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Stuttering and Language Ability in Children:


Questioning the Connection
Article in American Journal of Speech-Language Pathology March 2012
DOI: 10.1044/1058-0360(2012/11-0078) Source: PubMed

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Marilyn A Nippold
University of Oregon
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Stuttering and Language Ability in Children:


Questioning the Connection
Marilyn A. Nippolda

Purpose: This article explains why it is reasonable to question


the view that stuttering and language ability in children are
linkedthe so-called stutteringlanguage connection.
Method: Studies that focused on syntactic, morphologic,
and lexical development in children who stutter (CWS) are
examined for evidence to support the following claims:
(a) that CWS, as a group, are more likely to have disordered
or weak language skills (language deficits) than children
who do not stutter (CWNS); (b) that language deficits play
a causal role in the onset of stuttering; and (c) that stuttering,
over time, restricts childrens language development.
Results: Analysis of the evidence suggests that CWS, like
CWNS, show the full range of language abilities (high,

average, low); that language deficits are not associated with


stuttering onset or persistence; and that stuttering has little or
no impact on language development.
Conclusions: A connection between stuttering and language
ability was not supported. An alternative perspective is that
CWS have a compromised motor control system that makes
it difficult for them to move forward in speech and that the tie
to language lies not in a deficient linguistic system but in
difficulty expressing the intended meaning via a fully
functional speech system.

one or more areas of development (e.g., linguistic, cognitive,


motoric, emotional), stuttering is likely to occur. This suggests that the presence of a language disorder could make
a young child vulnerable to stuttering (Bajaj, 2007; Bernstein
Ratner, 1997; Blood, Ridenour, Qualls, & Hammer, 2003).
Another factor, also related to the DC model, is that stuttering often increases as children attempt to produce long and
grammatically complex utterances (e.g., Bernstein Ratner
& Sih, 1987; Logan & Conture, 1995; Melnick & Conture,
2000; Weiss & Zebrowski, 1992). This suggests that the
presence of a language disorder could make it especially
difficult for a child to manage stuttering during the effort to
express complex thoughts (Arndt & Healey, 2001). Moreover, given the overlap in timing between stuttering onset
and the emergence of syntax, combined with the fact that
stuttering does not occur during the earlier developmental
stages of babbling and single-word productions, it has even
been suggested that stuttering itself is a type of language
disorder (for discussion, see Bloodstein, 2006).
More than 20 years ago, Nippold (1990) reviewed many
of the earlier studies that examined a connection between
stuttering and language ability in children. The outcome of
that review indicated that some children who stutter (CWS)
have language disorders, but that similar patterns can be
found in children who do not stutter (CWNS). Nippold also
reported that, because of methodological limitations affecting some studies, the evidence was not convincing to show
that CWS, as a group, are more likely to have language
disorders than CWNS. These limitations included failure
to match the groups on key factors such as gender and socioeconomic status (SES); use of screening procedures that

or more than 80 years, scholars have been intrigued


by the possibility of a connection between stuttering
and language ability in children and the implications
that such a link may hold for expanding the knowledge base
concerning the nature, causes, and treatment of stuttering
(e.g., Anderson & Conture, 2000; Bernstein Ratner, 1997;
Berry, 1938; Bloodstein, 2006; Byrd & Cooper, 1989;
Johnson, 1955; McDowell, 1928; Nippold, 1990; Ryan,
1992; Silverman & Williams, 1967; Watkins, 2005; Watkins
& Johnson, 2004; Watkins, Yairi, & Ambrose, 1999; Westby,
1974; Yaruss, LaSalle, & Conture, 1998). Several factors
have contributed to the belief that stuttering is linked to
language ability. One factor is that stuttering typically begins
between the ages of 2 and 4 years (Yairi, 2004), a time of
rapid syntactic, morphologic, and lexical development when
children are acquiring the ability to produce increasingly
complex utterances (Owens, 2012). As argued by the
DemandsCapacities (DC) model of stuttering (Adams,
1990; Starkweather & Gottwald, 1990), when internal or
external demands for fluency exceed a childs capacities in

University of Oregon, Eugene


Correspondence to Marilyn Nippold: nippold@uoregon.edu
Editor: Carol Scheffner Hammer
Associate Editor: Patrick Finn
Received July 27, 2011
Revision received December 13, 2011
Accepted March 9, 2012
DOI: 10.1044/1058-0360(2012/11-0078)

Key Words: stuttering, language ability, children

American Journal of Speech-Language Pathology Vol. 21 183196 August 2012 A American Speech-Language-Hearing Association

183

excluded CWNS from participating if they showed signs of


a language disorder but included CWS regardless of their
language status; and use of timed speaking tasks to compare
the language skills of CWS to those of CWNSa procedure
that will inevitably put CWS at a disadvantage because of
their difficulty initiating and moving forward in speech.
Since Nippolds (1990) review, other investigators (e.g.,
Watkins, 2005; Watkins & Johnson, 2004; Yairi, 2004; Yairi
& Seery, 2011) have also questioned the view that stuttering
and language ability are linked. For example, Watkins
and Johnson (2004) emphasized the need for high-quality
research that could resolve the discrepant findings across
studies. To accomplish this, they recommended that investigators carefully match participant groups on variables
associated with language development (e.g., age, SES,
parental education), and that childrens stuttering and language development be examined over time, citing prospective longitudinal studies conducted in Germany (Hge, 2001;
Rommel, Hge, Kalehne, & Johannsen, 2000) that showed
that the receptive and expressive language skills of young
CWS were well within normal limits. Moreover, Watkins
(2005), in discussing her longitudinal studies of language
development in CWS (Illinois Stuttering Research Program),
concluded that there is virtually no evidence that language
development is vulnerable in any significant number of
young children who stutter (p. 246). Rather, she suggested
that the presence of advanced expressive language skills
may be a risk factor for the onset of stuttering in some
children, perhaps by placing excessive demands for language
production on an immature speech motor system.
Nevertheless, many scholars have continued to argue
that CWS, as a group, are more likely to have disordered
or weak language skills (language deficits) than CWNS
(e.g., Anderson & Conture, 2000; Anderson, Wagovich,
& Hall, 2006; Arndt & Healey, 2001; Blood et al., 2003;
Bloodstein, 2006; Hakim & Bernstein Ratner, 2004; Ntourou,
Conture, & Lipsey, 2011; Tetnowski, Richels, Shenker,
Sisskin, & Wolk, 2012; Yaruss et al., 1998). Scholars have
also argued that language deficits could play a causal role in
the onset of stuttering (e.g., Anderson & Conture, 2000;
Bernstein Ratner, 1997; Bloodstein, 2006; Ntourou et al.,
2011), and that stuttering, over time, could restrict a childs
language development (Arndt & Healey, 2001; Byrd &
Cooper, 1989).
It is important to evaluate these claims closely to ensure
that the knowledge base in childhood stuttering is as accurate
as possible. Thus, in the present article, these claims are
addressed by examining studies published in peer-reviewed
journals since 1990 that investigated syntactic, morphologic,
and lexical development in CWS.1 Phonological development and reading ability in CWS have been reviewed

The following journals were searched electronically for articles published


between 1990 and 2011 that addressed the primary research questions:
American Journal of Speech-Language Pathology; Child Language
Teaching and Therapy; Clinical Linguistics and Phonetics; International
Journal of Language and Communication Disorders; Journal of Communication Disorders; Journal of Fluency Disorders; Journal of Speech,
Language, and Hearing Research; Language, Speech, and Hearing Services
in Schools; and Pediatrics.

