Abstract
Purpose:
It is widely known that stuttering is variable, but few studies have examined the variability of stuttering behaviors and experiences in young children. This study aimed to increase understanding of stuttering variability in preschool children based on the perspectives of their primary caregivers.
Method:
This study employed a mixed-methods approach involving 104 primary caregivers of English-speaking children who stutter in the United States. The children's ages were 2 years 11 months to 6 years 2 months. Caregivers provided insights about the variability of their children's stuttering via an online survey that gathered information about the amount, severity, and type of variability observed. The survey also gathered information about children's emotional and behavioral reactions to variability across situations, tasks, and time, as well as about the impact of variability on children and on the caregivers themselves.
Results:
Analyses confirmed that a high percentage of caregivers observed variability in different aspects of their children's stuttering. For example, 89% of caregivers reported that the amount of stuttering they see in their children's speech is variable. Emotional factors were identified as the most significant influencers of this variability, followed by paralinguistic, linguistic, and social factors. Variability was reported to not only affect children's communication and emotional well-being; caregivers reported that variability also affected their own emotional responses, as well as their interactions with their children.
Conclusions:
The study highlights the need for comprehensive, multifaceted clinical assessments and interventions for young children that account for variability in the behavior, impact, and experience of stuttering. Further research is needed to determine appropriate means of addressing stuttering variability in the assessment and intervention process.
Stuttering is variable in its occurrence, duration, and intensity; this variability is seen across situations, in different settings and tasks, and over time (Constantino et al., 2016; Karimi et al., 2013; Silverman, 1971; Yaruss, 1997). Variability affects more than just the observable moments of stuttering. A speaker's emotional, cognitive, and social reactions to stuttering (e.g., Tichenor & Yaruss, 2019) may also vary across different contexts and time frames (Tichenor & Yaruss, 2021), though these aspects of stuttering appear to be more stable from day-to-day than observable stuttering behaviors (Constantino et al., 2016).
A considerable body of research has examined factors that might be associated with whether a particular sound, word, or situation might contain a moment of observable stuttering (for a review, see Bloodstein et al., 2021). For example, anxiety may increase stuttering for some adults but decrease it for others (Menzies et al., 1999; Sheehan et al., 1967; Van Riper & Hull, 1955; Weber & Smith, 1990). Factors such as initial sound, word length, grammatical function, and speaking rate may also impact stuttering (Brundage & Bernstein Ratner, 2022; Irani et al., 2023; Ramig, 1984; Wood & Ryan, 2000). Social factors, such as audience size and conversational partners (Armson et al., 1997; Young, 1965), and anticipation (Jackson et al., 2015) further influence stuttering severity. These situational, linguistic, and social factors have been well studied in adults; fewer studies have examined stuttering variability in young children. Though children exhibit notable variability in stuttering behaviors (e.g., Yaruss, 1997), the contributing factors and impact of variability remain unclear.
Although much research has examined factors that might affect the occurrence of stuttering in a given word, sentence, situation, or point in time, less research has focused specifically on the variability of stuttering itself. Instead, most authorities appear to take it as a “given” that stuttering varies (e.g., Costello & Ingham, 1984; Guitar, 2021). Investigating variability may bolster clinicians' and researchers' comprehension of the experiences of individuals who stutter, for variability is a salient aspect of the stuttering experience that can have a notable impact on people's lives (Tichenor & Yaruss, 2021). A better understanding of variability may also support the development of more tailored and effective treatment programs by accounting for the ways that different factors may affect an individual speaker's stuttering behaviors and experiences across time, tasks, and situations.
Prior Considerations of Stuttering Variability
Arenas (2017) introduced the speech and monitoring interaction (SAMI) framework to explore contextual stuttering variability. The framework highlights how external factors (e.g., social, physical, linguistic) and internal factors (e.g., cognitive, emotional) interact to influence when and how stuttering occurs. The SAMI framework emphasizes the importance of individual differences and suggests that variability of stuttering results from the interplay between speech production, self-monitoring, cognitive demands, and situational factors. Evaluating this framework requires further work on the nature of variability itself, examining factors such as the degree of variability that speakers experience across a range of real-world situations while performing different speaking tasks and over time.
Research on stuttering variability has highlighted the changes that speakers experience in their stuttering across contexts and time periods. For example, Karimi et al. (2013) measured daily stuttering variability in 10 adults who stutter. Although no consistent pattern of stuttering variability was revealed across participants, higher variability was generally linked to lower communication satisfaction. This study confirmed that stuttering frequency varies greatly throughout the day, with some periods showing higher stuttering rates than others. Constantino et al. (2016) studied daily variability of stuttering severity and its impact on six adults across various speaking and reading tasks over 2 weeks. They found that while observable stuttering frequency and severity, as measured on the Stuttering Severity Instrument–Fourth Edition (SSI-4; Riley & Bakker, 2009), varied significantly day-to-day, the impact of stuttering on participants' lives, as measured by the Overall Assessment of the Speaker's Experience of Stuttering (Yaruss & Quesal, 2016), showed less fluctuation. This suggests that while many aspects of the stuttering experience may be variable, different components of stuttering may be affected to varying degrees. Moreover, although some studies have shown significant variability in stuttering behavior, other studies have revealed more stable patterns. For example, Maruthy and Sharma (2018) found no significant day-to-day variability in stuttering in daily 350-syllable speech samples in 10 children and 10 adults. The authors concluded that a single daily sample is inadequate for documenting fluctuations in stuttering severity. Similarly, Hendrick et al. (2023) observed limited variability in stuttering frequency across days and weeks using structured speaking tasks. Thus, more research is needed to understand the degree of variability experienced by different individuals across different types of speaking tasks and situations.
