by Stephen B. Hood, Ph.D.
Normally nonfluent children tend to be disfluent on approximately 5% of the words they speak. In other words, they experience breaks in their fluency on roughly 50 words per 1,000 words spoken. Disfluencies are more frequent at times of excitement, linguistic uncertainty occurring when formulating sentences that are overly long and complex -- or when trying to think of the name of a particular word--, times of high communication demand, and other forms of communication stress. These disfluencies are easy and effortless, and there are no signs of tension or struggle: the child is generally unaware of these disfluencies. For the most part, these disfluencies will involve the easy, effortless and rhythmic repetition of whole word and phrases, the simple interjection of "ums and ahs" and other simple forms of fluency failure. The number of units of repetition will generally be just one or two: like-like this, or like-like-like this.
Children at Risk for Stuttering show disfluencies well in excess of 5%, and these disfluencies are more fragmented; in other words, they will more likely involve the repetition of single sounds and syllables, sound prolongations, and stoppages in speech flow. The number of units of repetition will generally be more than just two units: like-like- like-like-like this, or li-li-li-li-like this.
Danger Signs: What are they? Signs of increased fragmentation are a concern. For example, the child used to repeat phrases or whole words, and who later repeats syllables or sounds; or the child who used to repeat words and syllables and now prolongs sounds of becomes inaudible, is at higher risk for a stuttering problem. Increases in effort, tension and struggle are also important danger signs; for example, disfluencies accompanied by increases in loudness and/or pitch. In addition, children who mispronounce the first syllable during a repetition are at higher risk: for example, repetition of the correct syllable base-base-baseball is less serious than repetition of an incorrect syllable such as buh-buh-baseball.
With respect to emotional characteristics, disfluencies in normally nonfluent children, even when they are more nonfluent than usual, cause little or no concern or awareness to the child. Most children will be totally unaware of these breaks and bobbles in fluency. It is a danger sign when the child shows marked awareness, especially when this awareness lasts for any considerable time period.
Regardless of the exact cause of the problem, there are a number of factors that tend to make the problem worse, and increase the likelihood of the problem developing into one of increased severity. Clinically, we try on the one hand to reduce the occurrence of these negative influences, and work to help the child cope with them when they do occur. Listed below are some examples of factors that generally tend to increase disfluencies and stuttering in young children and, for that matter, in all of us:
For young children, who are just learning to use vocabulary and grammar in social situations, this is even more of a problem. It is difficult to verbally compete with an adult or sibling who interrupts and verbally monopolizes the conversation. Interruptions must be minimized to the extent possible. It is important to emphasize "turn taking." Just as traffic intersections have signal lights that tell us when to go and when to stop, the same concept is true in speaking, where we need to differentiate between the speaker who goes, and the listener who waits for his/her turn.
Pausing is an important component of turn taking. We need to allow some time in between turns. We need to allow the speaker to finish, before establishing our own turn.
There are lots of ways to contradict, some of which are relatively positive and some of which are relatively negative. Examples of more positive contradictions are such things as "Well, I'm not so sure about that", or "Not really, because it seems to be...." Examples of negative contradictions as statements such as "No, you're wrong again..." or, "Can't you ever understand what I am telling you" -- and "Now listen, I am telling you this for your own good."
To contradict and disagree may be very appropriate and necessary, but possibly there are ways to do this in a more positive manner. Try to maintain a vocal pattern that is soothing, pleasant, melodic and positive while disagreeing and giving an alternative answer. Try also to make "contradictory comments" in ways that are received in the most positive manner possible.
Being rushed or hurried can be a problem both in speaking, and in general. We live in a hurried society where things are always due ten minutes ago. We miss deadlines, hurry from place to place, arrive barely on time or just a few minutes late, or run so late we miss things all together.
Likewise in speaking, when we are running late, we tend to be hurried in general, and this takes a toll on talking too rapidly to make up for lost time. Wouldn't it be nice if we had a more leisurely paced existence? Yes, but easier said than done.
Here's an example of what some people have found the following ideas to be helpful: Set the family alarm clocks a few minutes earlier to get things off to a slower pace in the morning: examples -- allow time to walk to breakfast and eat slowly rather than rush to the table and gobble down the morning meal, then walk to the bathroom for hygiene rather than rush to brush teeth, then be able to drive at a leisurely pace to preschool/school rather than feel the need to hurry through the yellow light, etc. This is more helpful than rush-rush-hurry-hurry: "Get a move on Billy, you're late again, so hurry up so we're not late again."
In general, parents often tend to ask too many questions of their children. Too often these questions are asked in rapid succession. We sometimes ask what seem to be single questions with multiple parts. For example: "So, Billy, tell me about how school went today, and how did you do in your show and tell activity? And by the way, do you have anything to do to be ready for school and home work for tomorrow?
We tend to take great pride in what our children can do, both behaviorally and communicatively. But we need to be careful. Try to avoid the verbal displays: for example, "O-K Jane, show grandmother how well you can count to ten", or, "O-K Billy, show Aunt Mildred how well you can read this book." Being required to give "little speeches" (i.e., verbal 'show and tell'), reading difficult materials to impress adult listeners, being asked to recite things that have been memorized, or requests to explain difficult and abstract concepts are sources of stress that need to be reduced as much as possible.
We need to reduce verbal demands. Demanding too much talking, asking too many questions, requiring verbal justification, and exposing children to verbal interrogation can be communicatively and interpersonally stressful.
Calling undue negative attention to times of increased disfluency is to be avoided because this tends to make the child even more aware of the problem.
We also need to reduce time-pressures to "hurry up" -- both in speaking and in general life style.
