Lifestyle profile of school-aged children suffering from pathological stuttering

Background Stuttering is a speech disorder that involves intraphonemic disruption, part-word repetitions, monosyllabic whole-word repetitions, prolongation, and silent fixations (blocks). Objective The aim of the study was to investigate the lifestyle profile of children suffering from pathological stuttering and identify the factors that worsen or improve the condition of the child with pathological stuttering. Participants and methods The study sample consisted of 60 children suffering from pathological stuttering as well as their mothers or caregivers who attended the previous setting. Data were collected using two tools. The first tool was a structured questionnaire that included biosocial characteristics of the children and biosocial data of mothers. The second tool was an observation checklist developed by the researcher to observe children suffering from pathological stuttering as well as their mothers during speech therapy. Results It was found that 63.3% of children with stuttering were of a mean age of 8.17 ± 1.66 years. Significant difference was found between the mean age of stuttering children and their socialization skills. Significant difference was found between the mean age of stuttering children and response to treatment. Conclusion From the present study it can be concluded that pathological stuttering as a disease is easy to diagnose, difficult to treat, and has many negative impacts on the physical, psychological, social, and spiritual aspect of the child.


Introduction
Stuttering is a speech disorder in which there is disruption in the normal fl ow of speech. Disfl uency includes repetitions of a sound, syllable, or word, as well as silent blocks and prolongations. Certain behaviors such as eye blinks, facial twitches, and body movements may also accompany stuttering. Stuttering may become worse under stressful situations but may improve when speaking, reading aloud, or singing while alone. Stuttering is a communication disorder that begins in early childhood. When the disorder continues into later childhood and beyond, it may cause serious disturbances in both personal and professional pursuits [1].
Evidence from twin and family studies has clearly established a role for genetic factors in the development of stuttering. Seventy percent of the variance in stuttering could be attributed to additive genetic eff ects, and the remaining 30% to no shared environmental factors. Some examples of these factors include parental attitudes and expectations, the child's speech and language environment, and stressful life events. Th is does not imply wrongdoing on the part of parents. Often, these aspects are not harmful to a child who does not stutter, but can aggravate stuttering in a child who has a tendency to stutter. Finally, the child's fear and anxiety of stuttering can cause it to continue and even worsen [2,3].
Familial history of stuttering has been extensively documented, with an increased incidence of 15% in fi rst-degree relatives of probands, as compared with a 5% lifetime risk in the general population [4]. Th e onset of stuttering usually occurs in childhood, between the ages of 3 and 5 years; boys are three times more likely to suff er from stuttering than girls. Developmental stuttering most often occurs in children during the age at which they are developing their language and speech skills [5].
Acquired stuttering occurs in individuals who were previously fl uent. In such cases the onset of speech disorder is not gradual; disfl uency occurs rather abruptly, as it may be neurogenic or psychogenic. Neurogenic stuttering is caused by problems in signaling between Lifestyle pro le of school-aged children suffering from pathological stuttering Rahma S. Bhgat a , Mohamed E. Darweesh b , Mervat A. Ahmed a

Background
Stuttering is a speech disorder that involves intraphonemic disruption, part-word repetitions, monosyllabic whole-word repetitions, prolongation, and silent xations (blocks).

Objective
The aim of the study was to investigate the lifestyle pro le of children suffering from pathological stuttering and identify the factors that worsen or improve the condition of the child with pathological stuttering.

Participants and methods
The study sample consisted of 60 children suffering from pathological stuttering as well as their mothers or caregivers who attended the previous setting. Data were collected using two tools. The rst tool was a structured questionnaire that included biosocial characteristics of the children and biosocial data of mothers. The second tool was an observation checklist developed by the researcher to observe children suffering from pathological stuttering as well as their mothers during speech therapy. the brain and the various muscles and nerves used in generating speech. Psychogenic stuttering tends to occur after a trauma or period of extreme stress, or in individuals suff ering from mental illness [6].
Th e cause of stuttering is unknown; there are three leading theories that propose how stuttering develops. Th e learning theory proposes that it is a learned behavior and that most normal children are occasionally disfl uent. Th e second theory suggests that stuttering is a psychological problem that has an underlying problem that can be treated with psychotherapy. Th e third theory proposes that the cause of stuttering is organic and that neurological diff erences exist between the brains of those who stutter and those who do not [7].
Th e mother plays an important role in the care of stuttering children, which helps in improving the quality of life and facilitates the child's and family's adaptation to this illness. It is very important for the mother to study the lifestyle of stuttering children for eff ective accomplishment of her role [8]. She should help the child live a satisfactory life and be a productive member in the society [9].
Th e objective of this work was to study the lifestyle profi le of children suff ering from pathological stuttering and identify the factors that worsen or improve the condition of the child with pathological stuttering. Th ese data will have considerable importance when assessing the treatment strategies for this disorder.

