The incidence of pediatric fluency disorder refers to the number of new cases identified in a specific time period. Prevalence refers to the number of individuals who are living with fluency disorders in a given time period. Estimates of incidence and prevalence vary due to a number of factors—including disparities in the sample populations (e.g., age), how stuttering or cluttering was defined, and how stuttering or cluttering was identified (e.g., parent/caregiver report, direct observation).

Incidence of Stuttering

Overall, the lifetime incidence of stuttering was estimated to be 2.2% in 2002 (Craig et al., 2002). More recent studies have suggested that this number may be higher (Yairi & Ambrose, 2013). Cumulative incidence estimates vary by age range, as follows:

• 8.5% by 3 years of age (Reilly et al., 2009)
• 11.2% by 4 years of age (Reilly et al., 2013)
• 8% across childhood (Yairi & Ambrose, 2013)

The lifetime prevalence of stuttering was estimated to be 0.72% in 2002; newer estimates covering the full life span are not available (Craig et al., 2002). Prevalence estimates also vary by age, as follows:

• 2.73% for 3- to 5-year-old children (Zablotsky et al., 2019)
• 2.26% for 6- to 11-year-old children (Zablotsky et al., 2019)
• 1.43% for 12- to 17-year-old children (Zablotsky et al., 2019)
• 1.88%–2.02% across childhood (Choo et al., 2020; Zablotsky et al., 2019)
• 0.81% for adults 21 years and older with childhood onset stuttering, comprised of 0.53% overt stuttering and 0.28% covert stuttering (Gattie et al., 2025)

Data across countries where English is not the majority language showed similar prevalence estimates, as follows:

• 1.41% for 3-year-old children in Japan (Shimada et al., 2018)
• 8.4% for 3- to 5-year-old children in Cameroon (Oyono et al., 2018)
• 0.65% for 5-year-old children in Germany (Sommer et al., 2021)
• 1.03% for school-age children in Egypt (Abou Ella et al., 2015)
• 1.2% for school-age children in Iran (Karbasi et al., 2011)
• 1.38% for school-age children in Jordan (Al-Jazi & Al-Khamra, 2015)

Increased incidence of stuttering has been noted among individuals with a first-degree relative (e.g., parent, sibling) who stutters—and even more so if that relative is an identical twin (Kraft & Yairi, 2011). Approximately 60% of individuals who stutter report having a relative who stutters. People who stutter have greater odds of having a father who stutters than having a mother who stutters (Darmody et al., 2022). Researchers have estimated that children with a family history of stuttering are 1.89 times more likely than children with no family history to persist in stuttering (Singer et al., 2020).

Estimates have reported the male-to-female ratio of individuals who stutter to be as large as 4:1; however, more recent studies in preschool children have suggested that populations who experience onset at younger ages have smaller ratios in gender differences (Yairi & Ambrose, 2013). Stuttering in children was more prevalent in males, with a ratio of 2.54:1 (Choo et al., 2020). Researchers reported that males are 1.48 times more likely to persist in stuttering than females (Singer et al., 2020). Studies reported results that included only male and female categories; there were no indications as to whether the data collected were based on sex assigned at birth and/or gender identity.

Findings were mixed regarding the prevalence of stuttering among multilingual individuals as compared to monolingual individuals. Data may be confounded by the risk for misidentification of stuttering in this population due to how stuttering, multilingualism, and diagnostic criteria are defined (Byrd et al., 2020; Choo & Smith, 2020; Gahl, 2023). For further discussion on the identification of stuttering in multilingual individuals, see the Assessment section.

There was a higher prevalence of stuttering in children with comorbid conditions (4.19%) relative to children without comorbid conditions (1.02%; Choo et al., 2020). These differences in prevalence rate should also be interpreted with caution, as research has suggested that some of these populations may be at risk for overidentification of stuttering (Byrd, 2018).

Incidence of Cluttering

Experts in the field of cluttering have consistently estimated that approximately one third of children and adults who stutter also present with at least some components of cluttering (Daly, 1986; Preus, 1981; Ward, 2006). There are more clinical anecdotes than data to support this statement; further research on the incidence and prevalence of cluttering is needed (Scaler Scott, 2013). The prevalence of cluttering in children and adolescents was estimated to be between 0.0013% and 1.2% (Sommer et al., 2021; van Zaalen & Reichel, 2017). Among those diagnosed with stuttering, the prevalence of cluttering was estimated to be 1.2% (Sommer et al., 2021). Among children and adolescents diagnosed with cluttering, the prevalence of stuttering was estimated to be 15.7% (Sommer et al., 2021). This data should be interpreted with caution as the sample may not represent the full population.

The signs and symptoms presented below are consistent with the diagnostic and associated features of childhood-onset fluency disorder listed in the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR; American Psychiatric Association, 2022).

Signs and Symptoms of Stuttering

Stuttering can be described as overt or covert:

• Overt stuttering occurs when a person stutters openly with minimal attempts to suppress or conceal.
• Covert stuttering occurs when a person hides, or attempts to hide, their stuttering by using avoidance and escape behaviors.

Use of overt and covert stuttering can be situational. For example, someone may stutter overtly when at home with their family in a comfortable environment but be entirely covert at work.

Concealing one’s stuttering often begins as a response to negative listener reactions to stuttering. However, some people who stutter report that they conceal stuttering because stuttering is physically uncomfortable for them.

Concealment can begin as early as the preschool years but is more common in childhood and beyond (Gerlach-Houck et al., 2023). Efforts to conceal stuttering are associated with increased adverse impact of stuttering and psychological distress (i.e., anxiety and depression; Gerlach et al., 2021) as well as reduced quality of life (Boyle et al., 2018; Gerlach-Houck et al., 2023). Lower levels of overt stuttering do not directly relate to lower levels of psychological, emotional, social, or functional impacts that an individual experiences (Lucey et al., 2019; Tichenor & Yaruss, 2019a, 2020).

Signs and symptoms of overt stuttering (i.e., stuttering that can be observed by others) include

• monosyllabic whole-word repetitions (e.g., “Why-why-why did they go there?”);
• part-word or sound/syllable repetitions (e.g., “Look at the b-b-boy”);
• prolongation of sounds when emphasis is not the goal (e.g., “Ssssssssometimes we stay home”);
• blocking (i.e., inaudible or silent pauses or inability to initiate sounds); and
• production of words with an excess of physical tension or struggle.

The frequency, duration, and tension associated with overt stuttering may fluctuate from day to day and in relation to the speaking situation.

Related Behaviors

Certain related behaviors—secondary stuttering, avoidance behaviors, and escape behavior—may accompany moments of stuttering. These behaviors are discussed in the subsections that follow.

Secondary Stuttering

Secondary stuttering (also called “concomitant stuttering”) is a set of behaviors that accompany moments of stuttering and that may or may not be associated with an attempt to prevent overt stuttering. These behaviors range from being very subtle to being highly noticeable, and speakers may or may not be aware of them. Examples of secondary behaviors include

• body movements (e.g., head nodding, leg tapping, fist clenching);
• facial grimaces (e.g., eye blinking, jaw tightening); and
• unexpected sounds (e.g., throat clearing).

Avoidance Behaviors

Avoidance behaviors are those enacted before the moment of stuttering occurs, accompanied by an intent—conscious or unconscious—to temporarily conceal stuttering (Constantino et al., 2017; Douglass et al., 2018, 2019; B. Murphy et al., 2007; Starkweather, 1987; Tichenor et al., 2017; Tichenor & Yaruss, 2018, 2019a, 2019b, 2020).

Avoidance behaviors include

• using fillers (e.g., “like,” “um,” “uh,” “you know”);
• avoiding sounds or words;
• substituting words;
• inserting unnecessary words; and
• circumlocution.

Escape Behaviors

Escape behaviors are those enacted during a moment of stuttering, accompanied by an intent—conscious or unconscious—to stop the disfluency as it is happening.

There can be an overlap among secondary, avoidance, and escape behaviors. For example, blinking can be considered any one of these three types depending on the speaker’s intent and the timing of the behavior:

• secondary behavior: blinking during the moment of stuttering without making any attempt to conceal it (per the speaker’s report)
• avoidance behavior: blinking before the moment of stuttering with the intent to minimize the overt characteristics
• escape behavior: blinking during the moment of stuttering itself with the intent to end the disfluency

Attention/Phonological Working Memory and Stuttering

There may be a relationship between stuttering and working memory. Children who stutter may demonstrate decreased performance on phonological tasks such as nonword repetition (Wagovich & Anderson, 2010). The underlying relationship between stuttering and working memory is not fully understood (Bowers et al., 2018).

Impact of Fluency Disorders 

Stuttering—and the negative reactions that it can elicit from others—can impact experiences across four domains: social, academic, vocational, and emotional.

Social Domain

• Expressing wants and needs.
• Having conversations or telling stories.
• Forming friendships.
• Showing confidence.

Children who stutter may have a greater likelihood of being bullied (Blood & Blood, 2004; Davis et al., 2002; Langevin & Bortnick, 1998).

Academic Domain 

• Reading aloud.
• Answering questions verbally in class.
• Giving class or team presentations.
• Participating in class discussions.

Children who stutter may hesitate to engage with their overall peer group during class—including showing discomfort with reading aloud, hesitating to answer questions when called upon, and being unwilling or unable to give presentations or participate in group discussions.