elsewhere (Nippold, 2001, 2002, 2004; Nippold & Schwarz,


1990) and are not covered here. Studies that had not
undergone the peer review process (such as dissertations,
theses, or those published in book chapters or conference
proceedings) were excluded from the review because they
had not been independently scrutinized before dissemination. In selecting articles to include, research journals
published in English that are read by researchers and clinicians in speech-language pathology were targeted. To
secure as many articles as possible, the author searched
the journals electronically using the key words stuttering,
language, and children. After reading the abstract of each
article, the author determined if the article addressed any
of the claims. All relevant articles were included in the
review.
As discussed in this article, the evidence is not convincing to show that CWS, as a group, are more likely to have
language deficits than CWNS; that language deficits are
associated with stuttering onset; or that stuttering, over
time, restricts language development. Rather, the evidence
suggests that CWS, like CWNS, show the full range of language abilities (high, average, low), even at the time of
stuttering onset, and that stuttering has little or no impact
on language development. The reasoning behind these
conclusions is presented in four sections, each of which
addresses a specific question related to the stuttering
language connection:
Are CWS, as a group, more likely to have language
disorders than CWNS?
Are CWS, as a group, more likely to have weak language
skills than CWNS?
Are language deficits associated with stuttering onset?
Does stuttering, over time, restrict childrens language
development?

Stuttering and Language Disorders


Before addressing the question of whether CWS, as a
group, are more likely than CWNS to have language
disorders, it is necessary to clarify what it means to have
a language disorder. For clinical and research purposes, it
is common practice in speech-language pathology to identify language disorders in children who are monolingual
speakers of English by performing a formal evaluation
of a childs syntactic, morphologic, and lexical development.
Frequently, this is accomplished by administering normreferenced language tests such as the Test of Language
DevelopmentPrimary:2 (TOLDP:2; Newcomer &
Hammill, 1988), the Clinical Evaluation of Language
FundamentalsRevised (CELFR; Semel, Wiig, & Secord,
1987), and the Peabody Picture Vocabulary TestRevised
(PPVTR; Dunn & Dunn, 1981) (Leonard, 1998; Rice,
Hoffman, & Wexler, 2009; Rice, Redmond, & Hoffman,
2006; Tomblin et al. 1997). A language disorder may be
diagnosed if a child performs at least 1 SD below the mean
on one or more of these tests (e.g., Rice et al., 2006, 2009;
Tomblin et al., 1997). In addition, samples of a childs
spontaneous speech may be elicited, recorded, and analyzed

184 American Journal of Speech-Language Pathology Vol. 21 183196 August 2012

for mean length of utterance (MLU) to diagnose or confirm a


language disorder (e.g., Eisenberg, Fersko, & Lundgren,
2001; Rice et al., 2006, 2010). As with norm-referenced
tests, an MLU that falls at least 1 SD below the mean for the
childs chronological age may be interpreted as evidence of
a language disorder (Rice et al., 2006, 2009, 2010). The
valid use of these measures for clinical or research purposes
assumes that the child in question speaks English and was
attentive and cooperative during the assessment session.
Studies that examined CWS for the presence of language
disorders have employed these types of formal assessment measures in the context of various research designs,
including surveys of speech-language pathologists (SLPs)
caseloads, examination of clinical samples, and group
comparison studies.
Caseload surveys. Several studies have surveyed practicing SLPs about the children on their caseloads to determine how frequently language disorders co-occur with
stuttering. These studies often are cited to support the claim
that CWS are more likely to have language disorders than
CWNS (e.g., Hakim & Bernstein Ratner, 2004; Ntourou
et al., 2011; Tetnowski et al., 2012).
In one such study, Arndt and Healey (2001) surveyed
241 school-based SLPs from 10 states in the United States.
These SLPs were asked to report (a) the number of children
on their caseloads who stuttered, and (b) of those who
stuttered, the number who also had a language disorder
that had been verified through formal testing procedures
(as described earlier). Results indicated that a total of 467
children stuttered, of which 139 (30%) also had a language
disorder.
It should be noted that this 30% figure is markedly higher
than what has been reported for children not identified as
stuttering. For example, Tomblin et al. (1997) conducted a
large epidemiological study of kindergarten children living
in the Midwestern United States and found that 7% had
specific language impairment (SLI). As defined by Leonard
(1998), SLI is a language disorder that is characterized by
normal cognitive development and sensory and motor
functioning but significantly delayed language development,
often affecting syntax, morphology, and the lexicon. Arndt
and Healey (2001) concluded that a large percentage of
CWS have a language disorder. They also claimed that their
findings supported the DC model, arguing that some
preschool children might be vulnerable to developing poor
expressive language if the stuttering persists into the elementary school-age years and that problems or difficulties
in expressive language abilities might be a by-product of
stuttering for several years (p. 76).
Two years later, Blood et al. (2003) published a larger,
nationwide survey that involved 1,184 school-based SLPs
who were questioned about the children on their caseloads.
For each child who stuttered, the SLP was asked to indicate if
the child also had a documented language disorder. It was
reported that 2,628 children were receiving treatment for
stuttering. Of this total, 672 (26%) had a deficit in semantic
development and 527 (20%) had a deficit in syntactic development. The number of children who had both types of
language deficits was not reported. Again, these figures are
considerably higher than the 7% figure reported for SLI in

children not identified as stuttering (Tomblin et al., 1997).


Blood et al. suggested that a language disorder may place
excessive demands on a childs capacity for fluency, resulting in greater stuttering (p. 440). It should be noted,
however, that this claim that language disorders may play
a causal role in stuttering is the opposite of what Arndt and
Healey (2001) had argued, which was that stuttering over
time may precipitate a language disorder.
Before accepting the results of these two studies (Arndt
& Healey, 2001; Blood et al., 2003) suggesting that a large
percentage of CWS (20% to 30%) have a co-occurring
language disorder, it is important to consider the possibility
that caseload surveys may overestimate the frequency of
language disorders in CWS. Unfortunately, not all CWS
reach the SLPs caseload, and many children are denied
services, especially if they do not have an additional communication disorder (e.g., phonology, language). Evidence
for this was obtained by Nippold (2004), who conducted
a survey of 127 SLPs in Oregon who were asked about their
views concerning the treatment of stuttering. Results indicated that 31% of the SLPs reported that they were more
likely to provide treatment for a child who stutters if that
child has an additional communication disorder (p. 149).
In another part of the survey, 71% of the SLPs said they
would recommend treatment if a childs only problem was
stuttering, but that 94% said they would recommend treatment if the child also had a language disorder. When asked
to explain their responses, some SLPs expressed the belief
that an additional disorder would indicate a more serious
problem (Nippold, 2004, pp. 149150), and that it would
make it easier to qualify a child for services (p. 149).
Recognizing that Nippolds (2004) study reflected the
views of SLPs in only one state, the results should be viewed
as preliminary. Nevertheless, many SLPs across the country
have large caseloads, long waiting lists, and numerous
time constraints that prevent them from providing treatment
to all children who could benefit. Thus, it cannot be assumed
that children who are on SLPs caseloads are necessarily
representative of the larger population of CWS.
Clinical samples. In addition to SLPs caseloads, studies
that recruit participants from community or university
speech-language-hearing clinics also may yield inflated
estimates of the occurrence of language disorders in CWS.
For example, Yaruss et al. (1998) reviewed the diagnostic
records of 100 young children (Mage = 4;7 [years;months])
who had been evaluated at a university clinic over a 12-year
period for possible stuttering. Each child participated in a
3-hr session in which a battery of formal and informal measures was administered to evaluate speech and language
development in addition to fluency. Of particular interest
was expressive language development, which was examined using subtests from the Test of Early Language
Development (Hresko, Reid, & Hammill, 1991) or the Preschool Language Scale, Third Edition (PLS3; Zimmerman,
Steiner, & Pond, 1992). In addition, a conversational
language sample of 50 utterances was elicited, recorded, and
analyzed for MLU and Browns grammatical morphemes.
Yaruss et al. reported that formal and /or informal measures
of expressive language development were available for
83 children, and that each childs performance on those
Nippold: Stuttering and Language