Variability has also been examined in children who stutter. Yaruss (1997) found significant variability in stuttering severity among preschool children across speaking tasks, with greater differences found between situations than within a single peaking task. Patterns were highly individualized, though children with more stuttered types of disfluencies showed greater overall variability. Johnson et al. (2009) reported notable variability in stuttering severity when children were speaking with different communication partners and in locations and contexts, though these differences were not sufficient to change a participant's group classification as a child who stutters. In contrast, Meyers (1986) observed that changing communication partners, specifically different mothers, did not significantly alter stuttering frequency in preschoolers, implying that merely shifting partners may not directly influence the occurrence of stuttering. Thus, the results of the relatively few studies that have been conducted have been inconsistent.
Nevertheless, prior considerations of stuttering variability have shown that stuttering is highly variable and context sensitive. At the same time, there is limited understanding of the impact of this variability, particularly in younger children. Also, prior studies have not specifically examined variability across different aspects of the stuttering experience, such as emotional reactions to stuttering, and thoughts or beliefs about stuttering, and the impact of stuttering on a speaker's life. A better understanding of how these aspects of stuttering vary across time, task, and situation would help clinicians to develop more effective, individualized interventions.
Impact of Stuttering Variability
Fluctuations in the occurrence or severity of observable stuttering behaviors can lead to significant consequences for speech-language pathologists and researchers (Baxter et al., 2015; Constantino et al., 2016), as well as for people who stutter (Tichenor & Yaruss, 2021). For clinicians, variability poses challenges for accurately assessing stuttering severity, as the level of stuttering observed during evaluation may not reflect how it manifests in other situations or times (Brundage et al., 2021). This uncertainty makes it difficult to determine which context or time point should guide diagnostic decisions. Variability also impacts individuals who stutter, causing frustration and discouragement (Tichenor & Yaruss, 2021). Tichenor and Yaruss (2021) showed that variability was the second-most frustrating aspect of coping with stuttering. (The fact that the speakers stuttered was rated as the most frustrating aspect.) Moreover, variability affects both external, observable aspects such as stuttering frequency, as well as internal experiences such as negative thoughts and emotional reactions (Tichenor & Yaruss, 2021). This means that the variability of stuttering not only complicates personal and clinical understandings of the condition but also deeply affects the emotional well-being of those who stutter, making variability a critical area for further consideration. To date, research on the impact of stuttering variability has been limited to adult participants. To better understand the ways that variability might affect younger children, more research is needed.
Aims of This Study
Research with adults who stutter shows that several aspects of stuttering are variable (e.g., Constantino et al., 2016; Karimi et al., 2013). In adults, greater variability is linked to greater frustration (Tichenor & Yaruss, 2021) and reduced communication satisfaction (Karimi et al., 2013). These findings highlight the need to help speakers learn to successfully handle variability in order to enhance the effectiveness of therapy for adults who stutter. Still, research on variability in early childhood stuttering remains limited. There is limited knowledge about how variability in different aspects of stuttering manifests in young children, which factors may contribute to these fluctuations, and how variability may impact both the children and their caregivers.
This study aimed to address these gaps by examining the occurrence, contributing factors, and impact of stuttering variability in young children who stutter. Because many aspects of stuttering variability, such as differences in stuttering over time or across situations or tasks as well as the impact of variability on a child's life, are difficult for young children to discuss, the study involved a detailed survey conducted with children's primary caregivers. The overarching goal of the work was to improve clinicians' and researchers' understanding of stuttering variability and thereby improve their ability to help children who stutter and their caregivers successfully navigate the challenges associated with variability through more effective and individualized interventions.
Method
Participants
This study involved a mixed-methods investigation that explored primary caregivers' observations and experiences with the variability in various aspects of their children's stuttering. Participants were 104 individuals who self-identified as a primary caregiver of at least one English-speaking child who stutters. Participants were recruited via electronic distribution on social media platforms, including Facebook and Instagram, within the United States. The recruitment process also utilized the authors' personal contacts, including parents of children who stutter and speech-language pathologists working with this population. All survey questions were presented in English, and participants confirmed residing in the United States.
The mean age of the respondents' children was 4 years 9 months, with a range of 2 years 11 months to 6 years 2 months (SD = 1.2 years). Participants reported that the average time since the onset of their children's stuttering was 3 years 7 months, with a range of 2 years 7 months to 5 years 2 months (SD = 0.9 years). Caregivers reported that 88% of the children had received stuttering therapy. Additionally, 50.9% of caregivers mentioned that their children exhibited secondary behaviors associated with their stuttering, and 57.4% reported that their children experienced negative behavioral and emotional responses to their stuttering.
The study was deemed to be exempt from institutional review by the Michigan State University Human Subjects Research Protection Office under Statute 45 CFR 46.104(d) 2ii. All participants provided informed consent before initiating the survey.
Data Collection
Participants responded to a Qualtrics online survey (Qualtrics, 2020) containing both Likert scale agreement items and open-ended qualitative questions. The questions on the survey were developed based on prior research on stuttering variability, including the survey by Tichenor and Yaruss (2021) and other work that has examined differences in stuttering across time, task, and setting (Constantino et al., 2016; Karimi et al., 2013). A draft of the questionnaire was reviewed by experts in stuttering and stuttering research, and revisions were made through an iterative review process to ensure the clarity and relevance of the questions. A high degree of internal consistency of the agreement items was reflected by a Cronbach's alpha of .92. The survey is presented in the Appendix.
