My pre-schooler stutters and has problems with speech sounds: which one should I treat first?

**For a new study, see Parent dilemma: what to do when your child stutters and has speech sound problems – research update.

We know that 30-40% of children who stutter also have a speech sound disorder (Gregg & Yairi, 2007).

We also know that both stuttering and speech sound disorders can lead to kids being perceived negatively by their peers at school – and even their teachers (e.g. Langevin et al., 2010; McCormack et al., 2009).

So, if your child stutters and has a speech sound disorder, which should you treat first? Or should you treat them together?

We don’t know. The research evidence to date is lousy; almost non-existent!

From a real world, clinical point of view, many factors may influence your decision, including the severity of each condition, your child’s age, and the effect each issue is having on your child’s intelligibility, participation and quality of life.

A major factor, sometimes overlooked, is the nature of the treatments involved. For example:

we advocate the Lidcombe Program for many preschoolers who stutter. The Lidcombe program is a direct parent-delivered treatment which focuses on rewarding the child for fluent speech (see here for more detail).
for speech sound disorders, we recommend a variety of different evidence-based treatments, from traditional articulation programs through to more complicated phonological treatments like Cycles, Minimal Pairs and Maximal Oppositions. Most of these approaches also work directly on speech by rewarding correct production, often by repeating the sounds several times in isolation, syllables, words and phrases.

Our concern with treating a pre-schooler’s stuttering and speech sounds together is that you may inadvertently confuse your child (or even yourself!) about which behaviours are being rewarded, and why. For example:

in the Lidcombe Program, parents praise or otherwise encourage smooth or fluent, non-repetitive speech; and
in traditional articulation therapy, children are rewarded for saying the target sounds, syllables or words consistently and correctly.

So, if, one morning, you are praising Johnny for his fluent speech (with no repetitions) and then later on the same or the next day you are praising him for repeating a particular sound over and over, Johnny may – understandably – get confused. This may result in the treatments interfering with each other – or even (if some anecdotal evidence is to be believed) making things worse.

This is why, everything else being equal, we usually recommend “serial service delivery”: working on one goal (stuttering or speech sounds) first, before moving onto the other goal.

Depending on the age of the client and family preferences, we would normally suggest starting with stuttering treatment – especially if the child is about to start school. Our approach is consistent with the practice of a majority of Australian speech pathologists interviewed in a recent study (see citation below). But, in truth, we really don’t know enough about this group of children at this stage and need better research evidence to help guide clinical recommendations to parents.

Key source: Unicomb, R. et al., (2013). Clinicians’ management of your children with co-occurring stuttering and speech sound disorder. International Journal of Speech-Language Pathology, 15(4): 441-452.

Image: http://tinyurl.com/kppfc7z

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David Kinnane

David Kinnane is a Certified Practising Speech Pathologist with post-graduate training in the Lidcombe Program for childhood stuttering and the Camperdown Program for adults who stutter. David owns and operates Banter Speech & Language, a speech pathology clinic in Sydney, Australia and has a special interest in stuttering.