The Ultimate Guide to SLCN

Stammering

Stammering is a condition which affects a person’s ability to produce fluent speech. The accepted term in the UK is ‘stammering’, but you might also hear this described as ‘stuttering’, which is the predominant term in the United States, or ‘dysfluency’, which is a term commonly used by SaLTs.

You might be surprised to know that we all suffer from dysfluent speech at times, particularly when we are in high-pressured speaking situations. We all pause, hesitate, and repeat or revise some words when we are speaking, however for a person with a stammer, the experience can be much more debilitating and can have a significant impact on their quality of life. Even for stammerers, the frequency and severity of stammering varies day-to-day and situation-to-situation. Stammering is usually made worse by situations where there is increased pressure to speak, and many people with a stammer will avoid such situations.

People who stammer might repeat sounds, parts of words or whole words, make sounds longer than they should be, or be unable to get the sounds out when they are speaking. These disruptions to the flow of speech sounds might be accompanied by physical behaviours such as facial grimacing, involuntary head or body movements and physical tension in the body. In addition to these visible and audible symptoms of stammering, there are usually ‘hidden’ or ‘interiorised’ symptoms, for example avoiding saying certain words, avoiding social interactions and experiencing negative feelings or anxiety.

People who stammer describe their experience using an iceberg analogy: the noticeable features of stammering are compared to the portion of the iceberg which is visible above the water (i.e. the smallest part) and the hidden features, including their feelings about stammering and the psychological impact of these, are represented by the portion of the iceberg under the water (i.e. the largest part). This analogy highlights that thoughts and feelings about stammering are the bigger burden for the child to manage.

Some people will experience what is known as a ‘covert stammer’, whereby there are very few or no outward signs of stammering, usually because the person has become extremely skilled at avoidance or masking behaviours, but they continue to experience the interiorised symptoms of stammering which significantly impact on their quality of life and wellbeing.

Top Tip

Give the child lots of praise for things they are doing well and highlight their strengths as a communicator for them.

The most common type of stammering is developmental stammering (the focus of this chapter), which develops in childhood between the ages of 2 and 5 years old, at a time when language skills are developing rapidly. Some children will naturally grow out of it and others will require therapy to help them develop fluent speech. For some children, stammering will be a lifelong condition. Current evidence suggests that for about one third of young children who stammer, the condition will resolve within 18 months, and for a further third of children it will resolve within 3 years of the stammer emerging. The onset of stammering in children can either be gradual or sudden and stammering often fluctuates throughout childhood, so it’s not unusual for children to have periods of fluent speech and then for the stammer to return. Less commonly, stammering can be an acquired condition that develops later in life.

The longer a child has been stammering the more likely it is that they will continue to stammer, so it’s important to seek the advice of a SaLT as soon as concerns arise. Research indicates that early referral is associated with better outcomes for young children.

There has been a lot of research into what causes stammering, but it remains a complex issue. The ‘multifactorial model’ is widely used to explain the several factors which contribute to stammering and how these factors can interact with one another. These include physiological factors, e.g. a genetic predisposition to stammering; psychological factors, e.g. having a sensitive temperament; speech and language factors, e.g. having advanced language skills; and environmental factors such as having a busy home environment or recent changes to family circumstances. These types of factors can all play a role in determining the persistence, severity and impact of a child’s stammer, and it can be seen that there is not one cause, but a complicated pattern of influences. It’s important to remember that stammering is not caused by parents, but there are lots of things that parents can do to help and it’s important that families seek the advice of a SaLT.

The Multifactorial Model.

Just as there is no single cause of stammering, there are a number of different therapy techniques that can be used in treatment. The strategies used can involve making changes to the environment of the child and exploring how he/she feels about stammering as well as direct therapy to attempt to improve the child’s fluency in some cases. ‘Success’ in therapy is not always defined as having completely fluent speech. The aims are individualised for each child to maximise their ability to confidently and effectively communicate their ideas and fully participate in their social, academic, and future work lives. For therapy to be successful it is essential that the child receives consistent messages from everyone involved and that school and family are both completely on board. The most important thing is that the child is comfortable with their speaking and is able to confidently communicate no matter what their level of fluency.

Prevalence

Around 1 in every 20 pre-school children stammer. By school age this is estimated to have gone down to 1 in 80. Some will naturally grow out of it, and others will do so with therapy early on. Around 1% of children will continue to stammer into adulthood. Stammering is approximately four times more common in boys than girls.

