2003 IFA Congress: Montreal, Canada

Some Factors Influencing Early Referral of Dysfluent Children

Roberta Lees1, Cameron Stark2, Susan Birse3 and Pam Nicolla4
1Dept. of Speech and Language Therapy, University of Strathclyde, 76 Southbrae Drive, Glasgow, G13 1 PP, Scotland.
2Honorary Senior Lecturer, Highlands and Islands Research Insititute, University of Aberdeen, Scotland.
3Health Information and Resources, Highland Health Board, Inverness, Scotland.
4Royal Northern Infirmary, Ness Walk, Inverness, Scotland.


Two studies are reported on the attitudes and knowledge of possible direct or indirect referrers of young dysfluent children to speech and language therapy. The first study looked at the referral rates and underlying assumptions held by primary care professionals (general practitioners and health visitors) and the second study investigated understanding of dysfluency and ability to recognise stuttering of pre-school educators. One of the main factors affecting referral by primary care professionals was having training in dysfluency. The majority of pre-school educators wished more training and had little information on aetiology, though a surprising number claimed to be able to recognise stuttering.

  1. Introduction
The longitudinal studies of Yairi and his colleagues have shown that 75% of the risk of stuttering is prior to 42 months. Yairi & Ambrose (1999) have also shown that 74% of children who stutter will experience spontaneous recovery within four years of the onset of the disorder. This has led to much discussion on the optimum treatment time. There is a general consensus that early intervention leads to a better prognosis and reduced treatment time. Ingham & Cordes (1999) found a 27% decrease in the number of children who met their criterion of successful therapy outcome if treatment were delayed by more than 15 months post onset of stuttering. If early intervention is beneficial to the child then this requires early referral to therapy services. The British Stammering Association (BSA) has, for many years, recommended early referral of dysfluent children to speech and language therapy and to this end they initiated the Primary Healthcare Workers project in the early l990’s. One of the aims of this project was to educate health visitors (HVs) and general practitioners (GPS) to the necessity of early referral of dysfluent children. Leaflets about early stuttering were prepared and placed in health centres and doctors’ surgeries and some training in stuttering identification was also given. Christie led this project and in her final report (2000) she concluded that sending leaflets and providing training to key referrers led to an increase in the number of referrals of dysfluent children, particularly pre-school dysfluent children.

This project therefore reported on primary health careworkers as potential referrers of children for treatment. However, there is a move for all children in the UK to have government funded pre- school places before the age of three. The implication of this would be that pre-school educators would also require to have some understanding of early stuttering. Currently, in the geographical area investigated, they would be unlikely to directly refer children for therapy; they would either refer the children to the health visitors or they would ask the parents to take the child to the GP for referral.

The ability to recognise stuttering would be an important pre-requisite for referring children. Also, if professionals believe that stuttering is developmental and all children will spontaneously recover then referral would be most unlikely. There could also be a delaying of referral if referrers believe they can predict chronicity, so a ‘wait and see’ approach could be adopted. On a practical level, referrers might not refer to therapy if they are aware of long waiting lists or if they do not understand the referral systems in their areas.

Two Studies on knowledge and attitudes to dysfluency held by possible direct or indirect referrers have been carried out.

  1. Study One
The aims of the first study were to assess:
  • - the referral patterns of primary care professionals in relation to dysfluent children
  • - factors affecting referral by these primary care professionals
  • - the understanding of stuttering and attitudes towards it of the primary care professionals

This study was with primary care professionals in the Highland Community NHS Trust area of the Highlands of Scotland (163 GPs and 51 HVs). This involved the development of a self-completion questionnaire, based on published questionnaires with some additional questions which were directly relevant to the BSA’s guidelines on the treatment of pre-school children. Respondents were asked to complete background information on how long they had been qualified and whether or not they knew someone who stuttered. In the questionnaire there were 25 questions in total which assessed understanding of stuttering, the influence of waiting lists on their decision to refer and their knowledge of local referral guidelines. Responses were based on a 5 point scale from strongly agree to strongly disagree. These questionnaires were mailed to all GPs and HVs in this area and although respondents were assured that all replies would be confidential, they were not anonymous. Hence it was possible to send reminders to non-respondents 3 weeks after the initial mailing. Respondents were assured that the service would see only collated responses.


There was a high response rate of 76.2% (49 HVs and 114 GPs). This represented a differential response rate of 96% for HVs and 70% for GPs. Health visitors reported referring significantly more dysfluent children to Speech and Language Therapy per annum than did GPs. Relevant background factors of the respondents are presented in Table 1.


Table 1. Background factors influencing referral practices

Those who had some type of post-graduate training in stuttering referred significantly more dysfluent children than those who had no such training. Also, those who had received referral guidelines referred significantly more dysfluent children to speech and language therapy. Having a friend or relative who stutters did not seem to be a significant factor in the decision to refer. Thus, 98 Theory, research and therapy in fluency disorders two major influences on referral practices in these two groups were post - graduate training and information on referral guidelines.

The responses of both groups of respondents were very similar but in some instances there were significant differences between GPs and HVs. General practitioners professed to having less knowledge about stuttering and being more influenced by waiting lists than HVs. Health visitors were more confident of their ability to predict chronicity of stuttering than were GPS. General practitioners were also less convinced of the Value of early intervention, and were more unsure of outcomes of therapy. More detailed information on these results is in Lees et al., (2000)

  1. Study Two
The aims of the second study were to assess the knowledge of and attitudes to dysfluency in young children of pre-school educators.