185

measures was examined in relation to normative data. The


findings then were used to classify the child as performing
above normal limits (ANL), within normal limits (WNL), or
below normal limits (BNL) in expressive language development. Of the 83 children, 21 (25%) were ANL, 38 (46%)
were WNL, and 24 (29%) were BNL in expressive language
development.
It should be noted that the 29% BNL figure is consistent with the 20%30% range reported in the Arndt and
Healey (2001) and Blood et al. (2003) survey studies that
examined SLP caseloads. However, before accepting these
results as convincing evidence of a high rate of language
disorders in CWS, it is important to consider alternative explanations. One possibility is that the participants in caseload and clinic studies might not be representative of the
larger population of CWS. A question about which we know
very little is why some CWS come to the attention of the
SLP at a school or clinic, and others do not. It is conceivable
that if parents are not concerned about their childs speech
or are unaware of services or unable to pay for them, or
if their pediatrician has advised them to wait and see,
that particular child will not be included in studies of SLP
caseloads or clinic samples. It is conceivable also that CWS
who have additional issues that draw greater parental concern (e.g., restricted expressive vocabulary, numerous speech
sound errors) could come to the SLPs attention sooner
than those whose only problem is fluency. Future research
is necessary to investigate these possibilities.
Group comparisons. A number of studies have compared groups of CWS and CWNS on language development,
frequently using norm-referenced language tests and occasionally using language sampling tasks. Both preschool and
school-age children have been studied. It was important
to study children of a wide age range in order to provide a
comprehensive examination of this topic.
Preschool children. Ryan (1992) conducted a study in
which preschool CWS (n = 20) were compared to preschool
CWNS (n = 20) on language development (Mage: CWS =
4;4, CWNS = 4;5). The groups were matched on the basis
of age, gender, and mothers educational level. All children spoke Standard American English as their primary
language. According to Ryan, the CWS were self-referred
to the university clinic, and the CWNS were recruited
from neighboring preschools (p. 335). Each child was
administered a battery of norm-referenced tests, including
the PPVTR and the Test of Language Development
Primary (TOLDP; Newcomer & Hammill, 1982). In addition, a fluency interview was conducted, and the number
of stuttered words per minute (SWM) was determined
from an audio recording. As expected, the CWS produced
a greater number of SWM than the CWNS, a difference
that was statistically significant. Although both groups
performed within normal limits on the PPVTR (mean
standard score: CWS = 105.4; CWNS = 111.2) and the
TOLDP (mean standard score: CWS = 92.2; CWNS =
100.8), the CWNS outperformed the CWS on the TOLDP,
a difference that was statistically significant. Nevertheless,
the study did not find evidence to support the claim that
CWS, as a group, are more likely to have language disorders
than CWNS.

Anderson, Pellowski, and Conture (2005) examined language development in preschool children (n = 90) ages 3;0
to 5;11 (Mage = 4;1). Half of the children stuttered (CWS)
and half had normal fluency (CWNS). All children spoke
Standard American English. The two groups were matched
on the basis of age, gender, race, and SES. To qualify for the
study, all children in the control group had to score at the
20th percentile or higher on a battery of norm-referenced
language tests. However, no such screening procedure was
used with children in the stuttering group, allowing their
language skills to vary. To examine language development,
the investigators administered the following tests to each
child in the study: the Peabody Picture Vocabulary Test
Third Edition (PPVTIII; Dunn & Dunn, 1997), the Expressive Vocabulary Test (EVT; Williams, 1997), and the
Test of Early Language Development, Third Edition (TELD3;
Hresko, Reid, & Hammill, 1999). Collectively, these
tests evaluated the childrens syntactic, morphologic, and
lexical development. The results showed that both groups
performed within the normal range on all tests, and that they
did not differ significantly on the PPVTIII or the EVT.
However, the CWNS outperformed the CWS on the receptive and expressive subtests of the TELD3. Although there
was no evidence of language disorders in the CWS, the
authors suggested that the overall language abilities of
the CWS were lower than those of the CWNS.
Before accepting this conclusion, caution is advised. Although the two groups had been matched for age, gender, race,
and SES, all children in the control group had to have
scored at the 20th percentile or higher on a set of normreferenced language tests, but no such requirement was made
for the children in the stuttering group, whose language
skills were free to vary. This type of differential subjectselection procedure (Schiavetti & Metz, 2006, p. 144) constitutes a serious threat to the studys internal validity. Had
the language skills of all children in the Anderson et al.
(2005) investigation been free to vary, the outcome might
have been different.
In an effort to expand the Anderson et al. (2005) study,
Coulter, Anderson, and Conture (2009) administered the same
set of norm-referenced language tests used by Anderson
et al. to additional groups of CWS and CWNS (n = 40 per
group). The children in this study ranged in age from 3;0 to
5;8 (Mage = 4;0), all spoke Standard American English, and
none had participated in the previous study. As before, to
be admitted to the control group, children were required to
have performed at least within the average range on a normreferenced language test (standard score 85), but children in
the stuttering group were not required to meet this criterion.
As with the previous study, both groups performed within
normal limits on all language tests, including the PPVTIII,
the EVT, and the receptive and expressive subtests of the
TELD3. Then, to analyze the data with greater statistical
power, the investigators combined the scores from this investigation with the scores from all of the participants in the
Anderson et al. study. The results of this analysis indicated
that the CWNS (n = 85) significantly outperformed the CWS
(n = 85) on all of the norm-referenced language tests.
Again, a note of caution is advised before concluding that
preschool CWS have weaker language skills than their peers

