Original Contribution

Kitasato Med J 2020; 50: 123-129

Selection of screening items for stuttering: a preliminary study
Yuki Hara,1 Mari Higashikawa,1 Wakana Hata,1 Yuri Sasaki,1 Takeshi Murakami,1Yoko Mizuto,1 Yosuke Kita,2,3 Ikuyo Ishizaka1
1

Department of Rehabilitation, Kitasato University School of Allied Health Sciences
National Center of Neurology and Psychiatry, Tokyo
3
University of Helsinki, Helsinki, Finland
2

Objective: This study aimed to develop screening items that can identify stuttering, even by those whoare not familiar with stuttering (e.g., kindergarten teachers, nursery school teachers, and itinerant
counselors).
Methods: A total of 13 items to assess symptoms of disfluency with additional examples were created.
There were 4 nursery school teachers (NTs) and 1 speech-hearing-language therapist (ST) who observed
52 children (age range, 3−6 years-old) and checked the 13 items, classifying each child as: "Stuttering,""No stuttering," "May be stuttering," or "Don't know if it's stuttering, but I'm worried."
Results: There were 3 children identified to have a tendency to stutter. Comparing items marked by
the NTs and the ST, the 13 original items were merged into 3 items: "Multiple repetitions on the firstsound or part of a word," "First sound prolongation," and "Difficulty with saying first sounds of words
and requiring physical effort to speak, despite having something to say." For children rated as having≥2 items, using this scale we could identify children who stutter with a sensitivity of 100% andspecificity of 98%.
Key words: stuttering, screening, checklist, preschool children

recovery rate for school-age children than preschool
children.2,10
In Japan, there is a health checkup system for children
between 3 and 3.5 years old, for which the consultation
rate is close to 90%. Additionally, although relatively
few, there are currently some regions in Japan in which
5-year-old health checkups are conducted. The 3-yearold health checkups are likely the best time for parents,
because it might be as much as 6 months to 1 year after
the onset of stuttering when a mother has usually begun
to worry about her child's stuttering. Providing
appropriate information on stuttering during healthcheckups for children in this age range can provide
guidance and support for parents to help reassure themand about how to help their children.
Furthermore, there is an itinerant consultation system
in Japan. In early childhood development, specialists
regularly visit preschools to conduct observations andevaluations of children, as well as to provide services forchildren with disabilities. Additionally, they give advice

Introduction

S

tuttering, alalia syllabaris, the most common fluency
disorder, is an interruption in the flow of speaking
characterized by repetitions of sounds and syllables, soundprolongations, blocks, and may be accompanied byphysical tension, negative reactions, secondary behaviors,
and avoidance of sounds, words, or speaking situations.1
Moreover, stuttering has been found to have an incidence
rate of 5%−8%. 2-8 The symptoms of stuttering arevariable, and 70%−80% of the affected children havebeen found to recover naturally.7-9 Even when parents
worry about their child's stuttering, pediatricians andpreschool teachers tend to downplay the anxiety it causes
the parents. Therefore, parents might possibly continue
to be anxious if they do not receive any reliable
information and/or support. And many parents miss theopportunity to consult with speech-language-hearing
therapists (ST) concerning their child's speech disorder.
Furthermore, it is generally thought that there is a lower

Received 30 January 2020, accepted 7 February 2020
Correspondence to: Yuki Hara, Department of Rehabilitation, Kitasato University School of Allied Health Sciences
1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
E-mail: bara@kitasato-u.ac.jp123Hara Y. et al.