This study was with pre-school educators in the Highland region. A questionnaire was developed to assess their perceived competence in recognising stuttering and on their understanding of this disorder. Background information was completed by each respondent which included their experience in this sector, previous training in stuttering and experience of children who stutter in thegroup or of relatives/friends who stutter. It also asked respondents if they would like more training and, if so, what type. This questionnaire had 29 questions in total. and again responses were based on a 5 point scale ranging from strongly agree to strongly disagree. 255 questionnaires were mailed to all pre-school establishments registered with Highland Council, but excluding Childminders. Two of these were returned as the establishment had closed. So, the potential total sample size was 253. Reminders were sent after 3 weeks if no response had been obtained.


In this study the response rate was again high with 193 replies (76%). Of the 193 returns 110 (57%) were in establishments run by Highland Council, 62 (38%) were in units run by voluntary organisations and 19 (11.7%) were in the independent sector. The number of paid staff in each institution ranged from 0 - 27 with a median of 3 and an interquartile range of 2 - 4. The number of children taken per session was 1 - 97 with a median of 15 and an interquartile range of 7 - 20. The independent sector tended to take significantly more children (Mann Whitney U Test, p<0.001,). The responses to the background questions showed that the experience of those replying varied from 0 - 35 years with a median of 6 years and an interquartile range of 3 - 10 years. The amount of previous training according to the sector in which they currently work was as follows: Highland Council 33 (30.3%), voluntary organisation 14 (22.6%) and the independent sector 6 (31.6%)

Thus 53 (27%) had some training. Most of the training experienced by respondents could be grouped under 4 headings viz.
  1. During initial training (9)
  2. Visits by speech and language therapists (4)
  3. Four one hour sessions organised by speech and language therapists (9)
  4. Half day workshop or training session in day release (25)
Of the total group 28 (14.7%) currently had a child who stammers in their group, 89 (46.6%) had at some time had a child who stammers in their group and 40 (21.1%) had a friend or family member who stammers. 183 (96.3%) of the respondents requested further training with 137 requesting a visit from a speech and language therapist, 102 wishing day release courses, 95 seeking talks at training days and 85 requesting leaflets.

The responses of this group to questions in the questionnaire related to their perception of their ability to recognise stuttering in young children are presented in Table 2.


Table 2. Responses to the questionnaire related to their ability to recognise stuttering in young children

In addition the pre-school educators were Very uncertain about their ability to predict chronicity of stuttering, and about the aetiology of stuttering. Around 43% did not consider it difficult to know how to respond to a child who stutters, while 35% had no strong feelings about this and only 22% considered this to be difficult. 64.5% did not know whether stuttering was easy to treat or not. Speech and language therapists were considered to be a good source of information on stuttering by >90%, whilst health visitors were considered a good source of information by 36% and GPS by 15%.

  1. Discussion
The response rate in both studies was high (approx. 76%) which might be related to the fact that postal surveys were used with respondents being reminded after three weeks if no return had been received. However it was not possible to conduct interviews with these professionals which might have produced more detailed qualitative information.

In the first study there were some interesting differences between GPS and HVS in their attitudes towards childhood dysfluency. Some health Visitors had confidence in their ability to predict chronicity but this confidence was not found amongst GPS (or pre-school educators in the second study).

It was clear that having some sort of training in dysfluency significantly affected referral rates amongst primary care professionals. It is not possible to explain the reasons for this in a cross sectional study. However, it is possible that those who were interested in this disorder sought out training, so an independent effect of training can not be assumed. However, if increased referral is affected by training then this study strongly supports implementation of the British Stammering Association’s guidelines based on the primary healthcare workers project. Generally in the Highland region it would be expected that health visitors and GPs would be the main sources of referral of dysfluent children.

If pre-school educators are to be encouraged to directly or indirectly refer dysfluent children to speech and language therapy then they must have some understanding of dysfluency. Christie (2000) noted that parents reported a lack of awareness concerning dysfluency in nursery teachers and she recommended that this group should be targeted for information giving. In the second study the number of pre-school educators who claimed to be able to recognise stuttering in young children is surprising with >70% claiming to be confident in this skill. This contradicts the parents’ perceptions 100 Theory, research and therapy in fluency disorders of nursery teachers, as reported by Christie (2000). However only a small proportion (<30%) consider it is easy to do this. Although there is an apparent confidence in recognising stuttering, <5% consider they have had adequate training in recognising speech problems in children. Most of the respondents requested further training, mainly in a face to face form with a speech and language therapist. In responding to questions on the aetiology of stuttering and on the ease with which this condition can be treated the majority of the pre-school educators (>60%) responded in the ‘neither agree nor disagree category.’

If dysfluent children are to be referred early to speech and language therapy then much more time and information must be given to primary care professionals and pre-school educators. This could result in a significant increase in referrals to an already busy service. This might be offset by a reduction in the number of cases of persistent stuttering but we would argue that this is necessary even if the cost is not neutral. In order to prevent the negative sequelae of stuttering, time and effort must be given to these potential referral sources so that they recognise stuttering and the importance of early referral. The challenge to therapists is to apportion their time to provide a good service not only to dysfluent children and their families but also to these potential sources of referral.

Christie, E. (2000). The primary healthcare workers project. London, British Stammering Association

Ingham, R., & Cordes, A. (1999). On watching a discipline shoot itself in the foot: Some observations on current trends in stuttering treatment research. In N.Bernstein Ratner & E.C. Healey (Eds),Stuttering research and practice.' Bridging the gap. Mahwah,NJ : Lawrence Erlbaum.

Lees, R., Stark, C., Baird, J ., & Birse, S. (2000). Primary care professionals’ -knowledge and attitudes on speech disfluency in pre-school children. Child Language Teaching and Therapy, 16, 241-254.

Yairi, E., & Ambrose, N. (1999). Early childhood stuttering 1: Persistence and recovery rates. Journal of Speech, Language and Hearing Research, 42, 1097 - 1112.
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