What to look for

When someone stammers you might hear repetitions of whole single-syllable words, e.g. “and and and”. You may hear repetition of sounds or syllables, or sounds may be prolonged. Sometimes a child may get stuck on a word and nothing comes out – this is referred to as blocking. Some children can become experts in ‘hiding’ their stammer. They might avoid talking completely in some situations, say less, or change words in order to appear more fluent. Within the classroom they might pretend they don’t know the answer, give very brief answers, not put their hand up, or avoid volunteering for tasks that involve speaking. Avoidance strategies can also negatively impact on the child’s social communication skills, for example leading to reduced eye contact and poor posture, which can cause children to look like poor or disinterested listeners. Children with stammers might struggle with conversational turn-taking, either avoiding or being unable to take their turn, or dominating conversations and interrupting in order to get their message out while they can. You might also find that they speak with an increased volume at times in order to make themselves heard. Frustration due to communication breakdowns may cause difficulties in peer relationships. Be aware that children who stammer may also be at risk for increased social anxiety and depression.

Difficulties

• Answering questions in the classroom
• Volunteering information in front of the class
• Reading aloud
• Answering the register
• Speaking under time pressure
• Anxiety about speech, making it hard to concentrate
• Being teased or bullied
• Frustration due to communication difficulties
• Monitoring and adapting speech, or using avoidance strategies, can be fatiguing

Strategies

• Ensure that no pressure is put on the child in speaking situations and monitor levels of anxiety.
• Give extra time for thinking and speaking and model using this yourself. Remember that while slowing down can improve fluency, telling a child to slow down can be frustrating and unhelpful – it’s better to use pauses and a slower rate in your own speech as we tend to unconsciously match the rate of our communication partner.
• Let children finish their sentences in their own time – do not answer for them or try to finish their sentences.
• Give positive reinforcement and try to reduce anxiety.
• Show that you are listening and let the child know that you’re more interested in what they’re saying than how they are saying it.
• Get down to the child’s level when speaking and maintain natural eye contact even when they stammer.
• Try not to suggest to the child that you are in a hurry, as the added pressure can make things worse.
• Avoid telling them to ‘hurry up’, ‘slow down’, or to ‘take a deep breath and start again’.
• Ask the child (discreetly) how they feel about their stammer and how they would like you to help.
• Support the building and maintaining of friendships.
• Try to find ways to let the child know that they’re not alone, as they might not know anyone else who stammers. Together with the child you could research celebrities who have or had a stammer.
• Be aware of potential bullying.
• Ensure that there is consistency in the way SaLT, home and school give support.

Myth Busting

Are all people who stammer shy or anxious? Do they stammer because they’re nervous?

While stressful or anxiety-provoking situations can aggravate stammering, it cannot be said that nervousness is a character trait which all people who stammer share. Nor would it be fair to say that stammering indicates that the person is unsure of what they want to stay. People who stammer have the same range of personalities as those who do not stammer and suggesting that the person doesn’t know what they want to say is just unhelpful.

Can young children develop a stammer because of copying a family member or peer who stammers?

Stammering is not contagious and therefore it is not possible for a child to develop a stammer as a consequence of being around other people who stammer. This idea places undue pressure on parents who have stammers themselves. It is true that stammering can run in families, with more than 50% of stammerers having at least one relative who has a stammer, but this is due to genetic factors.

How likely is it that I already know someone who has a stammer?

With 5% of children and 1% of adults having a stammer (including a number of highly successful professionals and celebrities), it’s highly likely that you have met somebody who stammers. However, you might not have noticed, as many people who identify as having a stammer have become experts at masking or avoiding their stammering. While we can applaud the effort of these people, we should also recognise that it takes an enormous amount of effort to constantly monitor and adapt your speech and, as such, there can be a significant emotional weight to having a stammer even when the symptoms are not overt.

Are children who stammer less intelligent than other children?

Stammering can make children less effective communicators and often less willing to share their ideas, which can give some people the impression that they are not as clever as their peers. This is not true. Children who stammer have the same range of intellectual abilities and learning difficulties as all children. There is no link between intelligence and stammering.

Will acknowledging that a child has a stammer make it worse?

Children need to hear that their difficulties are recognised, understood, and not unusual. Talking about stammering will help children to process their feelings and frustrations and protect their self-esteem. In fact, understanding the process of talking and learning about stammering is a really important part of the therapy process.

Role of SaLT

Stammering can be diagnosed and treated by a SaLT. If you are working with a child who has dysfluent speech, they may already be known to your local SaLT service. You should seek the advice of your local SaLT team if this is not the case.

Further Information

The British Stammering Association – www.stamma.org

Action for Stammering Children – www.actionforstammeringchildren.org

The British Stammering Association’s online training resource for school staff – www.stammeringineducation.net

Read more about stammering in The Link magazine, issues 10 & 9