Vocational Domain

• Perceiving and believing in one’s career possibilities.
• Interacting with coworkers.
• Being expected to engage in routine, necessary tasks that may draw attention to oneself, such as being on the telephone at work.
• Responding to time pressures for verbal communication with colleagues.
• Dealing with colleagues’ attitudes and social behavior at work.

Individuals who stutter may have low self-expectations and perceptions of their career possibilities and professional limitations (Klein & Hood, 2004). In addition, coworkers may have negative attitudes toward individuals who stutter, and those individuals may feel excluded because of this. There also may be time pressures for verbal communication and requirements to use the telephone, all of which may lead to stress and discomfort.

Individuals who stutter may experience limitations, discrimination, decreased earning potential, and glass ceiling–like effects (Bricker-Katz et al., 2013; Cassar & Neilson, 1997; Klein & Hood, 2004). An annual earnings gap is associated with stuttering: This gap is largely driven by discrimination, particularly for women (Gerlach et al., 2018).

Helping individuals who stutter become more accepting of and open about their stuttering may help them have workplace conversations about it, advocate for themselves, and build support systems within the workplace (Plexico et al., 2019). These efforts ideally are accompanied by initiatives to educate others about stuttering and reduce stigma.

Emotional Domain

• A sense of loss of control.
• Decreased self-confidence, self-efficacy, and self-worth.
• Depression and/or suicidal ideation.
• Dissociation— disconnection from feelings, memories, thoughts, and/or the environment.
• Increased social anxiety and avoidance of social interactions.

Stuttering may also be associated with psychosocial benefits, including personal and relationship benefits and positive perspectives about stuttering and life. These feelings may come from having a positive perception about the ability to face challenges (Boyle et al., 2019), increased empathy and compassion, and the tendency to focus on helping others (Hughes & Strugalla, 2013).

Signs and Symptoms of Cluttering

Per St. Louis and Schulte (2011), the characteristic signs and symptoms of cluttering include

• a speech rate that is perceived to be abnormally rapid and/or irregular;
• an excessive number of nonstuttering-like disfluencies;
• frequent irregular patterns of pausing; and/or
• frequent over-coarticulated speech.

Signs and symptoms of cluttering may also include

• maze behaviors or frequent topic shifting (e.g., “I need to go to . . . I mean I’m out of cheese. I ran out of cheese and bread the other day while making sandwiches and now I’m out so I need to go to the store”);
• unusual prosody, often due to atypical pauses in speech;
• omission of word endings (e.g., “Turn the televisoff”); and/or
• deletion and/or collapsing of syllables (e.g., “I wanwatevision”).

The speaker’s measured speech rate is not always greater than average, but the listener perceives it as rapid. This perceived rapid rate—and the resulting breakdown in speech clarity—is thought to be because speakers who clutter speak at a rate that is too fast for their systems to handle (Myers, 1992; St. Louis et al., 2007; Ward, 2006).

People who clutter can experience affective, behavioral, and cognitive reactions—including communication avoidance, anxiety, and negative attitudes toward communication (Scaler Scott & St. Louis, 2011; Scaler Scott & Yaruss, 2022). Although some people who clutter are not aware of their communication difficulties, many are aware that others have difficulty understanding them.

Causes of Stuttering

Causes of stuttering are thought to be multifactorial and include genetic and neurophysiological factors that contribute to its emergence (Smith & Weber, 2017). Environmental factors and speaking demands may exacerbate disfluency and may influence a person’s negative internal reactions to stuttering. Environmental factors include family dynamics, a fast-paced lifestyle, and stress and anxiety (J. D. Anderson et al., 2003).

Emotional problems and parenting style do not cause stuttering. However, a sensitive temperament (individual behavioral characteristics or reactions) and sensitive emotions are commonly seen as traits associated with persistent stuttering in young children. For example, emotional reactivity/regulation and behavioral disinhibition may affect the child’s ability to cope with disfluencies (Choi et al., 2013; Guttormsen et al., 2015; R. M. Jones, Conture, & Walden, 2014; Ntourou et al., 2013). For a review of temperament, emotions, and childhood stuttering, see R. M. Jones, Choi, et al. (2014).

Persistent Stuttering

It is not possible to determine with certainty which children will continue to stutter, but there are some factors that indicate a greater likelihood that stuttering will become persistent.

The following factors may be associated with persistent stuttering:

• Sex of the child—boys are more likely to develop persistent stuttering than girls (Craig et al., 2002; Yairi & Ambrose, 2013); it is unclear if studies used sex assigned at birth or gender identity to determine these categories. Additional research is needed regarding the intersex and non-binary/gender-nonconforming communities.
• Family history of persistent stuttering (Kraft & Yairi, 2011).
• Duration of greater than 6–12 months since onset or no improvement over several months (Yairi & Ambrose, 2005).
• Age of onset—children who start stuttering at age 3½ years or later (Yairi & Ambrose, 2005).
• Slower rates of language development (Leech et al., 2017, 2019) or co-occurring speech and language impairment (Ntourou et al., 2011; Yaruss et al., 1998).

Physiology and Genetics

Studies have shown both structural and functional neurological differences in children who stutter. For further reading, see Chang (2014), Chang et al. (2015, 2019), Chang and Zhu (2013), Desai et al. (2016), Neef and Chang (2024), Watkins et al. (2008), and Weber-Fox et al. (2013).

For further reading on how genetics relates to stuttering, see Drayna and Kang (2011), Frigerio-Domingues and Drayna (2017), and Kraft and Yairi (2011).

Causes of Cluttering

There is limited research available that identifies the causes of cluttering. For discussions of theoretical models, see Alm (2011), Bakker et al. (2011), Drayna (2011), Scaler Scott and St. Louis (2011), and Ward et al. (2015).

Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of fluency disorders. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).

Appropriate roles for SLPs include the following.

Assessment

• Screening communication when a fluency disorder is suspected and as part of a comprehensive speech-language evaluation.
• Conducting a culturally and linguistically relevant comprehensive assessment, with the understanding that awareness and concern about stuttering and/or cluttering may vary across individuals and cultures.
• Differentially diagnosing fluency disorders from disfluencies stemming from language-encoding difficulties—such as language delay or second-language learning.
• Referring the individual to other professionals to rule out other conditions and facilitate access to comprehensive services.

Counseling and Education

• Providing information to individuals and groups known to be at a higher likelihood of developing fluency disorders.
• Educating other professionals about the needs of individuals with fluency disorders and the role of SLPs in screening, assessing, diagnosing, and managing fluency disorders.
• Counseling individuals with fluency disorders and their families—as well as providing education aimed at self-acceptance and reducing negative internal reactions (see ASHA’s Practice Portal page on Counseling in Audiology and Speech-Language Pathology).
• Educating families about local support organizations for people who stutter and their families.

Treatment

• Assisting people who stutter and/or clutter in dealing with the stigma and potential negative responses to stuttering and/or cluttering.
• Consulting and collaborating with individuals with fluency disorders, families, other professionals, peers, and other invested parties to identify priorities and build consensus on an intervention plan focused on functional outcomes (see ASHA’s resources on interprofessional education/interprofessional practice [IPE/IPP], collaboration and teaming, and focusing care on individuals and their care partners
• Developing culturally and linguistically relevant intervention plans focused on helping the individual achieve more effective communication and/or self-acceptance of stuttering and/or cluttering, providing treatment, documenting progress, and determining appropriate dismissal criteria.
• Referring to other health care professionals when outside support is needed to facilitate treatment goals for co-occurring conditions (e.g., anxiety, depression).

Other

• Recommending related services when necessary for management and treatment in different settings (e.g., classroom, work, community).
• Finding opportunities for social support for individuals who stutter and/or clutter.
• Remaining informed of research in the area of fluency disorders and advancing the knowledge base of the nature of the disability, screening, diagnosis, prognostic indicators, assessment, treatment, and service delivery for individuals with fluency disorders.
• Advocating for individuals with fluency disorders and their families at the local, state, and national levels.

As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so. The American Board of Stuttering, Cluttering and Fluency Disorders, under the auspices of ASHA’s specialty certification program, offers voluntary clinical specialty certification in stuttering, cluttering, and fluency disorders. Board Certified Specialists in Stuttering, Cluttering, and Fluency Disorders (BCS-SCF) are SLPs who hold the ASHA Certificate of Clinical Competence (CCC-SLP) and have demonstrated advanced knowledge and clinical expertise in diagnosing and treating individuals with stuttering, cluttering, and fluency disorders.

Screening

Screening is conducted (a) whenever stuttering and/or cluttering is suspected or (b) as part of a comprehensive speech and language assessment.

Comprehensive Assessment

Individuals are referred to speech-language pathologists (SLPs) for comprehensive assessment when disfluencies are noted and when one or more of the factors listed below are observed along with the disfluencies. This list is not exhaustive, and not all factors need to be present for a referral to an SLP (e.g., Guitar, 2019; Yaruss et al., 1998).

• There is a family history of stuttering and/or cluttering.
• There is concern on the part of the parent/caregiver and/or the individual about disfluencies and/or negative internal or external reactions.
• The person exhibits negative internal reactions (e.g., affective, behavioral, or cognitive reactions) to their disfluency.
• The person is experiencing inappropriate listener reactions from others (e.g., peers, classmates, coworkers, family members).
• The person exhibits physical tension or secondary behaviors (e.g., eye blinking, head nodding) associated with the disfluency.
• The person is having difficulty communicating messages in an efficient, effective manner.
• Other speech or language concerns are also present.

