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Is a Focus on Fluency in Early Stuttering Therapy Really Worth the Risk?

I originally wrote this as a response on LinkedIn to a post by UTS: Australian Stuttering Research Centre, but I discovered I had quite a lot of thoughts about the topic, so I decided to turn it into its own blog post/article. 

The LinkedIn post from the Australian Stuttering Research Centre (ASRC) was about this journal article, entitled “Contemporary clinical conversations about stuttering: How clinically important is mental health during management of early stuttering?” published in the International Journal of Speech-Language Pathology. Basically, the journal article shares a discussion between 3 SLPs and a clinical psychologist, all from different countries (Canada, US, UK, and Australia). 

My first thought was that it’s great to see cross-disciplinary discussions happening when it comes to stuttering! This is a clinical area with significant overlap between SLPs and mental health professionals such as psychologists, counsellors, and social workers. I feel like it’s very important that we have these kinds of conversations so that we’re coming from the same place of knowledge and are better able to understand how our roles can each support a person who stutters (PWS). Often it seems like each field is in its own silo and not communicating with others who work with the same client populations, rather than sharing resources and information to ensure we’re giving the best possible care to the people we are serving. It is unfortunate that there was only one mental health professional involved in the conversation (compared to 3 SLPs), as I’m sure there are a variety of perspectives within that discipline, just as there are in speech-language pathology.

I’m glad that mental health within young children who stutter is being talked about, because we know from research that children who stutter may have negative attitudes towards stuttering from as young as preschool age. The conclusions from the conversation outlined in this article were that mental health is an important aspect to consider when it comes to early stuttering, that there are other factors than stuttering which may affect a child’s mental health, that a parent’s anxiety may impact the child, and that it may sometimes be appropriate for SLPs to refer out to a clinical psychologist. 

However, it was the discussion around the different approaches in intervention – specifically, behavioural vs multifactorial – that caught my eye. Or, more to the point, what wasn’t said — that a behavioural approach intended to directly lower frequency of stuttering moments may not only be ineffective in reducing mental health challenges (such as anxiety), but in fact may actually increase the likelihood that the child experiences them. A therapy program that labels fluent speech — either implicitly or explicitly — as “good/desirable” and stuttering as “bad/undesirable” sets a child up for feelings of failure and inadequacy when they are unable to consistently make their speech fluent. This will inevitably happen for a certain percentage of children, as we know that while 75-80% of children “recover” (for lack of a better word) from early childhood stuttering, there are another 20-25% who continue to stutter.

Moreover, recent research (notably, Bernstein Ratner & Brundage, 2025) shows us that children who received early childhood stuttering therapy approaches showed similar rates of recovery as children who did not receive therapy and recovered spontaneously. So… are the therapy approaches being employed with young children who stutter really the active ingredient in their recovery? Or would their stuttering have organically disappeared over time?

And even if the therapy does play a role in recovery for a certain percentage of young children — is it worth the risk of teaching the 20-25% who will not recover that their natural way of speaking — the way that they are neurologically wired to speak, their “default” mode — is “wrong” or “bad”?

As an SLP who works with older children & adults who stutter, by the time they come to see me, they often have some pretty ingrained negative beliefs about their speech. The first thing that usually comes out of their mouths is, “I want to fix my stutter.” 

What we are finding out directly from adults who stutter (at least anecdotally) is that speech therapy is one of the places that they developed negative attitudes and feelings towards how they speak. I recently came across a journal article (Reimagining stuttering therapy and outcomes through an acceptance and collaborative lens, Irani et al., 2025) that interviewed six SLPs who stutter. I’ve pulled out a few quotes here that I think are compelling in showing how speech therapy that values fluency and devalues stuttering can be not only unhelpful, but harmful (emphasis through bolding is mine):

“While good intentions and being considered best practice for stuttering therapy at the time, the fluency shaping approach coupled with the adverse impact of stuttering (e.g., bullying, stigma, etc.) led to the development of my stuttering iceberg where I developed negative thoughts and feelings in relation to my stuttering (i.e., fear, embarrassment, isolation).”

“I remember thinking to myself one day about how often I practiced the fluency techniques (easy onset, full breath, stretched syllable) over the years yet still I couldn’t implement them the way I wanted to at times. I also remember how exhausted I was after using them and thinking about them throughout the day.”

“It is the definition of a mixed message for a clinician to say (a) “it’s okay to stutter”, and (b) “let’s learn techniques to minimize that stuttering”. A and B cannot be true at the same time. Over time, I’ve learned that the only interpretation of ‘acceptance’ is to stutter openly, and to forgo any attempt to hide, because each attempt to avoid or hide stuttering ultimately felt like an apology to the listener.”

“When serving young children who stutter, it’s critical to lay the foundation of a healthy relationship with their communication and their stuttering. This entails teaching them about stuttering, telling them explicitly that they stutter and it’s ok, teaching them about ways they can advocate for themselves and others, etc. Even if young children grow out of stuttering due to spontaneous recovery, they will at least be equipped with empathy and knowledge of stuttering so they can be strong advocates for the stuttering community.”

“For children, treatment should prevent the “iceberg” from forming in the first place (e.g., Byrd et al., 2024). That is, if we truly believe that stuttering should not be stigmatized, we should prepare our 3-year-olds to be proud people who stutter for the remainder of their lives. The negative consequences of stuttering should not be considered an inevitable outcome.”

That last is my concern here – that intervention programs such as Lidcombe or Westmead may actually be contributing to the iceberg coming into being. If we know that a focus on fluency can potentially lead to the development of these kinds of negative attitudes towards the person’s communication – which of course, can have a debilitating impact on self-image, self-esteem, and quality of life – then we need to think very carefully about introducing these ideas to young children, who will easily absorb them without questioning and internalize them as they grow into adulthood. 

I also think we need much more research looking into the efficacy of the intervention programs currently being used with young children that focus on eliminating stuttering, to help us determine whether there is an actual impact of the intervention itself (beyond what would naturally happen). 

The bottom line: there are so many sources and influences that may already be sending them the message that there is something “wrong” with them — families, peers, teachers, media. As professionals who are there to support them become more engaged, confident, and fulfilled communicators, we have to make sure that they aren’t getting that message from us too. 

Whether you’re an SLP or mental health professional who works with someone who stutters, or a person who stutters themselves – what are your thoughts on this complex (perhaps controversial?) topic? Do you think the focus on fluency in stuttering therapy for young children is worth the risk?

(Also, if you’d like to get a copy of my handout “6 Things I Wish People Knew About Stuttering,” you can do so just below!)