Participants
Th is study was conducted in the Unit of Phoniatrics, ENT Department, Tanta University Hospital. Th e study sample was composed of 60 schoolaged children: 30 were suff ering from pathological stuttering and 30 were normal controls. Th eir mothers or caregivers who attended the previous setting were also included in the study. Th e duration of the study was 12 months. Children were of both sexes and their ages ranged from 6 to 15 years. Th ey were free of other speech-related disorders and were undergoing speech therapy. Th e children with mild stuttering had been receiving therapy sessions for 2 months, and those with moderate and severe stuttering had been receiving therapy sessions for 3 months at least.

Administrative process
(1) Children and their mothers were selected by means of a simple random method based on a review of the literature.
(2) Th e consent of children and their mothers was obtained before enrolling them in this study.

Development of study tools
Two tools were designed and used in this study: a questionnaire and an observation checklist.

Tools of data collection
Tool I: A structured questionnaire was developed to obtain the following information: (1) Biosocial data of stuttering children, such as: Tool II: An observation checklist to observe school-aged children suffering from pathological stuttering and their mothers during speech therapy (Appendix).

The actual study
(1) Children and their mothers/caregivers were interviewed using a questionnaire in the outpatient speech therapy program to assess their knowledge. Every child and his or her mother or caregiver were interviewed for 20-30 min. (2) Th e researcher observed children and their mothers/caregivers while undergoing speech therapy with regard to the following: (a) Speech production of school-aged children, such as: (i) Frequency of occurrence (always, sometimes, never) and duration (stuttering less than normal speech, equal to normal speech, more than normal speech) and consistency of stuttering (always, sometimes, never).
(ii) Intraphontric disturbance as repetition of fi rst sound of word or the word or the whole sentence (always, sometimes, never). (iii) Presence of any other speech disorder and symptoms during therapy. (b) Language skills: Th e following information was evaluated: (i) Syntactic skills: Th e child has diffi culty to remember and to use relevant terms. Th e child has diffi culty making word associations or comparisons. (ii) Social pragmatic skills: Th e child is cooperative and attentive. Th e child uses poor eye contact. Th e child has diffi culty using language for communicative purposes.

Statistical analysis
Th e collected data were organized, tabulated, and statistically analyzed using SPSS (version 19; SPSS Inc., Chicago, Illinois, USA) software. Numerical variables were presented as mean and SD. Th e Student t-test was used for categorical variables. Th e number and percentage distribution was calculated and the diff erence was tested using the Monte Carlo exact test. Spearman's correlation was used to test the association between stuttering and total socialization score. Th e level of signifi cance was fi xed at P value less than 0.05.

Results
Th e results of the current study are divided into three main parts as follows: (1) Part 1: Biosocial characteristics of stuttering children and their mothers/caregivers.   that about 55% of children with stuttering suff er from delayed language development. Table 3 shows the percentage distribution of mothers/ caregivers of stuttering children according to their biosocial characteristics (age in years, educational level, occupation, family size, accommodation, and family residence). It is clear that more than half of the sample were housewives, had 3-4 family members, and lived in urban areas. Table 4 shows the percentage distribution of stuttering children according to family history. A positive family history for stuttering was found in 25% of the sample. Table 5 shows the correlation between percentage of stuttering children according to psychological state and age during speech session. It is clear that about half of the sample suff ered from anxiety levels and a signifi cant diff erence was observed between children's age and response to speech therapy (P = 0.017). Table 6 shows the percentage distribution of study participants on the basis of frequency of stuttering and severity of stuttering (moderate, mild, or severe). Th ree-quarters of the sample had a very slow or very fast speech rate; any other additional behavior when speaking was recorded. Table 7 reveals the percentage distribution of stuttering children in terms of social relations and communication.
More than half of the sample had friendly relations and participated in school activities. Table 8 reveals the percentage distribution of stuttering children according to communication skills, diffi culty in remembering, and speech content: slightly more than half of the sample had limitations in these aspects.
Half of the sample used immature vocabulary.    signifi cant eff ect on children being cooperative with others and their interaction with doctors (P = 0.983).