See ASHA’s resource on the assessment of stuttering, cluttering, and fluency disorders in the context of the WHO ICF framework.

Symptoms and severity of stuttering and cluttering can vary depending on the environment (Davidow & Scott, 2017; St. Louis & Schulte, 2011).

Cluttering symptoms may

• decrease in formal settings (due to increased self-monitoring) or
• increase in informal settings (due to decreased self-monitoring).

Stuttering symptoms may

• increase in formal settings (due to increased self-monitoring/tension) or
• decrease in informal settings (due to increased self-monitoring/tension).

Some people who stutter substitute and/or omit words or use circumlocution to avoid stuttering (B. Murphy et al., 2007). These behaviors can mask the severity of stuttering. Therefore, a comprehensive assessment for stuttering and cluttering should include an assessment of both overt and covert features. Informal assessment should be considered, as the validity of standardized assessments is unclear—particularly for those with more covert stuttering patterns (Gerlach-Houck & Constantino, 2022; Gerlach-Houck et al., 2023).

Additionally, the affective, behavioral, and cognitive features of stuttering are important components of the assessment (Vanryckeghem & Kawai, 2015). Clinicians note any indicators of internalizing negative stereotypes about stuttering and cluttering (e.g., avoiding speaking and/or social engagements; Boyle, 2013a).

Evaluation is more accurate when it includes self-report and samples of speech across various situations and tasks (e.g., audiovisual recordings of speech outside of the clinical setting; Yaruss, 1997).

A comprehensive stuttering and cluttering assessment typically includes the following, organized according to the six core areas of a comprehensive stuttering evaluation (Brundage et al., 2021):

1. Stuttering- and cluttering-related background information, including
   • medical history;
   • general development;
   • a review of previous fluency evaluations and educational record;
   • a description of the disfluency and a rating of the severity;
   • age of onset of the disfluency and patterns of disfluency since onset (e.g., continuous or variable); and
   • previous speech treatment, treatment goals, and treatment outcomes.
2. Speech and language development, including
   • frequency of exposure to all languages used by the child as well as their proficiency (comprehension and production) in each language and
   • a family history of stuttering and/or cluttering.
3. Speech fluency, stuttering, and/or cluttering behaviors, including
   • an analysis of the speech sample outside of the clinical setting (in real time or via audiovisual recording);
   • stimulability testing (e.g., a person is asked to increase pausing and/or decrease speech rate in some other way)—where a reduction of overall speech rate typically helps in reducing cluttering symptoms;
   • speech and language concerns; and
   • an assessment of speech fluency (e.g., frequency, type, and duration of disfluencies), speech rate, speech intelligibility, and the presence of secondary behaviors in a variety of speaking tasks (e.g., conversational and narrative contexts).
4. Reactions to stuttering and/or cluttering by people in the speaker’s environment, including
   • exploration of caregivers’ reactions to the child’s moments of disfluency or speaking frustration;
   • consultation with family members, educators, and other professionals regarding fluency variability (when disfluencies are noticed most and least) and the impact of disfluency; and
   • information regarding family, personal, and cultural perception of fluency.
5. Reactions to stuttering and cluttering by the speaker, including
   • a determination of individual strengths and coping strategies and
   • an assessment of awareness in young children of disfluencies and the difficulties in speaking.
6. Adverse impact caused by stuttering and/or cluttering, including
   • an assessment of the impact of stuttering and/or cluttering, such as an assessment of the emotional, cognitive, and attitudinal impact of disfluency (e.g., negative internal reactions to stuttering and/or cluttering, tension, avoidance of speaking) and
   • an assessment of other communication dimensions, such as speech sound production, receptive and expressive language, pragmatic language, voice, hearing, and oral–motor function/structure.

Assessment may result in

• the diagnosis of a fluency disorder (stuttering and/or cluttering);
• a differential diagnosis between fluency disorders and reading disorders, language disorders, and/or speech sound disorders;
• descriptions of the characteristics and severity of the fluency disorder, including overt and covert behaviors and secondary mannerisms;
• judgments on the degree of impact that the fluency disorder has on verbal communication and quality of life (e.g., negative internal reactions, tension, confidence in speaking);
• a determination if the person may benefit from treatment;
• a determination of adverse educational, social, and vocational impact;
• recommendations for treatment and possible treatment goals related to fluency, avoidance reduction, negative impact reduction, and/or confidence in speaking;
• caregiver counseling to determine optimal responses to the child’s speech, stuttering and/or cluttering; and
• consultation with and referral to other professionals as needed.

Special Considerations for Assessment

Special considerations are made, based on age range, for the assessment of

• preschool children,
• school-age children and adolescents, and
• adults.

These special considerations are discussed in the subsections that follow.

Assessment of Preschool Children

The purpose of assessing fluency in preschool children is to determine the answer to the following two questions:

1. Are the child’s disfluencies part of typical development, or are they characteristics of stuttering and/or cluttering? (See ASHA’s resource on the characteristics of typical disfluency and stuttering.)
2. Is monitoring or treatment (direct or indirect) recommended?

Stuttering Assessment

The stuttering assessment identifies risk factors associated with stuttering, the degree of overt and covert stuttering, and the presence of other speech and language concerns.

Cluttering Assessment

A diagnosis of cluttering is typically not made during the child’s preschool years. Cluttering is often diagnosed at about 8 years old—when a child’s language becomes lengthy and/or complex enough for symptoms to be noticeable. However, age of onset may begin at approximately 33 months old (Howell & Davis, 2011).

Treatment

After assessment of stuttering and/or cluttering, the next decision point is whether or not to pursue treatment (and if so, whether it should be direct or indirect).

If treatment is pursued, then it is necessary to determine the timing for intervention and to create a plan for caregiver education and counseling.

If it is decided that treatment is currently not needed, then the SLP educates the family about how to monitor the child’s stuttering and/or cluttering to determine if and when they should be reevaluated.

Assessment of School-Age Children and Adolescents

The purpose of assessing school-age children and adolescents for stuttering and/or cluttering is to determine the presence, the extent, and—most importantly—the impact of stuttering and/or cluttering and the potential benefit(s) from treatment.

Disfluency may be masked in this population due to learned use of avoidance behaviors or highly situational symptoms. In such instances, the child may still benefit from treatment because of the negative or limiting effect of disfluency on their quality of life. Some children who stutter and/or clutter may only experience symptoms situationally. However, even when children show little observable disfluency, they may still indicate treatment because of the negative beliefs that they have around their communication and/or the effort that they are putting into managing or masking their disfluencies.

Stuttering and/or cluttering can impact educational performance and participation. When determining eligibility for speech and language services through the public school system, SLPs need to document the “adverse educational impact” of the disability using a combination of formal assessment tools (when available) and a portfolio-based assessment (Coleman & Yaruss, 2014; Ribbler, 2006). This includes the impact on functional communication in key school situations and on quality of life (Beilby et al., 2012b; Yaruss et al., 2012). The present levels of academic achievement and functional performance (PLAAFP) statement, which serves as the baseline for the individualized education program (IEP), refers to other areas that are not necessarily academic and that can include information about communication skills, social skills, and other activities of daily living. Frequency of disfluency is not mandated by the Individuals with Disabilities Education Act (IDEA, 2004) as an eligibility criterion for stuttering and/or cluttering service.

Clinicians should attempt to learn how the person feels in the moments before, during, and after stuttering and/or cluttering. SLPs may want to relate personal experiences when asking students to share such vulnerable information. For example, an SLP could share that they are sometimes uncomfortable about their own speech and that they understand the feeling of discomfort and embarrassment when someone makes fun of them.

Assessment of Adults

Adults who stutter and/or clutter are more likely to be aware of and able to describe their experience with stuttering and/or cluttering because

• it is likely that adults who stutter have been experiencing those symptoms since childhood,
• adults have more functional meta-cognitive skills than children, and
• it is more likely that they are self-referred.

Adult assessment focuses on determining the extent and impact of the stuttering and/or cluttering, potential treatment benefits, and motivation to participate in treatment. Some adults who clutter initially may have been diagnosed with a stuttering disorder. SLPs should consider this and the potential effects of the initial misdiagnosis on the individual during assessment and treatment. Individuals in this situation may require different treatment and counseling approaches from others with no history of misdiagnoses.

Overt characteristics of stuttering and/or cluttering may vary dramatically depending on the speaking situation. Therefore, when conducting an assessment with an adult, it is crucial to understand

• the individual’s lived experiences with stuttering and/or cluttering and with previous speech treatment,
• the perceived impact of these experiences with stuttering and/or cluttering, and
• their reason for seeking treatment at the current time.

Cultural and Linguistic Considerations

Multilingual children who stutter typically do so in all languages that they use (Nwokah, 1988; Van Borsel et al., 2001). Therefore, assessment is completed in all of a client’s languages to determine their stuttering profiles (Finn & Cordes, 1997). Frequency and nature of disfluencies may vary across languages spoken by an individual (Nwokah, 1988; Tellis & Tellis, 2003). These differences may be due to the social context in which the language is used (Foote, 2013) as well as the proficiency of each language spoken.