First, participants were asked whether they had observed variability in their children's overall amount of stuttering. If they answered yes, they moved on to the 33 quantitative items, which were designed to explore stuttering variability in their children, focusing on different aspects of stuttering (e.g., stuttering amount, severity, emotional and behavioral reactions, and secondary behaviors), how stuttering changes across settings, and the factors that appeared to influencing stuttering. These items also examined how emotional states, linguistic and paralinguistic complexity, and social factors appeared to relate to variability in the child's stuttering. Examples of these statements include the following: “The amount of your child's stuttering varies from day-to-day,” “The amount of your child's stuttering varies across tasks,” and “The amount of your child's stuttering varies across situations.” The same format was used for questions about the child's emotional and behavioral reactions to stuttering. The questionnaire also included items examining factors that might affect stuttering variability. These factors were selected based on the prior literature, including emotional factors (e.g., “Your child's stuttering varies depending on whether they are feeling stressed”), linguistic factors (e.g., “Your child's stuttering varies depending on whether they are producing longer or shorter sentences”), paralinguistic factors (e.g., “Your child's stuttering varies depending on whether they are speaking rhythmically”), and situational factors (e.g., “Your child's stuttering varies depending on whether they are speaking with different numbers of people”). Participants rated their agreement with each statements using the following response options: 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, and 5 = strongly agree. To ensure that participants understood the items, a brief description with additional explanation or an example was provided.
In the other section of the survey, open-ended questions were used to gather qualitative data that would enrich the depth and context of the findings. To minimize potential bias from leading questions and to increase reliability of these items, the qualitative questions were designed to explore variability without suggesting specific answers. Examples include the following: “Please describe your experiences observing the variability of stuttering in your child,” “Can you tell us some effects of stuttering variability on your child?” and “Can you tell us some effects of stuttering variability on you?” These questions allowed for participants to provide a range of insights, capturing potentially positive and negative aspects of stuttering variability.
Data Analysis
Quantitative data from Qualtrics were exported to RStudio (RStudio, 2023) for analysis. All data underwent manual checks for entry or coding errors. Descriptive statistics were calculated to summarize caregiver responses and identify apparent patterns that they reported in their children's stuttering variability. Caregiver consensus was quantified through weighted average scores of the 5-point Likert scale responses. The analysis included examining caregivers' agreement on emotional, linguistic, paralinguistic, and social factors influencing stuttering. Additional analysis examined variability in stuttering frequency, severity, type, and children's emotional and behavioral reactions to stuttering, as well as secondary behaviors.
The qualitative part of the study used thematic analysis to identify common themes in the qualitative responses, following procedures described by Braun and Clarke (2006). This method provided information about caregivers' perspectives regarding their children's experience of stuttering variability and its impact on the children and caregivers. The thematic analysis aimed to capture the essence of caregivers' experiences and uncover new insights into the phenomena being explored, aligning with Patton's (2014) emphasis on interpreting for meaning. Analyses involved a recursive process where the first and second authors initially read the transcripts twice to gain familiarity with the content. During this phase, each author independently identified information, took notes, and recorded general ideas. This step was used to establish an initial understanding of the data's depth and complexity, a concept highlighted by Patton as essential for qualitative interpretation. Subsequently, each author independently generated initial codes from the transcripts. These codes included detailed labels representing significant features of the data relevant to the research questions. The first two authors convened an online meeting to discuss the codes and identify potential themes and patterns. These themes were then reviewed by the third author. Through systematic discussion and comparison of codes, related codes were combined into broader themes that captured the essence of caregivers' perspectives.
Credibility
Prior to the analysis, an exploration of the analysts' potential biases regarding stuttering, variability, and their expectations about the study's outcomes was conducted (Noble & Smith, 2015). This step helped to identify and mitigate any preconceived notions that could influence the interpretation of data. Consistent with previous qualitative stuttering research using large data samples (e.g., Tichenor & Yaruss, 2019) and standard practice (Fusch & Ness, 2015), no saturation analysis was performed on the qualitative data.
Reliability of the analysis was assured through several strategies. The first and second authors independently coded the data, and the consistency of their coding was assessed through discussions. This process involved comparing the initial codes and resolving any discrepancies to ensure a shared understanding of the data. The alignment between qualitative and quantitative findings mitigated concerns about bias: The quantitative data indicated that variability in stuttering is a nearly universal phenomenon, a finding that is consistent with prior research (Constantino et al., 2016; Karimi et al., 2013; Yaruss, 1997). Throughout the thematic analysis, initial categories and themes were considered and then refined or excluded based on their relevance and coherence. For instance, subthemes related to specific daily routines, and seasonal changes were integrated into broader categories to provide a clearer and more comprehensive understanding of stuttering variability.
To ensure validity, the identified themes were reviewed by a speech-language pathologist and stuttering specialist with more than 30 years of experience in the field (the third author). After this review, the first author wrote the results section of the qualitative analysis, which was then reviewed and refined via collaboration with both the second and third authors through an iterative review and revision process.
Results
This study used a mixed-methods approach, with both quantitative and qualitative analyses designed to investigate caregivers' reports and experiences related to variability in their children's stuttering.
