31.4d Social (Pragmatic) Communication Disorder
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During this phase, children stutter most often when excited
or upset, when they seem to have a great deal to say, and
under other conditions of communicative pressure.
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Phase 2
usually occurs in the elementary school years.
The disorder is chronic, with few if any intervals of normal
speech. Affected children become aware of their speech dif-
ficulties and regard themselves as stutterers. In phase 2, the
stuttering occurs mainly with the major parts of speech—
nouns, verbs, adjectives, and adverbs.
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Phase 3
usually appears after the age of 8 years and up to
adulthood, most often in late childhood and early adoles-
cence. During phase 3, stuttering comes and goes largely
in response to specific situations, such as reciting in class,
speaking to strangers, making purchases in stores, and using
the telephone. Some words and sounds are regarded as more
difficult than others.
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Phase 4
typically appears in late adolescence and adulthood.
Stutterers show a vivid, fearful anticipation of stuttering.
They fear words, sounds, and situations. Word substitutions
and circumlocutions are common. Stutterers avoid situations
requiring speech and show other evidence of fear and embar-
rassment.
Stutterers may have associated clinical features: vivid, fear-
ful anticipation of stuttering, with avoidance of particular words,
sounds, or situations in which stuttering is anticipated; and eye
blinks, tics, and tremors of the lips or jaw. Frustration, anxiety,
and depression are common among those with chronic stuttering.
Differential Diagnosis
Normal speech dysfluency in preschool years is difficult to dif-
ferentiate from incipient stuttering. In stuttering occurs more
nonfluencies, part-word repetitions, sound prolongations, and
disruptions in voice airflow through the vocal track. Children
who stutter appear to be tense and uncomfortable with their
speech pattern, in contrast to young children who are nonfluent
in their speech but seem to be at ease. Spastic dysphonia is a
stuttering-like speech disorder distinguished from stuttering by
the presence of an abnormal breathing pattern.
Cluttering is a speech disorder characterized by erratic and
dysrhythmic speech patterns of rapid and jerky spurts of words
and phrases. In cluttering, those affected are usually unaware
of the disturbance, whereas, after the initial phase of the disor-
der, stutterers are aware of their speech difficulties. Cluttering is
often an associated feature of expressive language disturbance.
Course and Prognosis
The course of stuttering is often long term, with periods of
partial remission lasting for weeks or months and exacerba-
tions occurring most frequently when a child is under pressure
to communicate. In children with mild cases, 50 to 80 percent
recover spontaneously. School-age children who stutter chroni-
cally may have impaired peer relationships as a result of teasing
and social rejection. These children may face academic difficul-
ties, especially if they persistently avoid speaking in class. Stut-
tering is associated with anxiety disorders in chronic cases, and
approximately half of individuals with persistent stuttering have
social anxiety disorder.
Treatment
Evidence-based treatments for stuttering are emerging in
the literature. One such treatment is the Lidcombe Program,
which is based on an operant conditioning model in which
parents use praise for periods of time in which the child
does not stutter, and intervene when the child does stutter
to request the child to self-correct the stuttered word. This
treatment program is largely administered at home by parents,
under the supervision of a speech and language therapist. A
second treatment program being investigated in clinical trials
is a family-based, parent-child interaction therapy that identi-
fies stressors possibly associated with increased stuttering and
aims to diminish these stressors. A third treatment currently
under investigation in clinical trials is based on the knowl-
edge that speaking each syllable in time to a particular rhythm
has led to diminished stuttering in adults. This treatment pro-
gram appears to be promising when administered early on, to
preschoolers.
Distinct forms of interventions have historically been used
in the treatment of stuttering. The first approach, direct speech
therapy, targets modification of the stuttering response to flu-
ent-sounding speech by systematic steps and rules of speech
mechanics that the person can practice. The other form of
therapy for stuttering targets diminishing tension and anxiety
during speech. These treatments may utilize breathing exer-
cises and relaxation techniques, to help children slow the rate
of speaking and modulate speech volume. Relaxation tech-
niques are based on the premise that it is nearly impossible to
be relaxed and stutter in the usual manner at the same time.
Current interventions for stuttering use individualized combi-
nations of behavioral distraction, relaxation techniques, and
directed speech modification.
Stutterers who have poor self-image, comorbid anxiety dis-
orders or depressive disorders are likely to require additional
treatments with cognitive-behavioral therapy (CBT) and/or
pharmacologic agents such as one of the selective serotonin
reuptake inhibitor (SSRI) antidepressants.
An approach to stuttering proposed by the Speech Foun-
dation of America is labeled self-therapy, based on the prem-
ise that stuttering is not a symptom, but a behavior that can
be modified. Stutterers are told that they can learn to control
their difficulty partly by modifying their feelings about stutter-
ing and attitudes toward it and partly by modifying the deviant
behaviors associated with their stuttering blocks. The approach
includes desensitizing; reducing the emotional reaction to, and
fears of, stuttering; and substituting positive action to control
the moment of stuttering.
31.4d Social (Pragmatic)
Communication Disorder
Social (pragmatic) communication disorder is a newly added
diagnosis to DSM-5 characterized by persistent deficits in using
verbal and nonverbal communication for social purposes in
the absence of restricted and repetitive interests and behaviors.
Deficits may be exhibited by difficulty in understanding and