Moments of stuttering may be difficult to distinguish from typical disfluency or reduced language proficiency, especially for a person unfamiliar with the language (Shenker, 2011). Some children from multilingual or multicultural backgrounds may experience a temporary increase in disfluencies as a result of being in new and unfamiliar situations, learning a new language, or being exposed to mixed linguistic input (Byrd et al., 2015; Johnson & Mills, 2023; Shenker, 2013).

Multilingual children tend to produce higher rates of monosyllabic word repetitions, sound repetitions, and syllable repetitions than monolingual speakers.

Recent research suggests that persistent stuttering is not more prevalent in multilingual speakers—and that exposure to a second language does not increase the likelihood of developing a stuttering disorder. However, the same frequency thresholds that are used to identify monolingual individuals as people who stutter may not be valid when applied to multilingual individuals during assessment. The differences between disfluencies stemming from reduced language proficiency and stuttering are evident in many ways—lack of awareness, struggle, tension, blocking, and lack of self-concept as a person who stutters—that are not seen in typical multilingual learning profiles (Byrd, 2018).

Enlisting the help of a person familiar with the language and rating fluency in short speech intervals may also help to accurately and reliably judge unambiguous stuttering (Shenker, 2011).

Multilingual SLPs who have the necessary clinical expertise to assess the child—and are familiar with the languages they speak—may not always be available. When a multilingual SLP is not available, the clinician collaborates with an interpreter. See ASHA’s Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology and Collaborating With Interpreters, Transliterators, and Translators.

As with monolingual clients, caregivers of multilingual children can be taught to provide perceptual ratings of fluency in any language spoken by the child (Shenker, 2013). Parents can also report if secondary behaviors are present in both languages. Any scales used for these purposes should be translated into the preferred language of the caregiver. An interpreter is still necessary when evaluating a child who uses a language different from what the clinician uses.

Black and Hispanic children are more likely to be diagnosed with stuttering than their White counterparts, possibly due to confounding variables such as linguistic bias (Zablotsky et al., 2019).

Language differences as well as caregiver, community, and individual values and preferences are considered during assessment. Developmental milestones differ across languages, and a direct comparison of scores across languages can be misleading even if the assessments appear similar (Elin Thordardottir, 2006). It is not appropriate to determine a standard score if the normative sample of the assessment does not represent the individual being assessed.

Co-Occurring Diagnoses

The following disorders frequently co-occur with stuttering:

• attention-deficit/hyperactivity disorder (Donaher & Richels, 2012; Lee et al., 2017)
• autism (Briley & Ellis, 2018)
• intellectual disability (Healey et al., 2005)
• language or learning disability (Ntourou et al., 2011)
• other developmental disorders (Briley & Ellis, 2018)
• seizure disorders (Briley & Ellis, 2018)
• social anxiety disorder (Brundage et al., 2017; Craig & Tran, 2014; Iverach et al., 2018)
• speech sound disorders (St. Louis & Hinzman, 1988; Wolk et al., 1993)

Disorders that frequently co-occur with cluttering include the following:

• attention-deficit/hyperactivity disorder (Alm, 2011)
• auditory processing disorders (Molt, 1996)
• autism (see Scaler Scott, 2011, for a review)
• Down syndrome (Hokstad & Næss, 2023)
• fragile X syndrome (Bangert et al., 2022)
• hearing deficits (Arenas et al., 2017)
• learning disabilities (Wiig & Semel, 1984)
• Tourette’s syndrome (see Van Borsel, 2011, for a review)
• word-finding/language organization difficulties (Myers, 1992)

Stuttering as It Relates to Cluttering

Although stuttering and cluttering can co-occur there are some important distinctions between the two (see Scaler Scott, 2010).

• Individuals who stutter are more likely to be self-aware about their disfluencies and communication.
• Individuals who stutter may exhibit more physical tension, secondary behaviors, and negative internal reactions to communication.
• Individuals who clutter may exhibit more errors related to reduced speech intelligibility due to rapid rate of speech (Scaler Scott, 2020).

Stuttering as It Relates to Reading Disorders

Children who stutter typically know how to read (decode) the printed form of words, but they may not be able to speak the printed form fluently. In contrast, children with reading disorders are likely to have difficulty decoding the printed form—which, in turn, has a negative impact on oral reading fluency (Kuhn & Stahl, 2003).

When children who stutter are reading aloud,

• they may show increased disfluency rates (decreased reading fluency) because they cannot change the words to avoid moments of stuttering as easily as they can in conversation, and
• their disfluencies may be accompanied by physical tension and secondary behaviors.

Oral reading ability is not a reliable measurement of reading fluency for children who stutter because fluency breakdowns tend to slow one’s reading rate (Howland & Scaler Scott, 2015). Reading slowly may be perceived as a decoding problem even though the underlying cause is stuttering. It is also important to differentiate true decoding errors from those caused by over-coarticulation in cluttering, such as a dropped ending in a word.

SLPs may consider using alternative measures of reading fluency (e.g., tests of silent reading fluency) for children who stutter. For more information, see the handouts for parents and teachers by ASHA’s Ad Hoc Committee on Reading Fluency For School-Age Children Who Stutter in the Resource list (ASHA, 2014).

Fluency Disorders in the Context of Language Difficulties

A subgroup of people who stutter may appear to have additional difficulties with expressive language because of a tendency to avoid speaking or speaking in a way that is unclear to the listener. Over time, avoidance can lead to less talking and reduced linguistic complexity.

However, it is unclear if people who stutter have expressive and receptive language skills that are equal to or different from those of their peers (Ntourou et al., 2011; Silverman & Bernstein Ratner, 2002; Wagovich & Hall, 2017). For further reading, please see Kreidler et al. (2017).

Children with a history of language difficulties at the sentence, narrative, or conversational discourse level may exhibit increased speech disfluencies. They are likely to use interjections or to repeat phrases, and to revise what they are saying. However, their disfluencies likely do not involve prolongations, blocks, physical tension, or secondary behaviors that are more typical for children who stutter (Boscolo et al., 2002). Word-finding problems can also result in an increase in typical disfluencies that are similar to those observed in cluttering.

Cluttering as It Relates to Other Disorders of Speech Intelligibility

Cluttering and other disorders, such as apraxia of speech and/or articulation and phonological disorders, can affect speech intelligibility. See ASHA’s Practice Portal pages on Childhood Apraxia of Speech and Speech Sound Disorders-Articulation and Phonology.

Speech production assessment can be used to help determine potential causes of reduced speech intelligibility. For example, if an individual slows their speech and then their fluency dramatically improves, then it may be an indicator of cluttering versus stuttering. However, such a change is not definitive; similar changes may also occur with stuttering.

Clinicians note if an individual reports any feelings of loss of control while speaking—because that may indicate stuttering as opposed to another disorder. Such information can be gathered during informal interviews.

For further information on differential diagnosis of cluttering, see Scaler Scott (2022).

Treatment for stuttering and cluttering is highly individualized and is based on a thorough assessment of speech fluency, language factors, emotional/attitudinal components, and life impact (Byrd & Donaher, 2018). SLPs use linguistically and culturally appropriate clinical resources and are sensitive to the unique values and preferences of individuals and their families to create a treatment plan (Sisskin, 2018).

The clinician considers

• the degree to which the individual’s disfluencies, coping patterns, and overall communication are influenced by a coexisting disorder (e.g., other speech or language disorders, Down syndrome, autism, attention-deficit/hyperactivity disorder);
• the communication environment (e.g., accepting or hostile social environment); and
• how treatment might be adjusted accordingly.

SLPs typically treat stuttering and/or cluttering using an approach that focuses care on individuals and their care partners. The SLP

• educates the individual who stutters and/or clutters and their family members about stuttering, cluttering, and communication and
• facilitates conversations between the individual and their family about the experience of stuttering and/or cluttering, the individual’s communication expectations, their life goals, and how to holistically support communication (see, e.g., Berquez & Kelman, 2018; Millard et al., 2018; Rocha et al., 2020).

SLPs consider the individual’s age, preferences, and needs within family and community contexts when selecting treatment approaches and materials. See Yaruss and Pelczarski (2007) for a discussion of a process for selecting evidence-based approaches based on individual needs.

Stuttering Treatment

The clinician should consider the holistic impact of stuttering on the individual’s entire communication experience and quality of life. Most individuals who seek treatment for stuttering have some degree of both observable disfluency and adverse impact of stuttering on quality of life (Beilby et al., 2012b; Ribbler, 2006; Tichenor & Yaruss, 2019a; Yaruss et al., 2012).

Treatment should consider overt stuttering as well as the affective and cognitive reactions to stuttering. Increasing fluency may not be a goal for an individual or may be only one aspect of a comprehensive and multidimensional approach (Amster & Klein, 2018). Personalized goal setting is very important when providing stuttering treatment (Sønsterud et al., 2020).

Goals may focus on minimizing negative internal reactions to stuttering and difficulties communicating in various speaking situations. Such goals help the individual (a) reduce the effort used to hide or avoid their disfluencies and (b) communicate with more ease and confidence. These improvements allow the speaker to focus on the content of a message rather than on how it is said.

As the person communicates more freely, they may notice an increase in observable disfluent behaviors. In this case, stuttering more often can—in and of itself—be a positive therapy outcome. Stuttering itself does not inherently require remediation. Stuttering can be easy, free-flowing, and even a source of pride. It is the associated struggles—physical, mental, and social—that people who stutter often view as burdensome. See Boyle and Gabel (2020a) for further information.