Quantitative Data
Variability in Aspects of Children's Stuttering
Caregivers overwhelmingly indicated that their children's stuttering is variable: 89 out of 100 respondents (89%) either agreed or strongly agreed that the overall amount of their child's stuttering varies. More specifically, caregivers agreed or strongly agreed that the amount of stuttering varies across time (89 out of 101 respondents, 88.11%), situations (88 out of 101 respondents, 87.12%), and tasks (70 out of 102 respondents, 68.62%). This consensus corresponds to a weighted average score of 3.83 on the 5-point Likert scale, with higher scores indicating greater agreement regarding variability in the occurrence of children's observable stuttering behavior. Similarly, caregivers either agreed or strongly agreed that the severity of their children's observable stuttering behaviors varies across time (82 out of 102, 80.39%), situations (89 out of 102, 87.25%), and tasks (67 out of 102, 65.68%). The weighted average score reflecting this perspective was 3.65 on the 5-point Likert scale. Furthermore, 65.32% of caregivers agreed or strongly agreed that they had observed variability in their children's behavioral reactions to stuttering, such as speaking less or covering their mouth when they stutter; the weighted average score was 3.35. Participants reported variability in their children's emotional reactions to stuttering: 63.91% of caregivers agreed or strongly agreed that these reactions varied across tasks, situations, and time; the weighted average score was 3.34. The type of stuttering exhibited by children was also judged by caregivers to be variable, though less so than frequency or severity: 62.92% of caregivers either agreed or strongly agreed that disfluency types are variable across tasks, situations, and days; the weighted average score was 3.33 on the 5-point Likert scale. Analyses also revealed variability in secondary behaviors associated with stuttering. Approximately 49.63% of caregivers either agreed or strongly agreed that secondary behaviors varied; the weighted average score was 3.00. Figure 1 illustrates the distribution of caregivers' responses concerning the variability in different aspects of stuttering.
Figure 1.
Distribution of responses of caregivers regarding variability in different aspects of stuttering. Violin plots depict caregiver observations of the variability across different aspects of their children's. On the y-axis, higher values correspond to greater agreement levels reported by caregivers. The black line within the box indicates the median of the data; the box shows the interquartile range, which is the middle 50% of scores; the whiskers extend to the highest and lowest values within a certain distance from the box, representing the data's range.
Factors Influencing Stuttering Variability
Caregivers were asked to rate how various emotional, linguistic, paralinguistic, and social factors appeared to affect their children's stuttering variability. The most influential factors affecting variability were emotional factors: 77.74% of caregivers either strongly agreed or agreed that emotional factors significantly affected their children's stuttering variability; the weighted average score was 3.85 on the 5-point Likert scale. Paralinguistic factors were the second most influential: 72.21% of caregivers either strongly agreed or agreed that these factors influence stuttering variability; the weighted average score was 3.63. Linguistic factors were also judged as a factor affecting stuttering variability, though less than emotional and paralinguistic factors: 70.10% strongly agreed or agreed that these factors affect variability; the weighted average score was 3.61. Social factors were the least influential, though they still appeared to play a significant role in affecting children's stuttering variability: 66.85% of caregivers strongly agreed or agreed that these factors affected children's variability; the weighted average score was 3.58. Table 1 displays the ranking of factors influencing stuttering variability, as determined by the average scores from caregivers' responses.
Table 1.
Ranking of factors affecting stuttering variability based on the mean scores of caregivers' responses.
| Rank | Category | M |
|---|---|---|
| 1 | Stress | 4.09 |
| 2 | Excitement | 4.02 |
| 3 | Rate of speech | 3.99 |
| 4 | Speaking with friends | 3.76 |
| 5 | Length of sentence | 3.7 |
| 6 | Rhythm of speech | 3.69 |
| 7 | Sadness | 3.66 |
| 8 | Happiness | 3.61 |
| 9 | Robotic style of speech | 3.54 |
| 10 | Hardness of word | 3.53 |
| 11 | Number of people | 3.47 |
| 12 | Speaking with family | 3.47 |
| 13 | Loudness of speech | 3.4 |
| 14 | Topic of speech | 3.37 |
| 15 | Speaking with unfamiliar people | 3.09 |
| 16 | Anger | 3.09 |
Note. The table presents the mean ratings for various factors that caregivers perceived as affecting the variability of stuttering, rated on a 5-point Likert scale, where 1 = strongly disagree and 5 = strongly agree.
Variability Across Different Scenarios
Caregivers rated the variability of different aspects of their children's stuttering across days, situations, and tasks. The amount of stuttering was consistently rated as exhibiting the highest degree of variability, closely followed by the severity of stuttering. The type of stuttering, while variable, was judged to be less variable. Emotional and behavioral reactions to stuttering, as well as secondary stuttering behaviors, also varied across these different contexts but to a lesser extent. Table 2 shows the variability of different aspects of stuttering over time, across various situations, and in different tasks. Additionally, Figures 2, 3, and 4 illustrate the distribution of caregiver responses concerning the variability of stuttering aspects in various scenarios.
Table 2.
The variability of different aspects of stuttering over days, across various situations, and across different tasks.
| Aspect of stuttering | Variability across days (%) | Variability across situations (%) | Variability across tasks (%) |
|---|---|---|---|
| Amount of stuttering | 88.12 | 87.13 | 68.6 |
| Severity of stuttering | 80.39 | 87.25 | 65.68 |
| Type of stuttering | 70.03 | 69.31 | 49.02 |
| Behavioral reactions | 67.3 | 65.3 | 63.3 |
| Emotional reactions | 65 | 64.36 | 62.38 |
| Secondary behaviors | 50.9 | 47.5 | 51 |
Note. The percentages in this table indicate the proportion of caregivers who either agreed or strongly agreed with the specified aspect of stuttering variability.
Figure 2.
Distribution of responses of caregivers regarding variability in different aspects of stuttering across days.
Figure 3.
The distribution of responses of caregivers regarding variability in different aspects of stuttering across situations.
Figure 4.
The distribution of responses of caregivers regarding variability in different aspects of stuttering across tasks.
Qualitative Data
Content analyses of the qualitative responses to open-ended items in the questionnaire yielded five major themes. The thematic analysis aimed to capture the essence of caregivers' experiences, focusing on the variability in stuttering. These themes are listed in Table 3.
Table 3.
