttering. They have treated the child who stutters just like they treat their other children, yet they may still feel responsible for the problem.
They will benefit from reassurance that their child's stuttering is a result of many causes and not simply the effect of something they did or didn't do.
The distinctions among normal disfluency, mild stuttering, and severe stuttering are summarized in Table 1: Checklist for Referral.