Motivational Interviewing as a Treatment Strategy

Motivational interviewing is a person-centered approach that can be useful in developing functional goals and enhancing readiness for change (Miller & Rollnick, 2013; Rollnick & Miller, 1995). It incorporates techniques such as open-ended questions, feedback, reflective listening, affirmations, and summarizing to resolve resistance or ambivalence to therapy. Motivational interviewing may be used to help individuals who stutter and/or clutter better understand the thoughts and feelings associated with their speech and make positive changes to improve communication. Speakers may be more motivated to participate in therapy when they are able to participate in decisions about treatment goals and select goals that they consider important (Finn, 2003; Sønsterud et al., 2020).

Treatment is sensitive to cultural and linguistic factors and addresses goals within the World Health Organization’s (WHO’s) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2023; Coleman & Yaruss, 2014; WHO, 2001; Yaruss, 2007; Yaruss & Quesal, 2004, 2006). See ASHA’s resource on treatment goals for stuttering, cluttering, and fluency disorders in the context of the WHO ICF framework. See also ASHA’s resources titled Person-Centered Focus on Function: Preschool Stuttering [PDF], Person-Centered Focus on Function: School-Age Stuttering [PDF], and Person-Centered Focus on Function: Adult Stuttering [PDF] for examples of treatment goals consistent with the ICF framework.

Counseling as a Treatment Strategy

Counseling allows clinicians to target all aspects of a disorder and is a necessary part of treatment. It is integrated into all treatment styles. Counseling helps speakers improve their quality of life by setting realistic expectations, empowering the speaker to meet their goals and minimizing negative thoughts and feelings around their communication.

Counseling in areas not related to communication should be completed by another professional (e.g., psychologist). Please see ASHA’s Scope of Practice in Speech-Language Pathology for further information. Referrals are appropriate and necessary if such a condition or situation is noted. For example, a person who stutters might experience suicidal ideation (Tichenor et al., 2023). In such cases, SLPs refer the client/patient to mental health professionals.

Caregiver involvement is an integral part of any treatment plan for children who stutter and/or clutter. The SLP can instruct caregivers in how to modify the environment to facilitate ease of communication and reduce communication pressure. Caregivers can also learn about how to help their child take the skills they learned from the treatment room and generalize them to different settings—and with different people. SLPs can include teachers in the treatment process by educating them about stuttering and/or cluttering, involving them in treatment sessions, and having them assist with assignments outside of treatment sessions.

SLPs educate caregivers and teachers on the child’s treatment goals, especially when increasing fluency is not an explicit goal. SLPs explain that goals may focus on building one’s speaking confidence by (a) reducing negative internal reactions to stuttering and/or cluttering, (b) reducing avoidance, and (c) focusing on the content of speech versus focusing on disfluencies.

An effective client–clinician relationship facilitates the identification of potential roadblocks to success (Plexico et al., 2010). This relationship is recognized as one of the common factors that account for the effectiveness of counseling (for a discussion of common factors theory, see Wampold, 2001).

See ASHA’s Practice Portal pages on Counseling in Audiology and Speech-Language Pathology and Cultural Responsiveness for more information related to counseling.

Treatment of Preschool Children Who Stutter

Parent and family involvement in the treatment process is essential (Kelman & Nicholas, 2020). The SLP works with parents and families to create an environment that facilitates struggle-free communication and helps them develop healthy and positive communication attitudes (Yaruss & Reardon-Reeves, 2017). For further reading, see Shenker et al. (2023).

Young children may or may not verbalize their reactions to stuttering. Clinicians and parents also look for reactions—such as avoidance of words or speaking situations, increased physical tension or secondary behaviors, reduced utterance length, or slight changes in pitch or loudness during stuttering episodes. It is important that parents and clinicians acknowledge and respond to a child’s verbal and nonverbal reactions in a supportive manner; this helps minimize the likelihood that the child will develop negative internal reactions to stuttering.

Treatment Approaches for Preschool Children Who Stutter

Clinicians use the following treatment approaches for preschool children who stutter:

• indirect treatment
• direct treatment
• operant treatment

Indirect treatment focuses on counseling families about how to make changes in their own speech and how to make changes in their child’s environment. These modifications are used to facilitate ease of communication and reduce negative internal reactions and may include

• reducing their own communication rate;
• focusing more on what is said rather than how it is said;
• using indirect prompts rather than direct questions;
• recasting/rephrasing to model fluent speech or easier communication (Millard et al., 2008; Yaruss et al., 2006); and
• building resilience within the child and family (Berquez & Kelman, 2018).

Fluency-focused treatment approaches may include

• aiming for a reduced rate of speech;
• using prolonged syllables;
• modifying a stuttered word; and
• building resilience in the child and family (Caughter & Crofts, 2018; Druker, Mazzucchelli, Hennessey, & Beilby, 2019).

See the Speech Modification Strategies section below for a further explanation of these approaches.

Operant treatment (e.g., Palin Parent–Child Interaction Therapy, Kelman & Nicholas, 2020; Lidcombe Program, Onslow et al., 2003) involves principles of operant conditioning—that is, using positive and negative reinforcement to modify behavior. The clinician positively reinforces fluent speech and negatively reinforces (i.e., “corrects”) disfluent speech.

With this approach, caregivers are trained to provide verbal contingencies—that is, comments that parents and/or clinicians make following a child’s stuttered or stutter-free moment and that are based on whether a child’s speech is fluent or stuttered (M. Jones et al., 2005; Onslow et al., 2003). In this way, caregivers use positive reinforcement to increase or strengthen the response of fluency (i.e., the desired behavior).

Treatment of School-Age Children, Adolescents, and Adults Who Stutter

Comprehensive treatment approaches for school-age children, adolescents, and adults who stutter are tailored to each individual and their unique needs (e.g., communication in the classroom, in the community, or at work).

Treatment is focused on

• increasing effective and efficient communication;
• increasing acceptance and openness with stuttering;
• reducing secondary behaviors and minimizing avoidances if they are burdensome to the speaker;
• improving social communication;
• increasing self-confidence and self-efficacy;
• responding to bullying if it is relevant; and
• minimizing the adverse impact of stuttering (Yaruss et al., 2012).

Disfluent behavior becomes more complex as fear of speaking, anxiety, and resulting avoidance increase. Communication apprehension, loss of control, and shame may also develop as individuals experience greater difficulty with communication and negative listener reactions. Treatment may include strategies to reduce negative internal reactions to stuttering (Yaruss et al., 2012) and inappropriate listener responses to stuttering. For example, clinicians may use treatment strategies to reduce bullying by educating the individual’s peers about stuttering (W. P. Murphy et al., 2007a, 2007b) and reduce its impact on the child by teaching them about self-advocacy. Integrated treatment focused on parental involvement, self-regulation, and improved overall communication (which could be increased fluency, communicative ease, social participation, or whatever is deemed as most important to the individual) may also be beneficial (Druker, Mazzucchelli, Hennessey, & Beilby, 2019).

Chronic problems associated with illness, injury, or other traumatic events can have a negative impact on an individual’s emotional health and quality of life (e.g., Bonanno & Mancini, 2008). For stuttering, examples of chronic problems could be challenging social environments or high levels of struggle while speaking.

Resilience—the ability to adjust and cope in the face of adversity—can help lessen the negative impact of stuttering (e.g., Coifman & Bonanno, 2010). Resilience has been examined in stuttering literature as one factor that may protect people from the adverse impact of persistent stuttering (Craig et al., 2011; Freud & Amir, 2020).

One potential approach to improve resilience involves training the parents/caregivers of individuals who stutter (Druker, Mazzuccheli, & Beilby, 2019).

Treatment Considerations for Adolescents

Treatment for adolescents who stutter poses a particular challenge because of the issues related to this developmental stage. Typical adolescent experiences of emotional reactivity, resistance to authority, and social discomfort may be exacerbated in adolescents who also experience stuttering (Daly et al., 1995; Zebrowski, 2002). Adolescents also may be susceptible to peer pressure and bullying at this stage in life. The attitudes of high school peers toward stuttering and toward people who stutter can be improved through education in the form of classroom presentations about stuttering (Flynn & St. Louis, 2011). Students who improve their attitudes toward stuttering tend to maintain these healthy views years later (St. Louis & Flynn, 2018).

In addition to the challenges associated with typical adolescent experiences, treatment may not be a priority for some adolescents because of other academic and social demands, being in denial, and concern about the stigma of seeking treatment. Building trust by following the student’s lead, finding out what experiences may be motivating, and bringing together peers for support are treatment options to consider (Hearne et al., 2008).

Despite these challenges, some of the therapy that applies to adults can be just as effective with teens/adolescents. They can also benefit from therapy and support groups (Fry et al., 2014).

Treatment Considerations for Adults

Adults with fluency disorders have likely experienced years of treatment with varied outcomes. They may have long-held beliefs about stuttering that positively or negatively affect self-perceptions about their communication skills and their motivation for change (Daniels, 2007). Some adults lack confidence in communication because of their negative perception of their own stuttering (Beilby et al., 2012a) or due to repeated exposure to stereotypes about stuttering, which, in turn, may create self-stigmatization (Boyle, 2013a).

Adults who stutter may be dealing with years of shame or stigma (Boyle, 2013a), which may negatively impact their mood, social participation, and overall health.