Discussion
Stuttering is one of the most controversial diseases. It has several defi nitions and several theories in terms of etiology. Th e line of treatment also diff ers greatly and produces variable degrees of improvement. Th e aim of treatment is not only to reduce dysfl uency but also to replace stuttering with natural speech production with a normal rate. Th e lifestyle profi le can be generally divided into survival skills, health-maintenance skills, and health-promoting skills [5].
Th is study aimed to investigate the lifestyle profi le of children suff ering from pathological stuttering and identify the factors that worsen or improve the condition of the child with pathological stuttering. Th e study was conducted at a speech therapy session covering a period of 5 months. A convenient sample of 60 children with pathological stuttering and their mothers/caregivers were recruited into the study. Th e children were aged 6-15 years and were undergoing speech therapy.
Two tools were used to collect the necessary data. Th e fi rst tool was a structured questionnaire that included biosocial characteristic of the children, such as age, sex, birth order, educational level, and development history, and biosocial data of the mothers, such as age, educational level, occupation, family size, number of siblings, and family history of stuttering. Th is tool assessed the three main categories of health-promoting lifestyle: survival skills, health-maintenance skills, and health-promoting skills.
Th e second tool was an observation checklist developed by the researcher to observe children suff ering from pathological stuttering as well as their mothers during speech therapy. It covered speech production of children with stuttering, communication skills, vocalization, and social pragmatics.
As regards age, the present study showed that the number of children with stuttering was inversely proportional to age. Th e mean age of the children was 8.17 ± 1.66 years, and of them 63.3% were between 6 and 8 years old. Th is fi nding is in agreement with that of Craig et al. [10], who found the highest prevalence rate of 1.40-1.44% in young children and the lowest rate of 0.53% in adolescents [10,11].  Th e male to female ratio in this study was 65%:35%. Th is result is in agreement with that of Mansson [12], who found a boy to girl ratio of 1.65:1%. Boys generally have more speech disorders because girls begin to speak earlier than boys and they have better speech and language skills, especially for social purposes [12,13].
As regards family history of stuttering, the present study revealed a positive history of stuttering among 25% of children. Th is explains the importance of counseling for prevention, especially in case of positive family history. Th is fi nding is in agreement with a study by Andrews and Harries [14], who found that 25-60% of stutterers had relatives who stuttered.
As regards developmental milestones in stuttering children, this study showed that 51.7% of children started recognizing family members at 6 months of age and 36.7% recognized at 8 months. Th is result is in agreement with the diff erentiation phase described by Mahler [15], who reported that the infant identifi es characteristics that diff erentiate his mother from self and from others at age 6-10 months [15].
However, more than a quarter of the sample spoke their fi rst sentence at 18, 20, and 24 months. Th is result is in agreement with Piaget's theory; he stated that the child forms his fi rst sentence at 2 years [16].
Th e results of the present study revealed that 55% of stuttering children have a history of delayed language development. Th is is in agreement with the observation of Peters and Guitar [17] who found that stuttering children were associated with concomitant problems like delayed language development.
With regard to the psychological state of children during speech sessions, more than half of the sample had anxiety, about 30% had anger-related issues, and nearly 5% of the sample had avoidance issues. Information on speech therapy and psychological assessment (anxiety, anger, and fear) is necessary to help those children understand the nature of their problems, method of therapy, and treatment details of stuttering. Th is may help reduce dysfl uency, replace stuttering with natural speech production having a normal rate, and improve communication and social adjustment, resulting in increased self-confi dence, as much as possible [12]. Th ere was signifi cant diff erence between child age and educational level and child response to treatment (P = 0.017 and 0.05, respectively). Young children and those with primary education responded better to speech therapy because they were still unaware about their problem.
Th e present study showed that the majority of the sample had a speech rate that was too slow or too fast. Th is result is in agreement with that of Dell [11], who found that stuttering was associated with speaking very rapidly. Th e majority of the sample had intraphonemic disruption (pathological stuttering), which needed speech therapy, whereas repetition of syllables and words (physiological stuttering) occurred in 25% and needed counseling only. Our fi nding is in agreement with that of Yairi and Ambrose [18], who found frequent repetition of sounds and syllables. Th is is useful in distinguishing between fl uent and dysfl uent speech.
In the present study more than three-quarters of children preferred to communicate with others, as shown previously by Bijleved [19]. Only 51.7% of the sample was participating in diff erent school activities; the remaining 48.3% did not like participating or they were not allowed to participate. Th is result may be attributed to the child's fear of occurrence of any problem that may trigger stuttering. School age and adolescence are periods of social interaction, development of relations, and development of selfidentity. Stuttering negatively aff ects the relation of the child with family, peers, and colleagues. Participation in school activities helps develop and promote the child's physical, social, and behavioral skills [10,12]. Th ere was a statistically signifi cant correlation between mothers'/caregivers' age in years and the child's response to treatment. Also, a statistically signifi cant correlation was found between the child's age in years, educational level, and response to treatment (speech therapy session). Th e rest of the parameters concerning the children and their mothers/caregivers showed no signifi cant correlation.

Conclusion
On the basis of the result of this study it can be concluded that pathological stuttering as a disease can be easily diagnosed, is diffi cult to treat, and has many negative impacts on the physiological, psychological, social, and spiritual aspect of a child's life.
Stuttering is a controversial disease; it is unpredictable and stutterers are often interrupted. People suff ering from stuttering often have fi nancial problems, low selfesteem, and dependency. Furthermore, their stuttering decreases their social and scholar activity and leads to frustration.

Recommendations
(1) Th is study recommends searching for the root cause of stuttering to tailor therapy to each case accordingly.  (2) Simple booklets containing an explanation of the disorder, advice about communication with others, and methods to reduce stuttering severity are necessary for children undergoing maintenance speech therapy. It should be available at the speech therapy center. (3) Mothers/caregivers should make an effort to enhance the child's school achievements by cooperating with school authorities and speech centers in framing suitable schedules of speech sessions to prevent communication problems. (4) Mothers/caregivers should discuss with school personnel to create recreational activities and suitable hobbies for children who stutter. Th is can improve the psychological state of such children. (5) Mothers/caregivers should encourage the parents of children receiving maintenance speech therapy session to improve communication.