Themes identified in qualitative analysis.
| Numbers | Themes |
|---|---|
| 1 | Unpredictability |
| 2 | Dynamic influences on stuttering variability |
| 3 | Individuality |
| 4 | Adverse impact on children |
| 5 | Adverse impact on caregivers |
Unpredictability
Caregivers consistently reported that their children's observable stuttering severity shows unpredictable and irregular variations. This unpredictability, characterized by a lack of discernible patterns, made it difficult for caregivers to identify specific triggers or underlying reasons for changes in severity. Factors such as emotional state, schedule changes, and interactions with strangers often contributed to these fluctuations, though the complex interplay of these elements remained largely unclear to caregivers. This theme was identified through detailed coding of caregivers' descriptions of their children's stuttering patterns and the challenges they faced in predicting these patterns.
Participant (P) (15): He definitely blocked and tensed up more with strangers and in more formal speaking situations. At the same time, it was hard to pinpoint what was contributing to his speech tension.
P (29): Stuttering sort of happens in waves, where it will be more intense for days or weeks and then very mild for periods of time. Sometimes there appear to be fluctuations related to life changes or stress, other times there is no clear indication of what causes variability.
Dynamic Influences on Stuttering Variability
Caregivers reported that their children's stuttering severity exhibited significant variability influenced by a range of dynamic factors. Although identifying consistent patterns was challenging, some caregivers were able to establish relationships between various factors and the severity of observable disfluencies. Key factors included the child's emotional state, changes in their schedule, and interactions with strangers.
P (41): When he is relaxed, he speaks fluently, but when there are many people or when he is nervous, he will have a hard time speaking. I think this is related to psychological factors.
P (70): Situations with fear, excitement, stress make it worse.
P (77): When he is stressed the severity is high and when he is calm it is better. When other children annoy him or when we argue with him stuttering increases but in a normal situation it is better.
P (92): We see changes in stuttering related to our preschool schedule, with increases in frequency right after breaks (like winter break, spring break).
Caregivers highlighted variability across different time spans, discussing both short-term changes (such as those happening over minutes, hours, and days) and long-term changes (occurring over weeks, months, seasons, and years). This aspect of variability was expected, as participants were specifically asked about changes over time. The thematic analysis identified this aspect by coding for time-related variability in caregivers' responses.
P (45): He would be smooth one minute or one afternoon or one day or one week, and then be filled with tension—we just never knew.
P (73): In morning when he wakes up it is more.
Variability was also discussed in the context of different situations that the child encounters.
P (9): For example, when he faced strangers or whenever we travel stuttering increases.
P (10): Speak fluently when playing with familiar friends, but stutter more frequently when facing strangers or introducing oneself in formal social situations.
P (15): During family gatherings, we've noticed that the stutter becomes more.
To construct this theme, initial codes related to time, situations, and variability were compared and refined. Some initial subthemes, such as specific daily routines and seasonal changes, were considered but ultimately integrated into broader theme.
Individuality
Analyses revealed notable individuality in the ways in which children were affected by different stimuli, situations, or experiences; caregivers reported that different factors affect children's stuttering in different ways. For instance, activities such as traveling or playing with peers were reported to increase stuttering severity in some children, while in other children, these same activities were reported to reduce apparent stuttering severity. These individualized responses underscore the personal and unique significance of each child's experience with the variability of stuttering.
P (19): When she's hanging out with kids her age, going on trips, or at places she loves where she can play freely without a bunch of rules, her stuttering really improves.
P (37): Travel, excitement, and being sick can really make her stuttering worse.
P (78): I think every child has his own unique stuttering pattern, which is as unique as their fingerprints like my child.
P (101): Certain foods seem to affect how much my child stutters. For instance, milk tends to make it worse.
Adverse Impact on Children
When asked about the effects of stuttering variability on their children, caregivers noted negative impacts, particularly when the frequency or intensity of stuttering increased (i.e., when stuttering was more “severe”). These impacts could be seen in the children speaking less, using gestures instead of talking, substituting words, or whispering in their caregivers' ears. Some caregivers reported that on days with more stuttering, their children became frustrated and confused, not understanding what was happening to them.
P (53): He speaks less on days when he stutters more.
P (60): Due to its unexpected nature, he suspects his speech.
P (107): When it's severe, he becomes clingy and fussy, which I think makes it even worse.
Adverse Impact on Caregivers
Responses showed that stuttering variability also negatively affects caregivers. According to participants, fluctuation in stuttering led to disappointment with their children's treatment and, in some cases, resulted in caregivers abandoning speech therapy services. Caregivers noted that when their children's stuttering becomes more severe, it affects many aspects of their lives. This makes caregivers upset and worried, and these feelings make it harder for them to focus on their own personal tasks and interpersonal relationships. Some caregivers mentioned that the increase in their child's stuttering caused more arguments with their spouse as they tried to figure out who was to blame. Others mentioned that when stuttering frequency or intensity increased, they became overprotective of their child, which sometimes caused problems with their other children.
P (89): When his stuttering gets more severe, I feel hopeless. I think all the work and speech therapy he goes to is useless.
P (111): It changes a lot. I don't know how I can best support my child when I can't find a pattern in his stuttering.
There were also a few instances of positive emotions among the experiences shared.
P (38): There are times that he speaks smoothly for days. I see hope.
P (62): It's worrying, but sometimes I feel hopeful too. Because most of the time the severity is low.
Caregivers expressed feelings of anxiety when their children's stuttering severity increased. This anxiety often stemmed from concerns that the increase might indicate a problem or that they had done something wrong.
P (78): Variability can increase my own anxiety as a parent, wondering if something we are doing causes increases in stuttering or if changes in his stutter are indicative of a problem.
P (91): Sometimes I feel it is my fault that she gets worse.
Some caregivers believed that their children were too young to experience any adverse impact of stuttering variability on their lives. They stated that for younger children, it is the caregivers who experience psychosocial adverse impacts, not the child.