186 American Journal of Speech-Language Pathology Vol. 21 183196 August 2012

who are fluent. As with the Anderson et al. (2005) study,


in recruiting the participants for the Coulter et al. (2009)
study, childrens language skills were free to vary if they
stuttered but not if they were fluent. Thus, it is not surprising that the control group, whose members were required to have normal language skills, outperformed the
stuttering group, whose members were not required to meet
this standard. On the positive side, there was no evidence
from either study to indicate that CWS, as a group, were
more likely to have language disorders than CWNS.
School-age children. In a study that included older
children, Kadi-Hanifi and Howell (1992) examined expressive syntactic development in CWS (n = 17) and CWNS
(n = 17). The participants ages ranged from 2;7 to 12;6
(Mage: CWS = 8;5; CWNS = 7;10). The two groups of
children were matched on the basis of age and grade level.
The CWS were recruited from a speech pathology clinic
in England, and the CWNS were recruited from nearby
schools. The children in each group were further divided into
three developmental subgroups, described as younger,
middle, and older. Mean ages of the subgroups for both
the CWS and the CWNS were 4, 7, and 11 years, respectively (n = 4, 7, and 6 children per subgroup, respectively).
A 10-min conversational language sample was elicited
from each child and was later transcribed and analyzed for
MLU and the use of simple and complex sentences. The
results indicated no statistically significant differences
between the CWS and CWNS at any of the developmental
subgroups. Hence, there was no evidence that CWS, as
a group, were deficient in expressive syntactic development compared to CWNS. Caution is advised, however, in
interpreting this result because of the small numbers of
children in each subgroup, making it difficult to generalize
the results of the study. Another potential limitation is
the use of the same type of language sampling task for
all participants. Although conversational tasks can reveal
syntactic deficits in young children (Rice et al., 2010),
they may be less sensitive to such deficits in older children
compared to narrative or expository tasks, which have a
greater capacity to challenge a speakers linguistic system
(Nippold, 2010).
In a subsequent study, Howell, Davis, and Au-Yeung
(2003) examined receptive syntactic development in CWS
(n = 20) and CWNS (n = 86) ages 5 to 10 years. All children spoke British English and were living in London, England.
The CWS were recruited from speech clinics, and the CWNS
were recruited from schools thought to have similar demographic characteristics to the clinics. Each child was
administered the Reception of Syntax Test (ROST), which
is a test that was designed by the investigators to examine
a childs ability to comprehend prerecorded spoken sentences by pointing to the corresponding picture on a computer screen. Sentences that contained later developing
features such as the passive voice, relative clauses, and
complex reasoning (e.g., not only X but also Y ; neither X nor
Y ) were included. The results indicated no statistically significant differences between the groups. Hence, there was no
evidence demonstrating that CWS were deficient in receptive syntactic development. Caution is advised in interpreting these findings, however, because of the unequal numbers

of participants in the groups of CWS and CWNS and the


relatively small number of CWS at each age level (e.g., at
age 6 years, n = 2 CWS, n = 32 CWNS; at age 9 years, n = 6
CWS, n = 29 CWNS). Unfortunately, this limitation makes
it difficult to generalize the results of the investigation.
Narrative discourse. During the 1990s, several studies
were conducted to examine narrative ability in CWS compared to CWNS. It was important to examine narrative
ability because this type of discourse, storytelling, places
greater demands on a speakers syntactic, morphologic, and
lexical skills than other genres, such as conversational discourse, thereby stressing the language system more fully
(Nippold, 2010). Moreover, narrative tasks can reveal subtle
language deficits in children that may not be revealed by
norm-referenced language tests (Roth & Spekman, 1986;
Westby, 1984).
In the first investigation of this topic, Nippold, Schwarz,
and Jescheniak (1991) examined spoken and written narrative ability in 10 CWS (Mage = 9:0; range = 6;911;3) and
10 CWNS (Mage = 9;1; range = 6;411;3). All participants
were boys who were attending public schools located in
lower middle-income neighborhoods in western Oregon. All
of the boys spoke English as their primary language. Narrative ability was assessed using a story reproduction task
and a story comprehension task. For the story reproduction
task, each child listened to two adventure stories that had
been prerecorded. Immediately after hearing a story, the
child reproduced it by retelling it to the examiner (spoken
narrative task) or by writing it down (written narrative task).
Stories were analyzed for length (total number of C-units),
syntactic complexity (mean length of C-unit, percentage
of total C-units that were complex sentences), and story
grammar components (e.g., settings, initiating events, internal responses, attempts, consequences). Story comprehension was assessed by asking the child a series of factual and
inferential questions immediately after he had reproduced
the story. In addition to the narrative tasks, each child was
administered the CELFR as a norm-referenced measure of
language development. The CELFR yields standard scores
on receptive language (RLS), expressive language (ELS),
and total language (TLS) development.
Results of the Nippold et al. (1991) study indicated no
statistically significant differences between the groups on
any of the spoken or written narrative tasks or the normreferenced language scores. It was also found that the performance of both groups varied widely on all measures. For
example, on the CELFR, there were children in both groups
who earned RLS, ELS, and TLS scores that fell into the
categories of below average, average, and above average.
Additionally, on the story retelling task, the total number of
C-units produced ranged from 4 to 19 for the CWS and from
3 to 25 for the CWNS. It was interesting also that despite
the presence of severe stuttering, some of the CWS told long
and complex stories, suggesting that their language skills
were robust.
In a similar investigation, Weiss and Zebrowski (1994)
examined spoken narrative ability in 8 CWS (Mage = 7;10;
range = 5;711;6) and 8 CWNS (Mage = 7;9; range = 5;7
11;6), matched on age and gender. During a screening session, all children had performed within normal limits on a set
Nippold: Stuttering and Language

187

of norm-referenced language tests, which included the


PPVTR and either the TOLDP:2 or the Test of Language
DevelopmentIntermediate:2 (TOLDI:2; Hammill &
Newcomer, 1988). Thus, the study excluded any child who
was found, through formal testing, to have a language disorder.
To elicit narrative samples, each child watched a videotaped story that lasted 6 min. Immediately after the tape
ended, the child was asked to retell the story to two different listeners. Following these tasks, the child was asked to
make up three different stories when provided with a story
starter for each (e.g., Once there was a boy named Alan who
had many different toys, p. 46). All five stories were transcribed, segmented into C-units, and analyzed for the total
number of C-units produced and the total number of complete episodes produced, where an episode had to contain
at least one initiating event, an attempt, and a consequence.
Combining the results from all five stories, no statistically
significant differences were found between the groups for
total number of C-units or total number of episodes (Weiss &
Zebrowski, 1994). In addition, both groups showed considerable variability in performance. For example, on total
C-units, the CWS ranged from 27 to 127, and the CWNS
ranged from 22 to 323. Thus, this study did not support the
claim that CWS are deficient in narrative ability compared
to CWNS. Caution is advised, however, because any child
known to have a language disorder was excluded from participating in the study, thereby diminishing the likelihood
of finding narrative deficits.
In another study of narrative ability, Scott, Healey, and
Norris (1995) compared the performance of 12 CWS (Mage =
7.9 years; range = 6.69.9 years) to 12 CWNS (Mage =
7.8 years; range = 6.59.8 years) on a story retelling task.
The groups were matched on the basis of age and gender.
Each child was asked to view a set of pictures that illustrated
a story. The examiner began by telling the child the story and
pointing to the pictures. After telling the story twice, the
examiner asked the child to retell the story while looking at
the pictures. Each childs story was audio recorded, transcribed, and assigned points depending on how many story
grammar components and relevant details were included
(maximum = 59 points). Additionally, in the case of the
CWS, all instances of stuttering were counted. The purpose
of the study was to determine if CWS produce less sophisticated narratives compared to CWNS, and if the frequency
of stuttering is associated with the level of story sophistication. It was expected that stuttering might increase as a
child attempts to tell a longer and more complex story because of the added linguistic demands that a more sophisticated story might place on the speaker.
Nevertheless, the two study groups obtained similar scores
on the narrative task (mean score: CWS = 44.4; CWNS =
43.6), and they did not show a statistically significant difference in performance (Scott et al., 1995). In addition, scores
on the narrative task were only weakly associated with stuttering frequency. In discussing their findings in relation to previous research on narrative ability (Nippold et al., 1991; Weiss
& Zebrowski, 1994), Scott et al. stated that there is accumulating evidence that, as a group, children who stutter retell a
story with the same degree of sophistication as their normally
fluent peers (1995, p. 286).

