ORIGINAL ARTICLE Identification and P Remediation of H Pediatric Fluency C and Voice Disorders Barbara M. Baker, PhD, CCC-SLP, & Patricia B. Blackwell, PhD, CCC-SLP When children cannot communicate well, the difficulty often is because they have articulation or language disorders, but other difficulties also may adversely affect children’s abilities to express themselves. Prob- lems with fluency (stuttering or cluttering) and voice quality can impair communication. Pediatric nurse practitioners need to be prepared to re- spond to parents’ questions about voice and fluency issues and, when appropriate, to make referrals for evaluation and possible treatment. This article presents a basic overview of the nature of fluency and voice disorders and provides guidelines for identifying children who should be referred, and to whom. ABSTRACT FLUENCY DISORDERS Early identification of pediatric dis- fluency and voice disorders is advis- Two different terms relate to fluency disorders. The more frequent and best able because these disorders may known is stuttering, which may include repetitions of words or parts of progress to lifelong communicative words, prolongations of sounds, and/or the temporary blockage of speech. impairments if left untreated. Espe- A second type of disfluency, cluttering, occurs far less frequently than cially with disfluency or stuttering, it stuttering, and results in speech that is “rapid, dysrhythmic, sporadic, is critical that an informed differen- unorganized, and frequently unintelligible” (Daly, 1992, p. 107). Arapid rate tial diagnosis be made to determine and lack of organization of ideas distinguishes cluttering from stuttering. whether a speech pattern represents Because stuttering is considerably more common, with a prevalence of normal disfluency or actual stutter- approximately 1% of the pediatric population (Guitar, 1998), it will be the ing. Voice disorders can be over- focus of this article. If, however, a child exhibits rapid, unorganized, and looked as laryngitis, when in fact the problem may be organic in ori- dysrhythmic speech in the absence of typical stuttering symptoms, a refer- gin. This article describes character- ral for evaluation and possible treatment for cluttering is appropriate. It istics of both disorders, etiologic factors, and checklists to assess chil- Barbara M. Baker is Professor and Program Director, Division of Communication Disorders, Department of Surgery, University of Louisville, School of Medicine, Louisville, Ky. dren for referral to an otolaryngolo- Patricia B. Blackwell is Assistant Professor and Clinical Director, Division of Communication Disorders, De- gist and/or speech-language pathol- partment of Surgery, University of Louisville, School of Medicine, Louisville, Ky. ogist. Medical and therapeutic Reprint requests: Barbara M. Baker, Department of Surgery, Division of Communication Disorders, University treatment recommendations also of Louisville, Louisville, KY 40292; e-mail: [email protected]. are discussed. 0891-5245/$30.00 J Pediatr Health Care. (2004). 18, Copyright © 2004 by the National Association of Pediatric Nurse Practitioners. 87-94. doi:10.1016/j.pedhc.2003.09.008 March/April 2004 87 PH ORIGINAL ARTICLE Baker & Blackwell C should be noted, however, that stutter- (Johnson & Leutenegger, 1955). Still oth- ing after initiating or changing medica- ing and cluttering may co-exist in the ers purport biologic factors interacting tions involving either of the aforemen- same child (St. Louis & Myers, 1997). with environmental factors (Conture, tioned types, the role of medication 2001). According to one interpretation should be investigated. Normal Disfluency and Stuttering of the latter theory, when a child is un- As early as the beginning of the 20th cen- der stress, the coordination of the mus- Prevalence of Stuttering tury, researchers in child language no- cles of speech appear to fail. This failure Approximately 5% of the population, at ticed transient periods of disfluency oc- of coordination, coupled with an over- some point during their lives, has expe- curring in the speech of young children load of communication pressure, such rienced true stuttering for at least 6 who otherwise seemed to be developing as accelerated speech rate, interrup- months (Guitar, 1998). Typically the on- normally (Brandenburg, 1915).Not un- tions, complex language demands, and set of stuttering occurs before a child’s til the 1930s and 1940s, however, did anticipation of speech difficulty, may fourth birthday and is termed develop- systematic research begin to investigate have a negative impact on speech flu- mental stuttering. Disfluencies that do the existence of these normal disfluen- ency (Logan & LaSalle, 1999). Condi- not begin until adulthood