P (13): My child is too young to notice variability; it's the parents who are bothered by its changing nature.
P (23): My son still doesn't know that he has a stutter, and since he hasn't gone to school and hasn't been in a social environment, it hasn't had any impact for now.
Discussion
Understanding the Variability of Childhood Stuttering
This study explored the variability of stuttering in children from the perspective of their caregivers, expanding upon existing literature by offering a comprehensive analysis of both quantitative and qualitative dimensions of variability. Analyses revealed a significant consensus among caregivers, with 89% of respondents agreeing that the overall amount of their children's stuttering varies. This finding aligns with Yaruss's (1997) study, which showed high levels of variability in children's observable stuttering across situations in a clinical setting. Present findings expand on that early research by revealing variability across speaking tasks and over time. Moreover, the vast majority of caregivers in this study affirmed variability in their children's stuttering severity (77.63% agreement) and types of stuttering behavior (62.92%), demonstrating that variability affects more than just the amount of stuttering observed.
While our findings are consistent with prior research highlighting variability in stuttering (Constantino et al., 2016; Karimi et al., 2013; Silverman, 1971; Yaruss, 1997), they contrast with other studies that suggest more stable patterns. In particular, the present findings do not align with those of Hendrick et al. (2023), who reported limited variability in adults who stutter. In addition to differences in participant age groups that could impact the results, this discrepancy may also stem from their small sample size (N = 5), which could have limited the range of variability observed. Methodological differences may also contribute; while Hendrick et al. used structured speaking tasks, our study relied on caregiver observations in real-world settings. Parents may observe stuttering in a broader range of naturalistic contexts, where environmental factors such as stress, fatigue, or speaking demands might contribute to greater variability. Additionally, their study employed a twice-weekly assessment schedule, whereas our study captured day-to-day fluctuations as perceived by caregivers.
Similarly, our study findings also differ from those of Maruthy and Sharma (2018), who reported no significant differences in the percentage of syllables stuttered across 5 days in both children and adults who stutter. This difference may be explained by variations in study design and data collection methods. Maruthy and Sharma analyzed a fixed 350-syllable speech sample per day, which may not have been sufficient to capture fluctuations in stuttering severity. In contrast, our study relied on caregivers' observations across days, situations, and tasks, potentially offering a more comprehensive view of variability in natural settings. These differences underscore the importance of considering diverse methodologies when assessing stuttering variability.
A novel contribution of this study is the exploration of variability in emotional and behavioral reactions to stuttering. Previous research (e.g., Bernardini et al., 2009; Clark et al., 2013) reflected the presence of children's reactions to stuttering; present findings highlight the variability in these reactions for many children, as reported by 64.65% of caregivers. Some aspects of stuttering, such as severity and frequency, were found to be more variable than others, such as the overall impact of stuttering on the child's daily life. This is consistent with findings from Constantino et al. (2016), who also reported greater variability in severity and frequency compared to the impact. In this regard, it is clear stuttering behavior is not a static phenomenon but one that fluctuates in different contexts (Tichenor & Yaruss, 2021); this variability necessitates detailed observations and assessments over multiple sessions and from multiple perspectives to accurately capture the range of the observable severity of children's stuttering as well as in children's reactions to stuttering.
Acknowledging the variability of stuttering necessitates assessment methods that track stuttering across various situations, tasks, and times (Brundage et al., 2021). This involves not only traditional clinical settings but also real-world environments where the child communicates daily, such as at home, in school, and during social activities. Certainly, several authorities have long suggested this practice (e.g., Costello & Ingham, 1984; Karimi et al., 2024); findings from this study affirm the importance of such recommendations. By incorporating a variety of tasks that differ in linguistic complexity and social pressures, clinicians can gain a comprehensive understanding of how stuttering, and its impacts, may change in response to different demands.
Results from this study also affirm that incorporating caregiver reports can be particularly insightful, for parents and others can serve as a valuable guide to understanding variability in the child's stuttering across natural, everyday contexts. While there were similarities in children's experience of variability across caregiver responses in this study, caregivers stated that their child experiences variability in their own unique ways. Previous studies have shown that the way stuttering appears in an individual's life varies. Present findings affirm that this variability results from a mix of different factors, including varying underlying causes, personal traits, limitations, and external influences (Tichenor & Yaruss, 2019). This individualized perspective underscores the need for tailored interventions and suggests that clinicians should be cautious in drawing broad conclusions about stuttering and its variability based solely on brief clinical or classroom observations.
Factors Influencing Variability in Childhood Stuttering
This study also explored caregivers' observations of emotional, linguistic, paralinguistic, and social factors that might affect children's stuttering variability. Findings build upon previous research by extending the understanding of factors that influence stuttering variability (not just the occurrence of stuttering behavior itself). For example, the impact of emotional factors on the occurrence stuttering is well documented, particularly in adults (Jackson et al., 2015; Menzies et al., 1999; Sheehan et al., 1967; Van Riper & Hull, 1955; Weber & Smith, 1990). Present findings show that a broad range of emotional and cognitive factors can combine and interact in influencing the variability of stuttering in children, as well. Similarly, linguistic factors may affect the occurrence of stuttering; present findings show how various linguistic factors can influence variability of stuttering behavior, as well (Brundage & Bernstein Ratner, 2022). For example, caregiver observations in this study confirmed that stuttering patterns shift with changing linguistic demands. These reinforces the idea that stuttering is shaped by multiple factors and is not static. (Note that these findings should not be misinterpreted to suggest that caregivers should limit linguistic input or demands in an attempt to diminish a child's stuttering; they simply reflect the fact that stuttering naturally fluctuates and varies as cognitive and linguistic demands vary.)