The impact of fluency disorders can extend to social and vocational aspects of the individual’s life. For example, stuttering has been associated with higher levels of social anxiety in adults who stutter (Blumgart et al., 2010), and this can lead to fear and avoidance of social interaction (see Craig & Tran, 2006, for a research review). Adults who stutter also may experience job discrimination and occupational stereotyping, including an earnings gap—especially for females (Gerlach et al., 2018).

SLPs work to develop an understanding of each individual’s stuttering experience and prior attempts to cope with their stuttering (Manning & DiLollo, 2018). As with all populations, treatment for adults is ideally individualized, dynamic, and multidimensional. The clinical process for an adult involves

• providing information,
• building a relationship,
• discussing the rationale for treatment decisions, and
• having flexibility based on individual needs and desired outcomes.

Treatment approaches for adults should also consider career and workplace factors as well as other domains of their life deemed relevant by the client (e.g., communication in dating).

Treatment Approaches for School-Age Children, Adolescents, and Adults Who Stutter

Below is a list of approaches used with school-age children, adolescents, and adults who stutter. All approaches should include a plan for generalization and maintenance of skills involved in activities of daily living.

Approaches may vary by therapeutic philosophy, goals and activities, duration and intensity, and age of the individual. However, many clinicians integrate several approaches when providing treatment.

Not all of these approaches are appropriate for the treatment of cluttering (see the Cluttering Treatment section below).

Strategies for Reducing Impairment in Body Function

Speech modification and stuttering modification are two different types of treatment approaches for improving fluency. They can be used separately or at the same time.

Speech Modification Strategies

Speech modification strategies (including fluency shaping; Bothe, 2002; Guitar, 1982, 2019) include a variety of techniques aimed at (a) making changes to the timing and tension of speech production or (b) altering the frequency and placement of pauses between syllables and words. These modifications are used regardless of whether a particular word is expected to be produced fluently.

Strategies aimed at changing the timing and tension of speech production include the following:

• easy/gentle onset—using a gradual onset of voicing (e.g., on initial vowels)
• light articulatory contact—using easy articulatory postures (e.g., on plosives)
• continuous phonation—maintaining voicing throughout an utterance
• prolonged syllables—“stretching” each syllable in words/utterances
• rate control—slowing the overall rate of speech

Strategies aimed at altering the frequency and placement of pauses are used to

• increase fluency and
• improve overall communication (e.g., intelligibility, message clarity).

Pausing is also an effective method of rate control.

Just as individuals may experience feelings of shame or fear associated with showing stuttering, individuals may also experience negative feelings associated with using speech modification strategies, which often make their speech sound different from “natural” speech (Gerlach-Houck & Constantino, 2022; Ingham & Onslow, 1985; Martin et al., 1984).

Stuttering Modification Strategies

The goal of stuttering modification strategies typically is to reduce physical tension and/or struggle. These strategies require an individual to identify a moment of disfluency before, during, or after it occurs and to reduce tension. The specific strategy that they select will depend on when the client “catches” the disfluency—in anticipation of the moment of disfluency, in the moment, or following the moment (Van Riper, 1973).

These strategies are introduced along a hierarchy of speaking situations, beginning with easier situations (e.g., with a familiar conversation partner) and working toward more difficult situations (e.g., speaking to a stranger on the phone).

Stuttering modification strategies include those that are more current and contemporary as well as those that are considered to be more traditional and conventional. Both types are discussed below.

Contemporary Strategies

The more current, contemporary approaches to stuttering modification follow four stages:

1. identification
2. desensitization
3. modification
4. generalization

These approaches aim to reduce associated physical tension and struggle by helping individuals

• identify core stuttering behaviors,
• recognize physical concomitant behaviors,
• locate the point of physical tension and struggle during moments of disfluency, and,
• ultimately, reduce physical tension.

These strategies help individuals learn about the speech mechanism and how it operates during both fluent and disfluent speech so they can modify it. Increasing the individual’s awareness and self-monitoring skills helps reduce unhelpful behaviors that interfere with speech, and it may allow them to alter moments of stuttering so that they have decreased tension, are shorter, and are less disruptive to communication.

Conventional Strategies

The more traditional stuttering modification strategies (Manning & DiLollo, 2018) include the following:

• Preparatory set—The speaker anticipates a moment of stuttering before it occurs and then uses stuttering modification strategies (e.g., volitional prolongation of a sound and light articulatory contact) to control a stuttering event while producing the word.
• Pull-out—During a stuttered word, the speaker “slides out” of the stuttered word by adjusting airflow, voicing, and the vocal tract to “stutter smoothly” (i.e., without tension or effort) through the word.
• Cancellation—After a stuttered word, the speaker pauses for a few seconds to examine and rehearse the physical features of the stuttered word and then adjusts airflow, voicing, and the vocal tract to produce an “easy” (i.e., more controlled and less tense) version of the stuttered word.

Strategies for Reducing Word Avoidance

Some individuals avoid moments of overt stuttering by avoiding specific words or using interjections (e.g., “um,” “uh”). Some individuals consider such word avoidance to be a form of ableism, defined as “valuing certain types of abilities and bodies over others. It often includes discrimination and stereotyping” (Sisskin, 2023, p. 115).

People who avoid specific words may become covert stutterers—individuals who are so skilled at hiding stuttering that their speech appears to be fluent (B. Murphy et al., 2007). However, such avoidance can negatively impact the person’s ability to say what they want to say when they want to say it. Ultimately, this can negatively impact quality of life.

Treatment for reducing word avoidance and increasing spontaneity in communication may be effective for such individuals. Although they may stutter, they can convey their intended message. Consistently using a stuttering-affirming approach like this can increase speaking comfort over time, which leads to improved confidence in their communication ability.

Strategies for Reducing Negative Internal Reactions

Numerous treatment approaches and strategies have been developed to help speakers reduce negative reactions that are associated with stuttering (e.g., W. P. Murphy et al., 2007a). In addition to the stuttering modification strategies described above, these approaches encompass both personal and environmental contexts and include

• awareness and identification,
• desensitization,
• cognitive restructuring,
• self-disclosure, and

Awareness and Identification

The first approach that helps speakers reduce negative reactions is awareness and identification. This strategy helps the speaker better understand communication, speech, and stuttering—and how they relate to their own attitudes, beliefs, and behaviors. Having greater self-awareness can help manage stress, which may improve fluency and/or confidence as well as reduce negative internal reactions. SLPs raise individuals’ self-awareness by providing education on communication.

Examples of ways to build awareness include the following:

• Openly discussing one’s experiences with stuttering, modeling pseudostuttering, and explaining attitudes and beliefs across speaking situations (Manning & Quesal, 2016; Watson, 1988).
• Discussing the physical experience of anxiety—as well as the sense of loss of control and time pressure (e.g., mindfulness and grounding; Beilby et al., 2012a; Boyle, 2011; Harley, 2018).
• Watching video recordings and/or engaging in pseudostuttering analysis. The client watches recordings of others who stutter; this helps them identify patterns, attitudes, and beliefs about communication and stuttering. This may progress from
  • the client analyzing the clinician’s or their own pseudostuttering, to
  • analyzing a video of their own stuttering, and eventually to
  • real-time analysis (Bray & Kehle, 2001; Bray et al., 2003; Cream et al., 2010; Harasym et al., 2015; Prins & Ingham, 2009).[1]
• Pausing and noticing—pausing during a moment of stuttering and purposefully continuing whatever behavior was occurring at that time to perform a self-analysis of what the person is doing when experiencing tension.

[1] Note: This approach should be used only if the client is open to watching videos of themselves speaking.

Desensitization

The second approach that has been developed to help speakers reduce negative reactions is desensitization. Desensitization strategies help speakers address anxiety related to stuttering by confronting those fears in structured, supportive environments.

One example of a desensitization activity is pseudostuttering—the use of voluntary stuttering behaviors. Individuals may use pseudostuttering in different—and increasingly difficult—situations where they might fear the occurrence of real moments of stuttering to decrease anxiety (e.g., Reardon-Reeves & Yaruss, 2013; J. G. Sheehan, 1970).

Another example of a desensitization activity is Avoidance Reduction Therapy for Stuttering (ARTS; Sisskin, 2018). ARTS is a treatment approach that aims to decrease the “struggle” that, for some individuals, can accompany stuttering. According to ARTS, stuttering can be divided into two realms: disfluency and struggle.

1. Disfluency is caused by neurological and genetic factors.
2. Struggle is caused by actions that the speaker takes that worsen the impact of stuttering, such as
   • physical escape and concomitant behaviors;
   • worry about judgments from others; and
   • unpleasant emotions related to stuttering, communication, or self.

Struggle can result in an individual avoiding, not participating in, or holding back verbally in social, academic, or professional situations (V. Sisskin, personal communication, 2024).

During ARTS treatment, the individual performs activities (e.g., self-disclosing, going to a place where they fear speaking) using a “fear hierarchy” of situations or events that range from “low risk” to “high risk.” The SLP then works with the individual, who—using strategies they’ve worked on—takes the skills they’ve learned in ARTS and generalizes them to other environments.

Cognitive Restructuring

The third approach that helps speakers reduce negative reactions is cognitive restructuring—a strategy designed to help speakers change the way they think about themselves and their speaking situations. Individuals learn to

• identify the thoughts underlying their negative attitudes and emotional reactions and
• examine the link between (a) these thoughts, attitudes, and emotional reactions and (b) their speech.