are often asso- cies, that is, stuttering-like occurrences tioning and other learning factors ap- ciated with psychogenic or neurogenic in the speech of typically developing pear to contribute to maintaining the factors (Brady, 1998). (For information children (Adams, 1932). It is now well problem. Over-concern, noticeable anx- concerning adult onset of stuttering, see accepted that some children, beginning iety, or negative reactions of parents can Baumgartner [1999] and Helm-Es- between the approximate ages of 2 to 4 draw attention to a child’s speech and tabrooks [1999]). Both the onset and years, easily repeat sounds, syllables, or consequently exacerbate the disfluent course of developmental stuttering words but are not necessarily stuttering varies by individual child. In the major- (Yairi & Ambrose, 1999). Some of the re- ity of children, onset is mild and devoid peating, pausing, and general confu- of struggles to speak, much like normal sion with expressive speech is normal. disfluencies. In approximately one It may reflect the complexity of the Stuttered speech may third of stuttering children, onset is language structures the child needs abrupt, with severe and frequent flu- to master, the difficulty the child is ex- be characterized by ency disruptions (Yairi, 1997). Approxi- periencing in coordinating his oral mately 74% of children who begin true movements efficiently, or the distrac- involuntary prolongations stuttering show remission within 4 tion associated with environmental years, but for the remaining 26%, stut- stress or excitement. These normal dis- of sounds, inability to tering becomes chronic (Yairi & Am- fluencies generally peak in frequency brose, 1999). 1 between 2 and 3 ⁄2 years of age and di- Although males are more likely to minish thereafter, although episodic in- start a word, or stutter than females, the ratio is not con- creases and decreased may be noticed sistent across ages. In young children, throughout childhood (Guitar, 1998). repetitions of parts of a the male to female ratio is 2:1, but in For some children, however, the ap- adulthood it increases to 5:1 (Ambrose, pearance of disfluencies marks the on- word or whole words. Cox, & Yairi, 1997). set of true stuttering. Primary Characteristics of Causes of Stuttering Stuttering Although stuttering was one of the ear- pattern. Peers’ reactions also may affect Stuttered speech may be characterized liest communication disorders to be stuttering. Recent evidence indicates by involuntary prolongations of sounds, studied (Brandenburg, 1915) and has that children as young as 3 years notice inability to start a word, or repetitions been the subject of numerous research disfluencies in the speech of others and of parts of a word or whole words. In articles, it remains one of the most chal- by 5 years attach a negative value to the the majority of children who stutter, lenging and least understood disor- disfluencies, that is, the stutterers are repetitions affect only parts of words, ders. A persistent question concerning doing “something wrong” (Ezrati- often the initial syllable (eg, “da-da-da- stuttering is its etiology. What causes Vinacour, Platzky, & Yairi, 2001). daddy”). Repetitions usually number stuttering? Some persons suggest a bio- Occasionally medication has been three or more per syllable. Children logic basis through genetic influences, observed to cause stuttering-like symp- who stutter also may prolong sounds and some evidence exists for this posi- toms. Burd and Kerbeshian (1991) re- (eg, “sssssoup”). Infrequently a young tion. Fifteen percent of stutterers have a ported the case of a 3-year-old child stutterer will have a tense pause with first-degree relative (mother, father, sib- who started stuttering after stimulants articulators, that is, lips, jaw, tongue, ling, or child) who is a current or recov- were taken. In a 1994 study, three and vocal folds, fixed in one position. ered stutterer (Felsenfeld, 1997). Other children began stuttering after taking Children who are beginning to stutter investigators suggest that stuttering theophylline (Rosenfield, McCarthy, may show some momentary frustra- arises from environmental factors such McKinney, & Viswanath, 1994). Stutter- tion and even say something to their as competition for speaking turns or ing symptoms resolved after medica- parents about the disfluencies, but their pressure to communicate at a time tion was discontinued. Although these concern seems largely transient (Guitar when the child is still learning language cases are rare, if a child begins stutter- & Conture, 2001). 88 Volume 18 Number 2 JOURNAL OF PEDIATRIC HEALTH CARE PH ORIGINAL ARTICLE Baker & Blackwell C TABLE 1 Health care provider’s checklist for referral* Variables The child