More recently, Bajaj (2007) conducted a larger study in


which he examined narrative ability in 44 boys who were
in kindergarten (n = 10), first grade (n = 24), and second
grade (n = 10). Half of the boys in each grade level stuttered
and half were fluent (n = 22 CWS; n = 22 CWNS). Mean
ages of the three grades, respectively, were 6;3, 7;3, and 8;4.
All children spoke English as their native language, had
normal hearing, and reportedly were making adequate progress in school. The wordless picture book, Frog Goes to
Dinner (Mayer, 1974), was used to elicit a sample of narrative discourse from each child. To introduce the activity,
the examiner provided a model of how to tell a story, using
the first five pages of the book. Then, the child was asked to
use the book in a similar way to tell an entire story from
beginning to end. Each childs story was audio recorded
and was later transcribed and analyzed for the following
variables: total number of C-units produced, a measure of
story length; accuracy of tense marking, a measure of morphological development; the Subordination Index, a measure
of syntactic complexity; and the Narrative Scoring Scheme
(NSS), a measure of the extent to which the speaker includes key story grammar components (e.g., introduction,
character development, mental states, conflicts, resolutions,
etc.).
Results of the study indicated no statistically significant
differences between the groups of CWS and CWNS at any
grade level, on any variables, including story length, morphological development, syntactic complexity, or the use
of story grammar components (Bajaj, 2007). It was also
found that the second graders outperformed the kindergartners on total number of C-units produced and on the Subordination Indexa pattern that reflects normal language
development during the targeted age range (Nippold, 2007).
No interactions between fluency group and grade level were
statistically significant. Thus, the findings of this study
were consistent with previous studies of narrative discourse
development, indicating that school-age CWS, as a group, do
not differ significantly from CWNS (Nippold et al., 1991;
Scott et al., 1995; Weiss & Zebrowski, 1994).
Summary. The claim that CWS, as a group, are more
likely to have language disorders than CWNS is not well
supported by empirical evidence. Rather, it appears that
CWS are as likely as CWNS to show the full range of
language abilities, including average, above average, and
below average levels, as measured by their performance on
norm-referenced tests of receptive and expressive language
development and samples of conversational and narrative
discourse. These patterns have been found in children of all
ages, including preschoolers and school-age children.

Stuttering and Language Skills


Even if one concedes that CWS, as a group, are not more
likely to have clear-cut language disorders than CWNS,
there is still the claim addressed by the second question, that
CWS are more likely to have weak language skills than
CWNS, and that these subtle deficits may be associated
with stuttering.
This hypothesis was addressed by Ntourou et al. (2011),
who conducted a detailed meta-analysis of 22 research

188 American Journal of Speech-Language Pathology Vol. 21 183196 August 2012

studies that examined the language abilities of CWS compared to CWNS. Studies were included in their meta-analysis
if the participants were between 2 and 8 years of age, had
been assessed using norm-referenced language tests or
language sampling tasks, and had not received a previous
diagnosis of language impairment. Studies that examined
phonological development were excluded, as the focus of the
review was on syntactic, morphologic, and lexical development. For each study included in the meta-analysis, group
differences between CWS and CWNS on the language measures were examined by calculating effect sizes. The results indicated that CWS scored significantly lower than
CWNS on measures of overall language ability, receptive
vocabulary, expressive vocabulary, and MLU. Despite these
group differences, however, in most of the studies, CWS still
performed within normal limits on the language measures,
confirming that they did not have language disorders. For
this reason, Ntourou et al. suggested that CWS, as a group,
demonstrate subtle differences in language abilities when
compared to their normally fluent peers (p. 173) and that
language may be an influential variable associated with
the difficulty that some CWS have establishing normally
fluent speech (p. 176).
Before accepting these conclusions, several issues must
be considered. First, it is essential that studies that are designed to compare the language abilities of CWS to those
of CWNS ensure that their groups are matched on factors
that are known to influence childrens performance on language tasks (see Nippold, 1990; Watkins & Johnson, 2004).
Most importantly, these include age, gender, and SES or
factors related to SES such as maternal education (Dollaghan
et al., 1999; Hoff, 2003; Hoff & Tian, 2005; Turnbull &
Justice, 2012). Of the 22 studies included in the metaanalysis by Ntourou et al. (2011), only four (18%) matched
the stuttering and nonstuttering groups on age, gender, and
SES; 13 (59%) matched them on age and gender; three
(14%) matched them only on age; and two (9%) matched
them only on gender (see Ntourou et al., 2011, Table 1,
pp. 167171). Because children from higher SES levels frequently score higher on language measures than children
from lower SES levels (Hart & Risley, 1995; Hoff, 2003;
Hoff & Tian, 2005), SES must be controlled in studies that
compare CWS and CWNS on language. Without properly
matching the groups, it is premature to draw conclusions
regarding language differences between them.
It should also be noted that of the four studies included in
the meta-analysis (Ntourou et al., 2011) that matched the
groups on age, gender, and SES (Anderson, 2008; Anderson
et al., 2005, 2006; Silverman & Bernstein Ratner, 2002),
only two of them (Anderson et al., 2005; Silverman &
Bernstein Ratner, 2002) found statistically significant
differences between the groups on the norm-referenced
language tests, with both favoring the CWNS. However,
these results should be interpreted cautiously. In the Anderson
et al. (2005) study, a prescreening process had been employed such that the CWNS were required to have scored
at the 20th percentile or higher on the language tests,
but the CWS were not required to meet this criterion; thus,
the language skills of the CWS were free to vary, making it
difficult to interpret the studys findings. As mentioned

previously, this differential subject-selection procedure


constitutes a serious threat to the internal validity of a
study (Schiavetti & Metz, 2006).
It is also noteworthy that in the Silverman and Bernstein
Ratner (2002) study, the groups differed in their performance
on the Expressive One-Word Picture Vocabulary Test
Revised (EOWPVTR; Gardner, 1990), a measure of expressive vocabulary development, but not in their performance on the PPVTR, a measure of receptive vocabulary
development. Although the results suggest a deficit in expressive language development for CWS, it is important to
recognize that a test such as the EOWPVTR that requires a
child to name a series of pictured objects, actions, and concepts may be especially difficult for CWS because of their
tendency to avoid saying certain words that might elicit
stuttering and to substitute others that are easier to say
(Bloodstein, 1995). Therefore, it is possible that for some
CWS, performance on such a test might reflect an effort to
avoid stuttering on certain feared words rather than a true
weakness in their expressive language development.
Finally, it must be mentioned that another limitation of the
Ntourou et al. (2011) meta-analysis was that seven of the
22 studies (32%) included in the review were unpublished
manuscripts (six doctoral dissertations and one masters
thesis). Hence, unlike the published studies, they had not
gone through the standard peer review process where they
would have been scrutinized by independent reviewers and
editors before dissemination. Had this process occurred,
additional methodological weaknesses might have been
detected, which could have resulted in different interpretations of the study findings, major revisions, or even rejection
of some manuscripts.
Nonword repetition tasks. Recently, a trend has emerged
of examining CWS for the presence of subtle (subclinical)
language deficits using experimental tasks such as nonword repetition. For example, Hakim and Bernstein Ratner
(2004) argued that a nonword repetition task might be a more
sensitive measure of language deficits in CWS than normreferenced language tests and language sampling tasks. To
support their argument, they cited research indicating that
children with SLI often have difficulty with nonword
repetition (Edwards & Lahey, 1998; Ellis Weismer, et al.,
2000; Gathercole, Willis, Baddeley, & Emslie, 1994).
In the Hakim and Bernstein Ratner (2004) study, 8 CWS
(Mage = 5;10, range = 4;38;4) were matched to 8 CWNS
(Mage = 5;9, range = 4;18;4) on the basis of age, gender, and
maternal educational level. All children were monolingual
speakers of English. To be included in the study, each child
had to have earned average or higher standard scores on
the Kaufman Brief Intelligence Test (K-BIT; Kaufman &
Kaufman, 1990) and the Test of Language Development
Primary:3 (TOLDP:3; Hammill & Newcomer, 1997),
thereby demonstrating normal cognitive and linguistic abilities. Although the CWNS earned slightly higher scores on
these measures than the CWS, no differences between the
groups were statistically significant. The Childrens Test of
Nonword Repetition (CNRep; Gathercole et al., 1994) was
also administered to all participants. This test requires the
child to listen to a series of nonsense words containing
two, three, four, or five syllables (e.g., rubid, commerine,
Nippold: Stuttering and Language