Another way in which present results expand upon earlier findings relates to speaking rate. Previously, authors have identified a child's speaking rate as a factor that can affect the occurrence of stuttering (Conture et al., 1993; Guitar, 2021). In this study, variations in speaking rates were reported by caregivers to significantly influence stuttering variability. Finally, present findings further highlight the influence of social dynamics on stuttering (Hahn, 1940; Mullen, 1986; Vanryckeghem et al., 2017) by affirming that factors such as audience size and the presence of authority figures influence the pattern of changes in stuttering, not just the occurrence of stuttering itself.
Overall, the findings of this study align with the SAMI framework (Arenas, 2017), which highlights how both internal factors (such as emotions) and external factors (such as linguistic and paralinguistic elements) interact to influence variations in stuttering. These findings underscore the importance of a holistic approach to assessment that accounts for the multifaceted and dynamic nature of stuttering across speaking tasks, in different situations, and over time.
Adverse Impact of Stuttering Variability
The qualitative data highlighted that stuttering variability posed challenges for both children and caregivers. Caregivers observed changes in their child's communication behaviors and emotions as stuttering fluctuated. For caregivers themselves, this variability led to frustration as they struggled to understand the unpredictable changes in stuttering severity. Additionally, they often experienced distress due to stuttering variability, fearing their responses were inadequate.
Note that these impacts were above and beyond the impact of the stuttering itself; caregivers specifically indicated that the unpredictability of their children's stuttering compounded the difficulties they experienced associated with the stuttering itself. This suggests a need to support caregivers in coping with stuttering variability in particular, in addition to helping them in understanding stuttering itself. It may not be necessary for caregivers to fully understand the patterns of variability; rather, they can learn that it is natural for stuttering to vary, and they can learn how to respond to variability in ways that help to reduce the impact of variability on themselves and their children.
One potentially valuable approach to accomplishing this goal is to encourage observation over judgment, based on the principles of acceptance and commitment therapy (see Beilby et al., 2012). Based on this approach, caregivers are encouraged to focus on accepting variability rather than predicting or controlling it by using strategies such as acceptance, mindfulness, and value-driven actions. Acceptance fosters nonjudgmental acknowledgment, mindfulness promotes presence in conversations, and value-driven actions support meaningful participation despite speech fluctuations (Beilby & Yaruss, 2018; Boyle, 2011; Naz & Kausar, 2022).
Another approach to helping children who stutter and their caregivers cope with the emotional aspects of stuttering variability is cognitive behavioral therapy (CBT; Grasky, 2010). This approach has been integrated as a part of comprehensive intervention programs for school-age children (Murphy et al., 2007), teenagers (Fry et al., 2014), adults who stutter (Menzies et al., 2008), and parents of children who stutter (Berquez & Kelman, 2018). CBT can help children who stutter and their caregivers in expressing feelings, challenging ideas, and developing coping mechanisms for difficult situations (Kelman & Wheeler, 2015).
Limitations and Future Directions
This study examined caregivers' observations and perceptions to gain insights into children's experience of stuttering variability. This approach was selected because there are some aspects of a child's experience of stuttering variability that can only be discerned by caregivers, such as variability over time and across speaking situations. Still, caregivers' perspectives may not always reflect their children's actual experiences. Future research should explore ways of including direct input from the children in future studies to gain a more comprehensive understanding of stuttering variability. Although this would be challenging to accomplish with preschool-age children, meaningful information could be obtained through direct observation of variability in stuttering behaviors, as well as assessment of other aspects of young children's experience of stuttering over time.
This study contributes to the field's understanding of stuttering variability in children across different aspects of stuttering. It also opens avenues for further in-depth investigations, such as longitudinal studies that track the development of stuttering variability over extended periods of time. Such studies would offer insights into the evolution of variations in stuttering patterns as children grow through various developmental stages. For example, it may be that children experience stuttering variability depending upon their history of language learning (e.g., whether the child is monolingual or multilingual, the child's language skills), nature and degree of social interaction with others, and other factors associated with their overall development. Longitudinal studies and studies in which additional data are gathered regarding children's personal characteristics will help to address these open questions.
Concurrently, there is a need for treatment-focused studies aimed at evaluating the effectiveness of various interventions designed to assist children and their caregivers in managing and adapting to the inherent variability of stuttering. As a prelude to such investigations, future research should focus on how variability in stuttering is currently managed in assessments and treatment by speech-language pathologists, with an aim to improve those methods. Additionally, while open-ended responses to online surveys can sometimes lack depth and elaboration, this study's participants provided substantial and detailed information. This richness in data suggests that the findings are robust and reflective of the true experiences of caregivers and children dealing with stuttering variability. Although we did not collect detailed information about participants' language backgrounds, it is possible that stuttering variability may be influenced by factors such as a child's history of language learning (e.g., whether they are monolingual or multilingual, their language skills), the nature and degree of their social interactions, and other aspects of their overall development. Longitudinal studies and research that gather additional data on children's personal characteristics will be essential to addressing these open questions.
Conclusions
This study enhances the field's understanding of stuttering variability in children, highlighting the complexity of stuttering and its variations as observed by caregivers. Analyses revealed that stuttering is not only variable across different speaking situations but also across days and tasks. A substantial majority of caregivers also reported variations in stuttering severity and types of disfluencies, as well as in children's emotional and behavioral reactions to stuttering. The study provided information about the potential influence of emotional, linguistic, paralinguistic, and social factors on stuttering variability and highlighted the at times unpredictable nature of stuttering in young children. Findings also underscored the potential negative impact that stuttering variability can have on caregivers and children, highlighting the importance of providing them with education and support specifically on the topic of stuttering variability through the therapy process. Overall, findings regarding stuttering variability on the well-being of children and their caregivers underscores the need for comprehensive approaches to intervention that account for the inherent variability of all aspects of stuttering for young children, resulting in improved validity of assessment and enhanced overall effectiveness of intervention.