and guidance to preschool teachers when necessary. They
also observe children who have been identified as"anxious" by childcare personnel, give advice andguidance when necessary, and refer children to specialized
agencies as needed. This itinerant system seems toeffectively support children whose stuttering does notdisappear by the age of 4 or 5 years old. Based on these
health checkups and itinerant consultations, it was deemednecessary to develop a system to perform step-by-step
interventions at appropriate times for children who stutterthat would likely lower the number of cases that may be
missed or overlooked of children who might otherwise
benefit from proactive interventions.
To accomplish this, we created screening items thatwere simple enough to be applied by childcare personnel
and itinerate consultants who may not be specialists instuttering, so that they would accurately be able to assesschildren who stutter. First, it was mandatory to adequately
capture the core symptoms of stuttering to create such
screening items. The basic core symptoms of stuttering
include the repetition of sounds, syllables, and parts ofwords, sound prolongation, and blocking.11-13 Even nonstuttering children (i.e., those within the normal range ofdisfluency) sometimes repeat whole and parts of uttered
words. And it is common for some children to show
nonfluctuations similar to stuttering, such as inserting
unnecessary fillers, stopping in the middle of an utterance,or revising, which alone is not stuttering.12 However,even for childcare professionals, with various
opportunities to interact with children, there is scant
information provided to them in training courses about
stuttering. Thus, among childcare professionals,
relatively little is known about the symptoms ofstuttering.14,15 Therefore, we considered what kinds ofspeech features, behaviors, and symptoms childcare
professionals may determine to be stuttering, along withthe definitions of stuttering by the ST in the present study,
to create this screening instrument for children who may
be suspected of stuttering.
This preliminary survey was conducted as the firststep in the development of a set of screening items to be
used in combination with other pre-established items to
distinguish developmental disorders likely to inflictchildren from preschool age (e.g., learning disabilities,
developmental coordination disorders, and the tic
disorder). The objective of this survey was to create
screening items that could be used by childcare personnel
and itinerant consultants to more effectively andaccurately identify children who stutter. The long-termgoal therefore is for them to be able to accurately
determine children who stutter or who may manifest otherspeech-related anxiety symptoms in order to provide suchchildren with referrals to qualified professionals wheneverdeemed necessary.

Materials and Methods
Developing a checklist for stuttering behavior
The symptoms of stuttering and the nonfluency symptoms
exhibited by children were listed in expressions that would
be easy for the general public to understand, and 13 itemsof disfluency symptoms with additional examples werecreated (Table 1). An evaluation was conducted regarding
the presence or absence of these 13 items. These items
were created based on the classification of disfluenciesof the Standard Test for Stuttering including somevariation items about the position and number ofrepetitions.12 Based on the results of these 13 items,

Table 1. Items used to assess dysfluency
No.
1
2
3
4
5
6
7
8
9
10
11
12
13

Description

Example in Japanese (in English )Initial syllable repetition only once
Initial syllable repetition many times
Final syllable repetition many times
Part of word repetition only once
Part of word repetition many times
Whole word repetition many times
Prolongation
Using interjections many times
The first word does not come out
Speaking with facial grimace
Speaking with body movement
Speaking with force and energy
Stop talking in the middle of a sentence or word124

bo boku-ga (a I am)bo bo bo boku-ga (a a a I am)
boku-ga ga ga ga (I am am am)oka okaasan-ga (mom mommy)
oka oka okaasan-ga (mom mom mommy)
boku-ga boku-ga boku-ga (I am I am I am)booooooooku-ga (I- - - - - - -)e-to, ano- (well, uh- - -)・・・boku-ga (- - - - - I am)Screening items for stuttering

items were selected and integrated to a smaller numberof new screening items so that they could be implemented
more easily.

Results
Children who stutter
The NTs classified 45 of 52 children as, "No stuttering,"
all of whom were also confirmed as, "No stuttering," by
the ST. The ST confirmed 3 children who stuttered, andthe NTs rated 4 children as, "Stuttering." Among all thechildren, there was 1 child classified as, "May be
stuttering" by an NT who was classified as, "No stuttering"by the ST. The NTs rated 2 children as, "Don't know if
it's stuttering, but I'm worried," for whom the ST classified
as, "No stuttering." Finally, there was 1 child who wasclassified as, "Stuttering" by an NT but as, "No stuttering"by the ST (Table 2).