189

woogalamic, defermication), presented in random order, and


to repeat each word immediately after it is heard. The test
contains a total of 40 words, and one point is awarded for
each word that is repeated correctly. On the CNRep, the
mean accuracy score was 24.5 (61%) for the CWS and
28.8 (72%) for the CWNS, a difference that was not statistically significant. However, a more detailed analysis
indicated that the CWNS outperformed the CWS on the repetition of 3-syllable words, a difference that was statistically
significant, but that the groups did not differ significantly
on the repetition of 2-, 4-, or 5-syllable words. Indeed, for
both groups, 2-syllable words were quite easy, whereas
4- and 5-syllable words were quite difficult. Hakim and
Bernstein Ratner concluded that their findings lend support
to the hypothesis of a relationship between stuttering and
some level of linguistic processing deficit (p. 192). However, for the authors to argue that the existence of a deficit
is supported on the basis of one out of four types of words
seems to overstate the findings, as an even stronger case
could be made for the nonexistence of such a deficit on the
basis of three out of four types of words.
In an effort to replicate and expand Hakim and Bernstein
Ratners (2004) study, Anderson et al. (2006) examined
nonword repetition in 12 CWS (Mage = 4;0) and 12 CWNS
(Mage = 4;0) whose ages ranged from 3;0 to 5;2. The two
groups were matched on the basis of age, gender, and parental SES. All children spoke English and had earned at
least average standard scores on a battery of norm-referenced
language tests, including the PPVTIII, EVT, and TELD3.
No statistically significant differences were found between
the CWS and the CWNS on any of the language tests. As
with the Hakim and Bernstein Ratner study, skill with nonword repetition was examined using the CNRep.
In terms of the total number of nonwords correctly repeated (40 possible), the CWS in the Anderson et al. (2006)
study earned a mean score of 14.2 (36%), and the CWNS
earned a mean score of 19.1 (48%), a difference that was not
statistically significant. However, the CWNS correctly repeated a greater number of 2- and 3-syllable words than did
the CWS, differences that were statistically significant. As
with the Hakim and Bernstein Ratner (2004) study, no differences between groups occurred for the 4- and 5-syllable
words. Further, to determine if nonword repetition was associated with language ability, correlation coefficients were
calculated between scores on the CNRep and scores on
the PPVTIII, EVT, and TELD3. None of the coefficients
was statistically significant for either group. Anderson
et al. (2006) stated that CWS performed similarly to their
peers across all language measures, while demonstrating differences from peers only in nonword repetition
(p. 194).
Although the studies conducted by Hakim and Bernstein
Ratner (2004) and Anderson et al. (2006) found that CWS
had some difficulty with nonword repetition, it is unclear
what this means for the hypothesis that CWS have subtle
language deficits, particularly when Anderson et al. showed
that childrens performance on the CNRep was not associated with their performance on any of the norm-referenced
language tests. If the CNRep truly reflects subtle language
deficits in CWS, as Hakim and Bernstein Ratner argued, then

it seems that scores on the CNRep and scores on the language tests would bear at least a weak relationship to one
another, with statistically significant coefficients possibly in
the low to low-moderate range. The absence of such findings
casts further doubt on the claim that CWS have subtle
language deficits.
It is also unclear to what extent a childs overt or covert
stuttering behavior may interfere with his or her ability to
repeat nonsense words such as brasterer, glistering, and
empliforvent (Gathercole et al., 1994). If stuttering is a deficit
in speech motor programming that hampers a speakers
ability to advance through a word, as some have argued
(Packman, Code, & Onslow, 2007), then poor performance
on nonword repetition tasks may have little to do with language ability in CWS. Rather, it may reflect motoric difficulties with speech production. Support for this position
comes from a growing body of research on neurogenic
factors associated with developmental stuttering. For example, in discussing this body of research, Watkins, Smith,
Davis, and Howell (2008) stated that stuttering is a disorder
related primarily to disruption in the cortical and subcortical neural systems supporting the selection, initiation and
execution of motor sequences necessary for fluent speech
production (p. 50). If future research confirms the view
that childhood stuttering is primarily a deficit in speech
motor programming, then continued efforts to link the
disorder to language deficits in CWS are likely to be
unproductive.

Language Deficits and Stuttering Onset


The third question asked whether language deficits are
associated with stuttering onset. Consistent with the DC
model, it has been suggested that language deficits could
make a child vulnerable to stuttering (Bernstein Ratner,
1997; Blood et al., 2003). If this is true, then one might
expect to find evidence of language deficits in children at
the time of stuttering onset.
In a study that addressed this possibility, Reilly et al.
(2009) examined the onset of stuttering in a cohort of 1,619
children living in Melbourne, Australia. The children were
participating in a larger longitudinal study of early language
development that began when they were 8 months old. All
parents spoke English, and the families were reported to
represent a diverse range of SES levels. When the children
were 24 months old, their parents were informed of the
characteristics of early stuttering and were asked to contact
the investigators if their child began to show any signs of
stuttering. If parents thought their child might be stuttering,
the investigators promptly evaluated the childs speech in
the home to confirm or rule out this condition.
The results indicated that 137 children (8.5%) had begun
to stutter by 36 months of age, and that stuttering was often
first noticed when the child began producing 2- and 3-word
utterances (Reilly et al., 2009). Because the study was designed primarily to examine language development, scores
on the MacArthur-Bates Communicative Development Inventories (CDI; Fenson et al., 1993) were available. This
enabled the investigators to determine if children were late
talkers, defined as performing below the 10th percentile