During cognitive restructuring, speakers follow a process of

• identifying their own underlying assumptions about stuttering,
• evaluating the helpfulness and validity of those thoughts, and, ultimately,
• adopting a more constructive outlook.

Cognitive restructuring can be combined with the desensitization strategies described above (W. P. Murphy et al., 2007a).

One example of cognitive restructuring is Acceptance and Commitment Therapy (ACT; Beilby & Brynes, 2012; Beilby et al., 2012a; Palasik & Hannan, 2013). ACT is a cognitive restructuring technique that uses a holistic, person-centered approach to encourage individuals to alter their relationships with their emotions and thoughts. Mindfulness—the practice of remaining aware of one’s emotions and feelings but not interpreting them—is one of the core principles of acceptance and commitment therapy. Mindfulness builds intentional awareness of the present moment to help an individual disengage from automatic thoughts, de-escalate emotions, and increase self-acceptance (Boyle, 2011; Harley, 2018).

Another example of cognitive restructuring is cognitive behavioral therapy (Menzies et al., 2009, 2019)—an approach that teaches individuals how to identify thought patterns and challenge cognitive distortions in order to reduce negative emotions and/or behaviors and replace them with positive ones.

Cognitive behavioral therapy and mindfulness may be effective when used together to treat stuttering (Gupta et al., 2016; Harley, 2018).

Self-Disclosure

Self-disclosure is the fourth approach that helps speakers reduce negative reactions. Self-disclosure involves communicating information to others that reveals one’s identity as a person who stutters. It is often referred to as “advertising” in the stuttering community.

Self-disclosure can include

• revealing that identity directly,
• talking about stuttering or its treatment,
• explaining stuttering or interpreting its symptoms,
• providing advice on how to respond to someone who stutters, or
• giving a classroom presentation with the guidance of the SLP or, in the case of school-age children, the classroom teacher (W. P. Murphy et al., 2007b).

Disclosing a fluency disorder has many benefits to both the speaker (Boyle & Gabel, 2020b; Boyle et al., 2018) and the listener (Byrd, Croft, et al., 2017; Byrd, McGill, et al., 2017; Ferguson et al., 2019; Healey et al., 2007). Self-disclosure has been linked to higher quality of life (Boyle & Gabel, 2020b) and can provide other benefits such as reduced tension and time pressure (Plexico et al., 2009). People who stutter may be perceived as “friendlier” when they self-disclose their stuttering, and self-disclosure may help put listeners more at ease (Healey et al., 2007). Educating others about stuttering and what it is like to be a person who stutters can also help dispel misinformation and raise awareness. Disclosing a fluency disorder may be done a number of ways—such as verbally stating “I stutter/have a speech disorder” or by pseudostuttering or openly stuttering, while doing so confidently (McGill et al., 2018).

Support

Support is the fifth and final approach, discussed here, that helps speakers reduce negative reactions. Support—both giving and receiving—can be valuable for improving attitudes, boosting self-confidence, and reducing feelings of isolation in adults (Yaruss et al., 2007) and children (Gerlach et al., 2019). Participation in support groups has also been linked to lower internalized stigma and higher psychological well-being (Boyle, 2013b). Partners may be sources of support for treatment of stuttering (Beilby et al., 2013).

Treatment approaches that incorporate support activities can provide opportunities to practice learned strategies in a safe environment and help promote generalization.

Support activities can be incorporated into group treatment and through participation in self-help groups (Trichon & Raj, 2018), attendance at self-help conferences (Boyle et al., 2018; Gerlach et al., 2019; Trichon & Tetnowski, 2011), and participation in summer camp programs (Byrd et al., 2016).

Examples of support groups and activities include Friends: The National Association of Young People Who Stutter, the National Stuttering Association, SPACE, and SAY: The Stuttering Association for the Young; online groups (e.g., online chats); and social media (e.g., blogs; Reeves, 2006).

Technological advances and the expansion of social media outlets have increased opportunities for adults who stutter to connect, share, and gain information through the Internet (Fuse & Lanham, 2016; Raj & Daniels, 2017) and stuttering-related podcasts (Dignazio et al., 2020). It is important for clinicians to verify online sites and virtual support groups recommended to clients and their families. SLPs also need to discuss with people who stutter and their families how to evaluate the veracity and trustworthiness of sites claiming to “cure” stuttering or cluttering that they may find on their own.

Strategies for Reducing Activity Limitations and Participation Restrictions

Stuttering and/or cluttering therapy focuses on integrating treatment goals into real-life situations. The “Generalization” and “Reasonable Accommodations” sections discuss methods by which goals by be integrated. “Effects of Treatment” discusses how employing these approaches may help to improve clients’ quality of life.

Generalization Activities

This concept of generalization is used across all stuttering treatment types and is characteristic of avoidance reduction therapy.

Time pressure, the environment, and conditioned negative feelings may trigger fear and old behaviors—and may limit an individual’s ability

• to modify their speech as they desire;
• to make choices to speak and participate, regardless of the level of fluency; and
• to take risks outside of the treatment setting.

The clinician can help individuals generalize skills to different environments/situations by using many different approaches, such as

• bringing peers into the treatment setting,
• planning strategies to use in different environments,
• taking outings to stores and other businesses, and
• making phone calls.

The SLP can use audio- or videoconferencing to augment this type of treatment.

Activities progress through a hierarchy of linguistic skills and environmental stressors. Activities begin in supportive, low-fear situations and progress to more challenging situations and settings as the individual demonstrates the ability to tolerate negative internal reactions.

Reasonable Accommodations

Children and adolescents with fluency disorders may qualify for accommodations whether they have an active individualized education program (IEP) or not. Section 504 of the Rehabilitation Act of 1973 (United States Department of Labor, n.d.) protects qualified individuals from discrimination based on their disability. These 504 plans outline reasonable accommodations for speaking or reading activities to help ensure a student’s academic success and access to the learning environment. This law also applies to organizations that receive financial assistance from any federal department or agency.

Reasonable accommodations include

• using audio/video recording,
• increasing the time provided for an oral reading or presentation,
• providing an alternative assignment to oral reading, and
• altering the size of the group or audience.

Section 504 of the Rehabilitation Act of 1973 also applies to individuals with disabilities in a work setting. It applies protections to ensure that programs and employment environments are accessible and to provide aids and services necessary for effective communication in these settings. Reasonable accommodations vary by work setting and type of work.

See ASHA’s Practice Portal resource on Postsecondary Transition Planning.

Effects of Treatment

Clients report that the benefits of stuttering therapy can include progressing from avoidance to acceptance and increasing self-confidence and self-efficacy (Plexico et al., 2005; Tichenor & Yaruss, 2019a). There are several indicators of positive therapeutic change, which may include (Manning & DiLollo, 2018):

• increased self-confidence/self-efficacy;
• a more positive identity and congruence;
• being more comfortable and open with stuttering and pseudostuttering;
• talking with others about stuttering;
• disclosing stuttering;
• advocating for oneself;
• reporting experiencing decreased anxiety while communicating;
• reporting less adverse psychological, emotional, social, and functional impacts;
• reporting enjoying social communication, including with strangers; and
• increased social communication participation.

Treatment can also encourage

• self-acceptance and fear reduction,
• unrestricted interactions,
• a sense of freedom,
• optimism, and
• continued management.

Cluttering Treatment

Cluttering treatment often involves teaching individuals various strategies that they can use to modify cluttering. Strategies include the following:

• Cognitive restructuring, used in a way that resembles how it is used for stuttering treatment (see “Stuttering Treatment” section above)
• Speech rate strategies (e.g., increased pausing), which are used to increase speech fluency and intelligibility for those who clutter (Scaler Scott, 2018; Scaler Scott & Tellis, 2024).
• Strategies similar to cancellation and pull-out techniques (used in more conventional types of stuttering treatment; Ward, 2006), such as
  • having the client simulate a fast rate of speech and applying pausing and
  • having the client simulate over-articulated speech and applying increased emphasis to increase intelligibility.
• Overemphasizing multisyllabic words and word endings.
• increasing awareness of when a communication breakdown occurs (e.g., through observation of listener reactions).

Note: Fluency shaping approaches, such as easy onset or continuous phonation, may not be effective for the treatment of cluttering.

Some people who clutter have decreased loudness at the ends of sentences or phrases. These individuals may benefit from learning to keep a steady volume throughout their utterances.

Cultural and Linguistic Considerations

Individuals and families may have different beliefs about the best way to approach treatment for stuttering and/or cluttering: Some people view stuttering and/or cluttering as a physical ailment to be addressed or hidden and want treatment to focus on minimizing disfluency. Others may view stuttering and/or cluttering as a neutral variance in neurotype and prefer that treatment focuses on increasing comfort with stuttering and/or cluttering as well as promoting advocacy, counseling, and education.

Clinicians need to be mindful of different beliefs and the stress imposed on the individual and family during treatment. See ASHA’s Practice Portal page on Cultural Responsiveness.

Because the clinical model may differ from cultural preconceptions of stuttering and/or cluttering, clinicians are tasked with providing education and, when possible, adapting to cultural concerns. However, the clinical focus is on the well-being of the individual who stutters, and clinicians work to decrease any feelings of shame or discomfort that are associated with stuttering and/or cluttering.

