Stuttering can have a big, negative effect on a young child’s life. So, too, can having a speech disorder. Early treatment is important for each. So what should you do if your child has both problems?
Stuttering gets harder to treat as kids get older and go to school (Lincoln et al., 1996), so I usually recommend treating preschoolers’ stuttering first. But that doesn’t mean we can just ignore a child’s speech sound problems because:
if speech sound disorders persist past school-age, kids might have difficulties learning to read (e.g. Nathan et al., 2004);
some children with speech disorders have issues with peer relationships, lowered self-esteem, and are at increased risk of dropping out of school, and poorer work outcomes (e.g. McCormack et al., 2009).
As many as 30-40% of children who stutter also have speech sound disorders (Nippold, 2004). In our clinic, we frequently work with children with both disorders.
So what to do?
There are three main treatment options:
Sequential treatment: Treat stuttering first, then speech sounds.
Cyclical treatment: e.g., treat stuttering for a while, then switch to speech, then switch back to stuttering, etc.
Treat stuttering and speech at the same time, either:
by choosing activities to target both together (the “simultaneous approach“); or
treating both in parallel, i.e. in the same sessions, but in different activities (“concurrent approach“).
Unfortunately, not much peer-reviewed research evidence exists to help speech pathologists decide which approach to recommend to families. As noted above, my “default” position has been to recommend treating stuttering first. But I’ve made exceptions, for example:
when working with kids with very serious speech sound disorders;
when families make the informed decision that speech is their priority; or
when health, behaviour, cognitive, family, and/or other issues make it difficult for a client to undertake an evidence-based stuttering treatment like the Lidcombe Program.
New research on treating both disorders concurrently
A small study about kids with both speech sound disorders and stuttering was published in 2017 by leading stuttering researchers, Dr Rachael Unicomb, from The University of Newcastle, and her colleagues Drs. Sally Hewat, Elizabeth Spencer and Elisabeth Harrison. It provides some support for the concurrent treatment of stuttering and speech issues.
In the study, the researchers treated five preschoolers using the Lidcombe Program for stuttering and traditional articulation and evidence-based speech sound therapies like minimal pairs and multiple oppositions for phonological issues. Both stuttering and speech treatments were administered in the same session, but in separate parts of the session, with different activities.
After 12 months, four of the participants had completed the Lidcombe Program, with fewer than 1% of their syllables stuttered. All five participants increased their percentage of consonants correct (a good proxy measure for increased intelligibility).
From reading the study, I took away some interesting clinical points for my practice:
Both the stuttering and speech treatments were evidence-based, direct behavioural treatments.
For the speech sound treatments:
the researchers used a “most knowledge” developmental approach for phonological issues. This is a treatment approach where we target earlier developing speech sounds, rather than later-developing, more complex speech sounds. The researchers cite some evidence that the most knowledge approach is preferable when working with kids who have speech issues and stutter (Sasisekaran, 2014; Wall & Myers, 1995), perhaps because more complex targets may increase the language demands of speech therapy beyond the child’s capacities, which may be unhelpful for treating stuttering (Starkweather & Gottwald, 1990); and
One of the five study participant’s stuttering increased after treatment. The researchers noted that this client exhibited “challenging behaviours” that made it difficult for the Lidcombe Program to be administered as per the manual.
As the authors note, this preliminary study had lots of limitations, including the study design (a clinical case study), the lack of clear cause-effect relationships between treatments and outcomes, the small size of the study, the lack of control groups and clinician blinding, the different kinds of speech sound errors treated and the ways they were treated, and the mild-moderate stuttering severity levels of the participants (no participant had severe stuttering at the start of the trial).
Notably, none of the study participants was bilingual, had a history of hearing issues, a developmental language disorder, and/or autism spectrum disorder. These “exclusion criteria” are common in stuttering and speech sound research because researchers want as few variables as possible to study treatment effects. But it means that the study participants sometimes look very different to the “real world” clients speech pathologists encounter, particular in diverse communities like Sydney.
Clinical bottom line
For some preschoolers who stutter and have speech sound disorders, concurrent, direct, treatment of both disorders using the Lidcombe Program for stuttering and a most knowledge approach to phonological treatments may be an effective, safe and efficient way to reduce stuttering and improve speech. But it’s likely that this approach is not for all kids. Speech pathologists need to measure outcomes carefully and be prepared to adapt management plans, particularly if (for example) one or both disorders worsen during treatment.
We need further, larger, and more sophisticated clinical trials to be published in peer-reviewed journals to help us determine things like:
which clients are more likely to benefit from this approach, and which clients might do better with sequential treatment;
the role (if any) played by a child’s expressive language development in helping speech pathologists and families to decide which treatment approaches should be preferred, particularly in light of recent research showing that the rate of a child’s language development may be a predictor of recovery from stuttering.
As always, we are very thankful for researchers like Dr Unicomb and her colleagues who publish treatment research like this addressing issues we face regularly in clinical practice.
- Children who stutter
- Speech sound disorders in children
- The Lidcombe Program for children who stutter
- The Lidcombe Program for stuttering: my 10 favourite therapy activities
- The Westmead Program for children who stutter
- My preschooler stutters: should we do the Lidcombe Program or the Westmead Program (or something else)?
- Stuttering: will my child recover? Factors that predict recovery and why you shouldn’t wait
- My child stutters. Is it because he’s shy? sensitive? hyper?
- 10 common speech error patterns seen in children of 3-5 years of age – and when you should be concerned
- In what order and at what age should my child have learned his/her speech sound consonants?
- How to treat speech sounds problems 1: the Cycles Approach
- How to treat speech sounds problems 2: The Complexity Approach – more bang for your buck?
Principal source: Unicomb, R., Hewat, S., Spencer, E., & Harrison, E. (2017). Evidence for the treatment of co-occurring stuttering and speech sound disorder: A clinical case series. International Journal of Speech-Language Pathology, 19:3, 251-264.
Hi there, I’m David Kinnane.
Principal Speech Pathologist, Banter Speech & Language
Our talented team of certified practising speech pathologists provide unhurried, personalised and evidence-based speech pathology care to children and adults in the Inner West of Sydney and beyond, both in our clinic and via telehealth.