It often helps if we change questions to Comments. Sometimes it is better to make comments rather than ask questions. By making comments, we invite the child to follow up with comments of his/her own rather than making it sound like we are "demanding a response."
Try to limit the scope of your questions. Rather than ask "How was your day at school?" Try a more general comment such as "Was there anything going on at school you want to tell me about?" Or a more limiting question such as "Do you want to tell me just one thing that happened today at school?"
It helps to keep the environment and atmosphere as calm and non-hurried as possible. Try to plan ahead so that your "walk, not run". This is easier said than done, but a little goes a long way.
To the extent possible, speak slowly, speak with increased melody and inflection, and allow greater pause time between speaking... and speaking again. Young children have problems when others speak too rapidly. By allowing pause time to occur we reduce the pressure to hurry, and this in turn allows time to organize our thoughts and formulate our language.
Advice to the child to "slow down and take your time" really isn't helpful. The child simply will not slow down when those around him are going 90 miles per hour. Slowing down must be a joint effort on the part of all. This is further enhanced when there is a degree of additional melody and inflection attached to the message. For those who would like a role model, it is suggested that you watch the Mr. Rogers program on television.
Allow the child to finish his thoughts before interjecting your own. It's often easy to anticipate what the child is saying and to begin your answer before the child has finished. It's more positive to allow the child to finish, then pause, and then respond. This is all part of the concept of turn taking.
The modelling of talking skills is important. In your own speech, strive for a slower rate and with increased melody and inflection. Children tend to copy the adult models to which they are exposed, so be a good model. Telling the child to "slow down and take your time" will be of little or no value if the rest of the people are talking rapidly, interrupting, contradicting and verbally competing with each other.
Reducing verbal competition can be helpful. When children must compete with siblings, parents and other persons for recognition, this can be difficult. The above mentioned ideas for verbal turn-taking, sharing the talking time and slowing down the overall pace of the communication can often prove helpful.
It helps to minimize distractions, and other things that compete for the child's attention. For example, it is often difficult to carry on a conversation when the child's attention has been captured by a television, radio or stereo.
A number of personality traits and issues pertaining to family dynamics are important. As with any list, parents need to carefully consider the extent to which any one, or several of these factors, might be serving as a source of actual or potential stress. Realize also that there are areas of considerable overlap among these factors. These factors, in and of themselves, are not necessarily the "single cause of stuttering:" however, when they co-exist with significant amounts of disfluency and stuttering, they may serve to make the problem worse.
Children who are excessively nonfluent and who are "beginning to stutter" are often overly sensitive. They tend to react emotionally and negatively when things don't go their way, when they make a mistake, when they are scolded or criticized, or when they feel that they do not live up to the expectations of other significant people in their environment. They often try overly hard to please others, and their feelings are easily hurt.
When things don't go well, most of us become frustrated. This is normal and to be expected. For some people, the frustration tolerance level is so low that every little set back becomes a major crisis. While on the one hand it is good to reduce the frustrations that the child experiences, efforts must also be made to increase the child's ability to tolerate and cope with these frustrations. Certainly this is a fine line to draw. Although some parents find this a difficult request to accept and follow, the bottom line is that children do need to learn to handle frustration: examples -- the child must learn to become a gracious winner and loser at board games such as Candy Land, Shoots and Ladders and Monopoly. Always letting the child win only postpones the day of reckoning. Tolerance for the fact that we do not always get our own way helps us develop an increased tolerance for handling frustration.
Making mistakes is a normal part of learning. We simply do not do things perfectly all the time, and we do make mistakes in the process of learning. Thus, while it is important that we instill in out children the famous Scout Oath "To Do My Best" we need to keep this in a proper perspective. Yes, we want to do out best, but we also want to be realistic concerning the mistakes we make in the process. (Even though our basic math skills are adequate, who among us has a perfectly balanced check book every month?) Children need to learn that making mistakes is a part of the learning process, and this is why pencils have erasers!! Indeed, we do fall down learning to walk, and we do fall of the bicycle learning to ride. We belly-flop learning to dive, and we stall the car learning to drive stick-shift. AND -- we have bobbles in our fluency while learning to talk.
Things don't always happen immediately and we need to learn this. Sometimes we have to learn to wait. Children who are impatient need to learn this. Children who are compulsive with respect to acting on immediate instinct must learn that some things happen, but happen later. Indeed, we need to learn to "Look before we leap." The attitude of "I want it and I want it now" must be replaced with the attitude "I would really like it, but I realize it might take a little while."
Sometimes, we expect too much of ourselves, and this is especially true if we are highly sensitive and perfectionistic. Sometimes, if we are perfectionists, we expect things to be perfect. As we mature, we need to be aware of our weaknesses as well as our strengths, and need to become realistic in terms of our expectations. Not all of us will become Olympic Champions, Phi Beta Kappa Members, or President of the Class. As parents, we need to be realistic in helping our children determine what is a realistic level of expectation. This is especially true in family environments where a young child is constantly compared and contrasted with adults, or older siblings, who are able to do things "better" simply because they are "older and bigger."
It is important that we feel good about ourselves. When we are constantly put down or made to feel inferior, or when we are (unfairly) compared to others, this hurts our morale and damages our ego strength. Emotional support from significant "hero figures" is important to all of us, and this is especially true for children.
Any list of suggestions has strengths, as well as weaknesses. Not all suggestions apply equally to all children. Further, there is always the problem that people will feel that these suggestions must be followed at the 100% level to be effective, and this is of course unrealistic. But coming closer can help. As a supplement to what is listed above, here are some examples:
There are several sources of information that may be helpful in providing additional information. Interested readers can contact the Stuttering Foundation of America or the National Stuttering Association for printed materials and audio tapes.
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