Improvements in fluency may generalize spontaneously from a treated language to an untreated language in multilingual speakers (Roberts & Shenker, 2007).

Treatment outcomes for multilingual children who stutter do not appear to be different from those of monolingual children who stutter (Shenker, 2011).

Treatment for stuttering and/or cluttering in multilingual individuals may require adjustments to protocols, processes, and approaches. Adjustments can include

• interpreting/translating information into the individual’s heritage language and/or
• providing opportunities to practice communicating in linguistically and culturally relevant contexts and activities.

As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs are obligated to provide culturally and linguistically appropriate services, regardless of the clinician’s personal culture, practice setting, or caseload demographics. When a clinician who speaks the client’s language is not available, then the clinician collaborates with an interpreter to provide services and education. See ASHA’s Practice Portal pages on Collaborating With Interpreters, Transliterators, and Translators and Multilingual Service Delivery in Audiology and Speech-Language Pathology.

Treatment Readiness

Treatment for fluency disorders helps the individual make changes that will facilitate communication in a variety of settings. One of the most widely used models of change is the transtheoretical model (also known as the “stages of change” model; Prochaska & DiClemente, 2005). This model describes stages in the process of behavioral change, and it can be used to determine an individual’s readiness to make a change.

The model describes the following stages of behavioral change:

1. Precontemplation—not intending to take action and may be unaware of the problem
2. Contemplation—starting to realize there is a problem and considering taking action
3. Preparation—intending to take action and may start taking small changes to change behaviors
4. Action—making specific overt changes to change behaviors
5. Maintenance—sustaining changes and working toward preventing relapse
6. Termination—having no temptation to return to older habits

See Manning and DiLollo (2018), Floyd et al. (2007), Rodgers et al. (2021), and Zebrowski et al. (2021) for further information on the transtheoretical model.

Treatment Progress

Clinicians can help clients progress to active stages through building self-efficacy. Self-efficacy is a positive belief in one’s own ability to successfully accomplish a set goal that is task dependent, which comes from (a) past experiences of mastery, (b) vicarious experiences, (c) verbal persuasion, and (d) emotional/physical states (Boyle, 2013a, 2013b, 2015; Boyle et al., 2018; Carter et al., 2017).

Often, there are pivotal points during treatment that indicate progress (T. K. Anderson & Felsenfeld, 2003; Plexico et al., 2005).

These include when the individual who stutters and/or clutters

• is more open and willing to disclose and talk about their stuttering and/or cluttering;
• reports effectively modulating anxiety;
• experiences reduced impact from stuttering and/or cluttering;
• generalizes attitudes, beliefs, and behaviors across contexts;
• reports feeling more authentic and enjoying social conversations; and
• reports changing their conception of stuttering and/or cluttering from having exclusively negative to having positive features.

Overall, these indicators demonstrate progression from avoidance and negative impact to acceptance, openness, and increased socialization (V. M. Sheehan & Sisskin, 2001).

Service Delivery

See the Service Delivery section of the Stuttering/Cluttering/Fluency Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Service delivery for stuttering and/or cluttering encompasses—among other factors—treatment format, provider(s), dosage, timing, and setting. Treatment is a dynamic process; service delivery may change over time as the individual’s needs change.

Format

Format refers to the manner in which a client receives treatment—individually, as part of a group, or both. There are benefits of both individual and group treatment.

Individual treatment allows for

• focused teaching of new skills and/or
• a discussion of personal individual challenges, such as affective and cognitive components (e.g., prior to, or in addition to, targeting generalization of skills in a group setting).

Group treatment allows the individual to

• practice treatment targets with more listeners,
• practice monitoring each other’s speech and secondary behaviors,
• have a sense of belonging and experience less stigma,
• gain insights from others who may be benefiting from treatment,
• have opportunities to gain self-confidence from mentoring others, and
• provide and receive support from others who share the lived experience of stuttering.

Children who stutter may be candidates for summer camps based around stuttering (Herring et al., 2022). Such programs provide an opportunity to develop stuttering-related advocacy skills within a network of peers.

Telepractice may be used to provide stuttering and cluttering services. However, clinicians should discuss this option with the client as video telecommunication may be more or less stressful of a communication setting. The decision may affect performance as well as willingness to attend therapy. See ASHA’s Practice Portal page on Telepractice.

Provider

Provider refers to the person providing treatment (e.g., SLP, trained volunteer, family member, or care partner or caregiver). SLPs are the primary providers of stuttering and cluttering treatment.

Dosage

Dosage refers to the frequency, intensity, and duration of treatment.

Dosage depends largely on the nature of the treatment (e.g., direct, indirect), age group, and the task level (e.g., learning basic skills requires more clinic room practice than does generalization).

Scheduling concerns, cost, and insurance reimbursement also are likely to be factors affecting dosage. Given these potential issues, determining dosage often comes down to the professional opinion of the SLP and the needs of the individual.

Timing

Timing refers to the initiation of treatment relative to the diagnosis.

Stuttering and cluttering treatment can occur at any point after the diagnosis. It can be particularly important in the preschool years when the onset of stuttering may affect family dynamics.

For school-age children and adolescents, initiation of treatment depends, in large part, on their motivation—which, in turn, depends on factors such as their perceived needs, their therapeutic relationship with the clinician, the degree of adverse impact that they experience, and their previous treatment experiences.

For adults, initiation of treatment depends on their previous positive or negative intervention experiences and current needs pertaining to the impact of their stuttering or cluttering on communication in day-to-day activities and participation in various settings (e.g., community or work).

Setting

Setting refers to the location of treatment (e.g., home, community-based [including work settings], school environments, clinic room). Clinicians use or simulate natural communication environments to promote generalization of skills.

Individuals with disfluencies are seen in all of the typical speech-language pathology service settings—including private practices, university clinics, hospitals, and schools.

ASHA Resources

Information About Stuttering

• ASHA Digital Toolkit: Stuttering 101
• Characteristics of Typical Disfluency and Stuttering
• Negative Thinking: Cognitive Distortions and Fluency
• Consumer Information: Stuttering
• Early Identification of Speech, Language, Swallowing, and Hearing Disorders
• El impacto de los Exámenes de Fluidez de Lectura Oral en Estudiantes con Tartamudez [PDF]
• How Can You Tell if Childhood Stuttering is the Real Deal?

ICF Framework

• Assessment of Stuttering, Cluttering, and Fluency Disorders In the Context of the WHO ICF Framework
• Person-Centered Focus on Function: Adult Stuttering [PDF]
• Person-Centered Focus on Function: Preschool Stuttering [PDF]
• Person-Centered Focus on Function: School-Age Stuttering [PDF]
• Treatment Goals for Stuttering, Cluttering, and Fluency Disorders in the Context of the WHO ICF Framework

Oral Reading and Fluency

• Oral Reading Fluency for School-Age Students Who Stutter [PDF]
• Oral Reading Fluency Measures and Accommodations for School-Age Students Who Stutter [PDF]
• Understanding How Oral Reading Assessment Affects Children Who Stutter [PDF]

Billing and Coding

• Private Health Plans: Tips and strategies for ensuring that speech and hearing services are covered

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• Camp Dream. Speak. Live.
• Center for Disability Rights: Ableism
• Cluttering Speech: A 1-Minute Explanation [Video]
• Friends: The National Association of Young People Who Stutter
• International Cluttering Association (ICA)
• National Stuttering Association
  • WeStutter@Work
  • WeStutter - Adults
• SAY: The Stuttering Association for the Young
• SPACE
• Stuttering vs. Cluttering Brochure [PDF]
• The Stuttering Foundation
• The Stuttering Homepage
• When I Talk, I Stutter [Video]
• Your Rights Under Section 504 of the Rehabilitation Act [PDF]

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Acknowledgments

Content for ASHA’s Stuttering, Cluttering, and Fluency Practice Portal page was developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA seeks input from subject matter experts representing differing perspectives and backgrounds. At times a subject matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Primary Version

• Craig E. Coleman, MA, CCC-SLP
• Joseph G. Donaher, PhD, CCC-SLP
• Diane C. Games, MA, CCC-SLP
• Brooke S. Leiman, MA, CCC-SLP
• Carolyn M. Mayo, PhD, CCC-SLP
• Charles A. Osborne, MA, CCC-SLP
• Corrin G. Richels, PhD, CCC-SLP
• Kathleen Scaler Scott, PhD, CCC-SLP
• Rosalee C. Shenker, PhD, CCC-SLP
• Vivian Sisskin, MS, CCC-SLP
• Anu Subramanian, PhD, CCC-SLP
• Glen M. Tellis, PhD, CCC-SLP
• Dale F. Williams, PhD, CCC-SLP
• J. Scott Yaruss, PhD, CCC-SLP

Subsequent Versions

• Nan Bernstein Ratner, EdD, CCC-SLP (2020)
• Hope Gerlach-Houck, PhD, CCC-SLP (2025)
• Dan Hudock, PhD, CCC-SLP (2020)
• Stephanie Hughes, PhD, CCC-SLP (2025)
• Farzan Irani, PhD, CCC-SLP (2020)
• Loryn McGill, MS, CCC-SLP (2020)
• James Panico, PhD, CCC-SLP (2025)
• Kathleen Scaler Scott, PhD, CCC-SLP (2025)

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Stuttering, cluttering, and fluency [Practice portal]. https://www.asha.org/practice-portal/clinical-topics/fluency-disorders/