190 American Journal of Speech-Language Pathology Vol. 21 183196 August 2012

on the CDI. Findings indicated that 11 out of 137 (8%)


children in the stuttering group were late talkers, and that
268 out of 1,482 (18%) children in the nonstuttering group
were late talkers, a statistically significant difference. It
was also found that total raw scores on the CDI were significantly higher in the stuttering group than in the nonstuttering group. Reilly et al. (2009) concluded that their
results do not support the premise that language problems are associated with stuttering onset (p. 275). Rather,
they argued that children who had begun to stutter by
age 36 months had language skills that were developing
appropriately, and in some cases, their language skills were
above average.
Similarly, if there is a causal relationship between language deficits and stuttering, then one might expect to find
that weaker language skills are associated with persistent
stuttering and that stronger language skills are associated
with transient stuttering. To address this possibility, Watkins,
Yairi, and Ambrose (1999) examined expressive language
development in preschool CWS (n = 84). The purpose of
their study was to determine if children whose stuttering
would persist differed in their language skills compared to
children whose stuttering would abate. All children were
participating in a larger longitudinal study of stuttering
(Illinois Stuttering Research Program). Participants were
recruited through a wide variety of sources (e.g., newspaper
advertisements, daycare centers, health professionals, SLPs)
and were judged by the investigators to be representative
of young CWS. No specific demographic or SES information was reported. Upon entry into the study, each child
fell into one of three age ranges: 23 years, 34 years, and
45 years. At the time of entry, a conversational language
sample was elicited from the child, transcribed, and analyzed
for MLU, number of different words (NDW), and number
of total words (NTW) produced. One year later, each child
was classified as one whose stuttering had persisted or
abated. The investigators then went back to determine if
these two subgroups differed in their initial expressive language skills. Watkins et al. found that children in both
subgroups in all age ranges had performed within normal
limits on all measures, that many performed above average, and that there were no differences in language ability
between those whose stuttering had persisted or abated. Thus,
there was no evidence linking persistent stuttering with language deficits.
In an earlier study that was designed to examine factors
that might predict persistence or recovery from stuttering,
Yairi, Ambrose, Paden, and Throneburg (1996) administered
a norm-referenced language test, the Preschool Language
Scale (PLS; Zimmerman, Steiner, & Pond, 1979), to a
smaller group of children (n = 32) who were participating in
the longitudinal Illinois Stuttering Research Program. The
PLS was administered to each child upon entry into the
study and again 1 year later. Examination of the childrens
fluency over time indicated that 20 would eventually recover from stuttering, and that 12 would persist in stuttering.
Results of the study indicated that both groups of children
performed well within normal limits on both the receptive and expressive sections of the PLS, on both occasions.
Thus, there was no evidence to show that language deficits

were associated with persistent or transient stuttering in


children.
In another study that was conducted as part of the Illinois
project, Watkins and Yairi (1997) looked more closely at
the language production abilities of the same children with
persistent (n = 12) or transient (n = 20) stuttering who were
examined by Yairi et al. (1996). Those with transient stuttering were further divided into two subgroups: those who
recovered early (within 18 months of stuttering onset; n = 10)
and those who recovered later (between 18 and 36 months
of stuttering onset; n = 10). In the Watkins and Yairi study,
a conversational language sample of at least 100 utterances
was elicited from each child on two occasions: upon entry
into the project (i.e., near the onset of stuttering) and 1 year
later. All samples were transcribed and were entered into
the Systematic Analysis of Language Transcripts computer
program (SALT; Miller & Chapman, 1993), which calculated MLU, NDW, and NTW produced. Each childs performance on these measures was compared to normative data
(Leadholm & Miller, 1992), with the results indicating that
all three subgroupsthose with persistent, early recovered,
or later recovered stutteringshowed age-appropriate performance on all measures on both occasions. Hence, there
was no evidence that language deficits were linked with
persistent or transient stuttering.

Stuttering and Language Development


The fourth question asked whether stuttering restricts
childrens language development over time. It has been
suggested that stuttering may restrict a childs language
development (e.g., Arndt & Healey, 2001; Byrd & Cooper,
1989). For example, Byrd and Cooper (1989) claimed
that for CWS, receptive language may be developing normally, but that expressive language may be delayed as a
result of childrens efforts to simplify their utterances as
they cope with stuttering.
In a relevant longitudinal study, Kloth, Janssen, Kraaimaat,
and Brutten (1998) examined a large group of preschool children (n = 93) who were at high risk for stuttering because
one or both of their parents had stuttered. All children spoke
Dutch and were living in the Netherlands. The purpose of the
study was to test the hypothesis that stuttering can dampen
a childs rate of language development. At the outset of the
study, the children were between 2 and 5 years of age (Mage =
3;3). At that time, none had begun to stutter, and all were
administered a battery of tests to assess their receptive and
expressive language development. The tests included the
Dutch versions of the Peabody Picture Vocabulary Test
(PPVT; Dunn, 1965; Manschot & Bonnema, 1974) and the
Reynell Language Development Scale (Bomers & Mugge,
1989; Reynell, 1983). In addition to the norm-referenced tests,
a sample of each childs spontaneous speech was elicited
and was analyzed for MLU as a measure of expressive language development. One year later, 26 of the children had
begun to stutter. Each of these children was matched to a child
of the same age and gender who had not yet begun to stutter.
Selected from the larger group of children who were at
high risk for stuttering, the 26 children in the control group
had each been given the same language measures upon entry
Nippold: Stuttering and Language

191

into the study. All measures were then re-administered to


all 52 children. The results indicated that the groups did not
differ significantly in their receptive or expressive language
skills at the initial testing session or at the follow-up session
1 year later, and that both groups had made substantial gains
in language development over the year. Thus, there was no
evidence that children who had begun to stutter had deficient
receptive or expressive language or that stuttering had slowed
their language development.
Because spontaneous recovery from stuttering is most
likely to occur by the time a child reaches 5 years of age
(Yairi, 1999), it is important to examine school-age children
whose stuttering has persisted in order to thoroughly test the
hypothesis that stuttering restricts language development
over time. In the study of narrative ability in school-age children conducted by Nippold et al. (1991), described earlier, an
additional goal was to determine if CWS were delayed in
expressive language development but not in receptive language development. This was accomplished by comparing
the RLS and ELS composites from the CELFR for both
groups of participants, CWS and CWNS. The results indicated that for both groups, the RLS composites were higher
than the ELS composites, a pattern that is expected to occur,
according to the authors (Semel et al., 1987) of the CELFR.
In addition, to determine if the discrepancy between
receptive and expressive language was greater in CWS
compared to CWNS, a difference (D) score was obtained
for each child by subtracting the ELS from the RLS. Statistical analyses indicated that the groups did not differ significantly in their D scores. Given that both groups performed
within normal limits on the composites and that their
D scores were similar, Nippold et al. concluded that the hypothesis that stuttering behavior might be a causal factor
in delayed expressive language development was not
supported (p. 303).
Correlational analyses. If stuttering behavior restricts
language development, as some researchers have proposed
(Arndt & Healey, 2001; Byrd & Cooper, 1989), one might
expect to find that as stuttering behavior increases, language ability declines. In other words, statistically significant negative correlation coefficients should be found
between the frequency of stuttering and scores on language
measures.
Ryan (1992), in the study of preschool CWS (n = 20)
described earlier, examined this possibility by calculating
correlation coefficients between a measure of stuttering frequency, stuttered words per minute (FSW), and measures of
receptive and expressive language development, including
the PPVTR and subtests from the TOLD:P. However, none
of the coefficients was statistically significant (e.g., FSW
and PPVTR: r = .25, p > .05; FSW and TOLD:P Sentence
Imitation: r = .10, p > .05). These results, therefore, did not
support the hypothesis that stuttering behavior restricts
language development in young children.
Similarly, as part of another study examining language
development in preschool CWS (n = 20), Anderson and
Conture (2000) elicited a 300-word conversational language
sample from each child. The sample was used to obtain a
score on the Stuttering Severity Instrument for Children and
Adults, Third Edition (SSI3; Riley, 1994) and to determine