Participants
Data were gathered from 52 children (26 girls, 26 boys;
aged 3−6 years: 14, 3-year-olds; 15, 4-year-olds; 13, 5year-olds; and 10, 6-year-olds). The evaluators were 4
nursery school teachers (NTs) and 1 ST. Each of the 4
NTs were in charge of their own class and therefore
knew each child in their class very well. Three NTs had
less than 5 years of childcare experience, and the other
NT had 20 years of experience. None of the NTs had
however learned anything about stuttering in their own
initial training courses. They stated that they knew
relatively little about stuttering except that it meant torepeat words or sounds of words. On the other hand, theST in the present study had more than 30 years ofexperience dealing with children who stutter.

The stuttering and disfluency symptoms
Of 52 children, 45 were classified as, "No stuttering" by
the NTs and the ST. For those 45 children, none of theevaluators selected any items of stuttering or disfluency.
Table 3 shows how the symptoms of stuttering anddisfluency were marked for 7 children (labeled A−G)
who were evaluated as, "No stuttering" by the NTs. NTs
evaluated 4 children as, "Stuttering." Child A was marked
as having, "Initial syllable multiple repetitions" (ItemNo. 2 in Table 1), "Prolongation" (Item 7), and "Speaking
with a facial grimace" (Item 10). Children B and C wereboth marked as having, "Initial syllable multiple
repetitions" (Item 2), "Blocking" (Item 9), and "Speaking
with a facial grimace" (Item 10). Child B also had, "Partof word multiple repetitions" (Item 5) marked, and ChildC was had, "Stop talking" (Item 13) marked. Child D
was marked as having, "Initial syllable multiple
repetitions" (Item 2), "Prolongation" (Item 7), "Blocking"(Item 9), and "Speaking with force and energy" (Item12). The NTs marked 3−5 symptoms, and the ST
confirmed 5−10 symptoms. The ST marked Items 1
and 4 (e.g., initial syllable and part of words repeated
only once), whereas the NTs did not mark those items.
One NT stated that Child C had shown these obvious
symptoms for 3 months, starting from 6 months ago, butthat they had not manifested for the last 3 months. That

Procedure
The evaluators checked each child regarding all of these13 items and Hayashi's Quantification Method II(QMII).16 NTs evaluated the children during their normal
daily school life, and the ST observed and talked with all
the children for 3 days during their school activities (e.g.,
playing, eating lunch, etc.). They not only checked all
the items but also classified all the children as, "No
stuttering," "Stuttering," "May be stuttering," or "Don't
know if it's stuttering, but I'm worried." In addition, except
for the children classified as, "No stuttering," the ST
conducted the Standard Test for Stuttering with eachchild in a quiet room in the nursery school. Utterances ofat least 100 words were recorded using an PCM-D100
recorder, Sony. Regarding the duration of the symptoms,
the NTs reported the period in months that the symptoms
were observed in the nursery school.
This research was approved by the Kitasato University
School of Allied Health Sciences Ethics Committee (No.
2016-032).

Table 2. Children's speech evaluations (N = 52)
Children evaluated bynursery school teachers

Children evaluated bya speech therapist

45
4
1
2

49
3
0
0

No stuttering
Stuttering
May be stuttering
Don't know if it is stuttering, but I'm worried.
125

Hara Y. et al.

NT was impressed by that child, remembering his speechdifficulties, and therefore evaluated him as, "Stuttering."
However, at the time of the ST's observation, none ofthese symptoms were present in Child C; therefore, theST evaluated Child C as, "No stuttering." Furthermore,for 3 children (E−G) who were evaluated as, "No
stuttering" by the ST, the NTs had marked 1 item only
for each of them. Child E was evaluated as, "Part ofword multiple repetitions" (Item 5), for whom an NT
marked, "May be stuttering." Regarding Children F andG, who were evaluated by an NT as, "Don't know if it's
stuttering, but I'm worried," that NT marked,"Interjections" or "The first sound does not come out."
Noteworthy, only Child F was found to havenasopharyngeal articulation (Data not shown).

possibility of it being a temporary condition).

