A 3 year old boy came in with the complaints of recent onset of stuttering of just 1 week. Both parents were extremely anxious. They had a video of him trying to speak- the repetition, the prolongations, the blockages...were something they had never observed in him so far.
Stuttering has now got a brand new label- childhood onset fluency disorder. About 5% of children stutter but longitudinal studies show that upto 65-80% remit by 16 years of age.
It has afflicted both kings and commoners. How King George VI conquered his stuttering to address his country is beautifully depicted in the movie "The Kings Speech". But a complete understanding of the pathophysiological underpinnings of this angst-ridden disorder eludes us still.
Functional MRI and PET scan studies in people who stutter have shown that the complex, perfectly coordinated loops (between the motor speech areas, auditory speech cortex, basal ganglia, thalamus and cerebellum) which underlie fluent speech are dysfunctional.
One key area is considered to be the auditory feedback received during speech which decides our motor speech rates and rhythms. This is the basis of many therapeutic interventions which have been tried such as choral reading, masking, metronome use and delayed auditory feedback systems.
Choral reading is reading out aloud with 2 or more people. It has been shown to instantaneously reduce stuttering by more than 80%.
A dreaded phenomenon in stuttering is silent blocks, where they are unable to utter a single sound. Masking auditory feedback ( MAF) devices have been sometimes found to be useful. This device produces a masking auditory feedback in ones ear when desired and enables the patient to restart speaking. The device can be switched on during silent blocks.
Electronic metronomes which can be worn behind the ear and provide a beat to which the patient must read aloud daily, (for 10-15 minutes) have also been used.
The Lidcombe therapy which was developed in Sydney has been particularly useful in preschoolers who stutter. They train the parents to provide appropriate feedback with effusive praise for fluent speech.
In view of the several overlapping clinical features of stuttering and Tourettes, dopamine blocking drugs have been tried and found useful. Medications which have shown some efficacy include haloperidol, risperidone, olanzapine and pimozide. Tricyclic antidepressants and SSRI's have not been shown to be useful. VMAT2 ( vesicular monoamine transporter2) inhibitors are under investigation in view of their use in Tourette's. https://dx.doi.org/10.3389%2Ffnins.2020.00158
TMS and DBS are some other options which are also being explored for refractory cases.
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