the frequency of within-word disfluencies (WWDs), which


included sound and syllable repetitions and sound prolongations. The resulting SSI3 and WWD scores were reported
by Anderson and Conture in a table (2000, p. 287) for each
CWS. Each childs performance on several measures of
language development was also reported in the table, including scores on the TELD2 and the PPVTIII and the MLU
obtained from the conversational language sample. Using
data from the table, this author (Nippold) calculated correlation coefficients between measures of stuttering severity
(SSI3, WWD) and measures of language development
(TELD2, PPVTIII, MLU). The results, shown in Table 1,
indicated that none of the coefficients was statistically significant except for one, the coefficient between WWD and
MLU (r = .52, p = .03), which was moderately strong and
positive. This indicates that as stuttering increased, so did
utterance length, which is the opposite of what should occur
if stuttering restricted language development. These findings
cast further doubt on the claim that stuttering negatively
impacts language development and suggest instead that
CWS attempt to express themselves in complex ways despite
their stuttering.

Conclusions
Studies published in peer-reviewed journals since 1990
that addressed a connection between stuttering and language
ability in preschool and school-age children do not provide
strong evidence to support the view that stuttering and
language ability are linked. Despite multiple efforts using
varied research designs, no study found convincing evidence
of language deficits in CWS compared to CWNS in terms of
receptive or expressive syntactic, morphologic, or lexical
development. Rather, the studies reported that CWS, like
CWNS, manifest the full range of language abilities. Other
critical findings that fail to support such a connection include
the fact that scores on language measures were not significantly correlated with the frequency of stuttering behaviors,
that stuttering onset or persistence was not associated with
language deficits, and that CWS use age-appropriate language even during challenging discourse tasks.
Future research. Nevertheless, given the enduring appeal of this topic and the persistent belief that CWS, as a
TABLE 1. Correlation coefficients (with p values) calculated
by this author (Nippold) between measures of language ability
(Test of Early Language Development, Second Edition [TELD2;
Hresko, Reid, & Hammill, 1991], Peabody Picture Vocabulary
Test, Third Edition [PPVTIII; Dunn & Dunn, 1997], mean length of
utterance [MLU]) and measures of stuttering severity (Stuttering
Severity Instrument [SSI; Riley, 1994], within-word disfluency
[WWD]) for children who stutter, using data provided by Anderson
and Conture (2000) (see their Table 1, p. 287).

SSI
WWD
Note.

TELD2

PPVTIII

MLU

.22 (p = .35)
.42 (p = .06)

.18 (p = .45)
.20 (p = .40)

.37 (p = .13)
.52 (p = .03)*

n = 20 for all variables except MLU, where n = 18.

*statistically significant.

192 American Journal of Speech-Language Pathology Vol. 21 183196 August 2012

group, are more likely to have language deficits than CWNS


(e.g., Ntourou et al., 2011; Tetnowski et al., 2012), it is likely
that investigators will continue to explore the existence
of a connection between stuttering and language ability in
children. If so, it is important that future investigators
actively consider what has already been learned from
research and that they closely attend to key methodological
factors that can threaten the validity of a studys results.
In future studies that examine a connection between stuttering and language ability, it is critical that groups of CWS
and CWNS be matched for all relevant factors (e.g., age,
gender, SES, parental educational levels) but that their language skills, the dependent variable, be allowed to vary
freely. In addition, the practice of recruiting CWS from SLP
caseloads or speech-language-hearing clinics should be
avoided. Rather, to minimize bias, the participants in both
groups should be drawn from larger populations of children.
For example, if CWS are drawn from community clinics but
CWNS are drawn from university-area schools or centers,
it is likely that the stuttering group will perform below the
nonstuttering group on language measures because of differences in parental educational levels, not necessarily because of stuttering (also see Watkins & Johnson, 2004).
Taking the time to recruit and match the groups appropriately
will eliminate this confound. It is critical also that large
numbers of children participate in future research in order to
obtain diverse and representative samples of CWS. Largescale epidemiological studies that recruit participants from
the larger population using stratified sampling techniques
(e.g., see Tomblin et al., 1997) could be informative. In addition, because older children with a chronic stuttering problem may present a different profile from younger children
whose stuttering may be transient (Yairi, 1999), studies that
examine children near the onset of stuttering and track their
language development longitudinally into the school years
may be helpful in future efforts to clarify the relationship
between stuttering and language ability. Finally, consideration should be given to the tasks used to examine language
ability. For example, tasks that place additional demands on a
child with an unstable speech motor system or a tendency to
avoid saying feared words should not be used. Additionally,
if the goal of a study is to examine language ability, then
tasks that require the repetition of multisyllabic words or
the naming of pictured objects also should be avoided.
A new perspective. Considerable time and energy has
been devoted to attempts to demonstrate a link between
stuttering and language ability in children. Despite these
efforts over many decades, the evidence that has been generated to support such a link is not convincing. Perhaps it is
time for a change in perspective. The fact that stuttering
typically begins in early childhood when spoken language
skills are first being acquired has led to the belief that the two
domains somehow must be linked, and that the struggle to
call up words and grammatical structures overloads the
childs immature language system, leading to the onset of
stuttering. In particular, it has been reported that stuttering
often is first noticed when children begin to produce 2- and
3-word utterances (Reilly et al., 2009), a time when syntax
is emerging (Bloodstein, 2006; Owens, 2012). The overlap
in timing between stuttering onset and the emergence of

syntax is not being questioned, nor is the association between frequency of stutters and utterance length and complexity. Rather, the point is that these factors alone do not
provide logical evidence of a link between stuttering and
language ability, and studies that have addressed the proposed
link do not provide empirical evidence of it.
An alternative perspective is to regard stuttering as a
speech disorder involving a motor control deficit, and not a
language disorder as Bloodstein (2006) had argued. In describing developmental stuttering, Olander, Smith, and
Zelaznik (2010) explained that during the disfluencies that
characterize stuttering, the speech motor system fails to
generate and /or send the motor commands to muscles that
are necessary for fluent speech to continue (p. 876). Similarly, as argued by Packman et al. (2007), developmental
stuttering is a problem in syllable initiation in which the
child is unable to move forward in speech because the speech
planning system is compromised. Further, they explained
that this difficulty is first noticed when the child attempts
to produce multisyllabic utterances requiring complex
sequential movements and varied linguistic stress patterns
across syllables to communicate the intended meaning.
According to Packman et al., children do not stutter when
babbling or producing first words (Bloodstein, 2006) because
these additional speech motor demands are not yet present.
In closing, this article has explained why it is reasonable
to question the view that stuttering and language ability are
linked. As with any long-running debate, this effort will
likely generate many passionate discussions among readers.
It is therefore hoped that this response will prompt new ideas
for studies that will continue to expand the knowledge
base in stuttering.

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196 American Journal of Speech-Language Pathology Vol. 21 183196 August 2012

Stuttering and Language Ability in Children: Questioning the Connection


Marilyn A. Nippold
Am J Speech Lang Pathol 2012;21;183-196; originally published online Mar 21,
2012;
DOI: 10.1044/1058-0360(2012/11-0078)
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