Data Availability Statement
The data sets generated and analyzed during this study are not publicly accessible due to participant privacy concerns. They can be obtained from the corresponding author upon reasonable request.
Acknowledgments
Research reported in this publication was supported by National Institute on Deafness and Other Communication Disorders Award R01DC018795. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Appendix
Stuttering Variability in Children Who Stutter
Section 1: Variability in General
Variability indicates that the frequency or intensity of your child's stuttering changes depending on the situation the child is in, the task the child is engaged in, or over time. The following questions are designed to help us understand more about the occurrence and impact of stuttering variability on your child.
Please share as much information as you can. We will use this information to help us better understand how variability affects children who stutter and their caregivers. Again, please do not include any personally identifiable information in your responses. Please rate your agreement with the following statement:
The overall amount of your child's stuttering varies. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
Please describe your experiences observing variability in your child's stuttering.
Please provide an example of when you have observed variability in your child's stuttering.
Can you tell us some effects of stuttering variability on your child?
Can you tell us some effects of stuttering variability on you?
Section 2: Variability in Different Aspects of Stuttering
The amount of stuttering that a child exhibit may vary from day-to-day, across tasks, or in different situations. Please rate your agreement with the following statements:
6. The amount of your child's stuttering varies from day-to-day. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
7. The amount of your child's stuttering varies across situations. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
8. The amount of your child's stuttering varies across tasks. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
Children can exhibit different types of stuttering behaviors. These include repetitions (e.g., “b-b-b-book”), prolongations (e.g., “Booook”), and blocks (e.g., “B----ook”). Please rate your agreement with the following statements:
9. The type of your child's stuttering varies from day-to-day. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
10. The type of your child's stuttering varies across situations. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
11. The type of your child's stuttering varies across tasks. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
The overall severity of a child's stuttering may vary from day-to-day, across tasks, or across situations. Please rate your agreement with the following statements:
12. The overall severity of your child's stuttering varies from day-to-day. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
13. The overall severity of your child's stuttering varies across situations. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
14. The overall severity of your child's stuttering varies across tasks. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
Reactions to Stuttering
Children who stutter can have various reactions to their stuttering. For instance, they may feel sad or experience stress at some times, while at other times, they may not be bothered by their stuttering. Next, we will ask some questions about how your child's reactions might change. Please rate your agreement with the following statement:
15. Your child reacts to their stuttering. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
Your child's emotional reactions to stuttering (e.g., sadness, stress, anger, shame, surprise, happiness) may vary. On certain days, situations, or tasks, your child might exhibit signs of emotions related to stuttering, while on others they might not. Please rate your agreement with the following statements:
16. Your child's emotional reactions to stuttering vary from day-to-day. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
17. Your child's emotional reactions to stuttering vary across situations. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
18. Your child's emotional reactions to stuttering vary across tasks. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
Secondary Behaviors
Some people who stutter experience secondary behaviors such as eye blinking, eye closing, jaw jerking, head jerking, facial contortions, or other involuntary movements during or associated with moments of stuttering. Please rate your agreement with the following statement:
19. Your child shows secondary behaviors of stuttering. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
Your child's secondary behaviors may vary. On certain days, situations, or tasks, your child might exhibit signs of secondary behaviors of stuttering, while on others they might not. Please rate your agreement with the following statements:
20. Your child's secondary behaviors of stuttering vary from day-to-day. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
21. Your child's secondary behaviors of stuttering vary across situations. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
22. Your child's secondary behaviors of stuttering vary across tasks. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
Section 3: Factors Affecting Variability
Some factors, such as how fast your child talks or your child's feelings, can make stuttering more severe or less severe. Please rate your agreement with the following statements:
23. Your child's stuttering varies depending upon whether they are feeling stress. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
24. Your child's stuttering varies depending upon whether they are feeling excitement. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
25. Your child's stuttering varies depending upon whether they are feeling anger. Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
26. Your child's stuttering varies depending upon whether they are feeling happiness. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
27. Your child's stuttering varies depending upon whether they are feeling sadness. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
28. Your child's stuttering varies depending upon whether they are producing longer or shorter sentences. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
29. Your child's stuttering varies depending upon whether they are producing harder or easier words. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
30. Your child's stuttering varies depending upon whether they are speaking more quickly or more slowly than usual. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
Children have the ability to modify the manner of their speech, such as speaking rhythmically, robotically, or adjusting their volume to be louder or quieter. Please rate your agreement with the following statements.
31. Your child's stuttering varies depending upon whether they are speaking rhythmically. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
32. Your child's stuttering varies depending upon whether they are speaking roboticly. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
33. Your child's stuttering varies depending upon whether they are speaking loudly or quietly. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
34. Your child's stuttering varies depending upon whether they are speaking about different topics (e.g., sad story, happy news, and … ). (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
35. Your child's stuttering varies depending upon whether they are speaking with different number of people. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
36. Your child's stuttering varies depending upon whether they are speaking with family. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
37. Your child's stuttering varies depending upon whether they are speaking with friends. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
38. Your child's stuttering varies depending upon whether they are speaking with unfamiliar people. (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
39. What other factors appear to affect your child's stuttering (e.g., diet, sleep patterns)?
Funding Statement
Research reported in this publication was supported by National Institute on Deafness and Other Communication Disorders Grants R01DC018795 (awarded to J. Scott Yaruss) and R01DC018000 (awarded to Bridget Walsh). The views expressed in this article are those of the authors and not an official stance of the National Institutes of Health.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data sets generated and analyzed during this study are not publicly accessible due to participant privacy concerns. They can be obtained from the corresponding author upon reasonable request.