Discussion
These NTs had no experience learning about stuttering
during their initial childcare training; therefore, at the
beginning of the present study, it was difficult to explain
what symptoms may manifest as stuttering. By showing
the items to be examined, the core symptoms of stuttering,"repetition," "prolongation," and "blocking" could be
accurately evaluated. When 2 or more symptoms
presented with tension symptoms, it was evaluated as
stuttering. The ST confirmed "Repeated once" of allchildren evaluated as stuttering, but none of the NTs
marked "Repeated once." It was considered that they did
not worry so much about only one repetition, so they did
not notice it in the children's daily conversations, or they
did not consider "only one repetition" to indicate
stuttering. In point of truth, it is appropriate to consider
multiple repetitions as stuttering; however, one repetition

Selection and development of the screening items
Based on the results of these 13 items, we selected theitems that the NTs could also recognize in 3 children
evaluated as stuttering by the ST. Three simplified
grouped items were formed by making more easily
understood appropriate sentences from the 13 originalitems: (Group item 1, Items 2 and 4 combined) multiple
repetitions on the first sound or part of a word (e.g., "bo bo
bo boku" [means, "a a a I" in English], "o ok oka okaasan"[means, "m mo mom mommy" in English]); (Group item
2, Item 7) first sound prolongation (e.g., "bo-------ku"[means, "a----------I" in English]); (Group item 3, Items
9−12 combined) "difficulty uttering the first sound andrequiring a physical effort to speak, despite having
something to say, sometimes with a facial grimace." Thus,
the results of these 13 items were combined into these 3
groups. To confirm these, we used the QMII16,17 to
examine the distinguishing ability to identify children
who stutter using these 3 groups. Analysis using the QMII
were accurate to distinguish the children who stutteredfrom their non-stuttering peers (correlation ratio η =0.778, correct classification rate = 98.1%).16,17 While
Group item 2 strongly contributed to the distinguishingability of the screening items (-2.783), Group items 1
and 3 had a mild distinguishing ability (-0.885). Thus, we
could successfully identify the children if they werepositive for 2 or more of 3 group items, which yielded
the high sensitivity and specificity of 100% and 98.0%,
respectively (Figure 1).
Furthermore, it is important to note that some of thechildren's stuttering was severe but had a short duration,
as in the case of Child C. Therefore, referencing thegroup items 1−3, we added a special category,"Symptoms continue for longer than 1 year even if
fluctuation was observed," (Data not shown due to theTable 3. Comparison of the 13 items evaluated by nurseryschool teachers (NTs) and a speech-hearing-language therapist (ST)Child (age: years/months)
GenderDuration of symptoms in nursery school (months)
Evaluator
No.
1
2
3
4
5
6
7
8
9
10
11
12
13

Evaluation
Items
Initial syllable repetition only once
Initial syllable repetition many times
Final syllable repetition many times
Part of word repetition only once
Part of word repetition many times
Whole word repetition many times
Prolongation
Using interjections many times
The first word does not come out
Speaking with facial grimace
Speaking with body movement
Speaking with force and energy
Stop talking in the middle of a sentence or word
Total

*NT1−3 indicates a different evaluator.
S, Stuttering; NS, No Stuttering; MS, May be stuttering;DS, Don't know if it is stuttering, but I'm worried.
126

Screening items for stuttering

Figure 1. Weighted scores determined by Quantification Method II
Negative values indicate the contribution to the distinguishing of children who stutter.
Group item 1: Multiple repetitions on the first sound or part of a word
Group item 2: First sound prolongation
Group item 3: Difficulty uttering the first sound of words and requiring physical effort to speak,despite having something to say, sometimes with a facial grimace

A (3/08)

B (4/00)

C (4/11)D (4/04)

E (5/06)

F (3/09)

G (3/07)

Female

Male

Male

Male

Male

Male

Female

20

>12

3

18

12

12

12

NT1

ST

NT2

ST

NT2

ST

NT2

ST

NT3

ST

NT1

ST

NT1

ST

S

S

S

S

S

NS

S

S

MS

NS

DS

NS

DS

NS

＊

＊
＊

＊

＊
＊

＊

＊

＊
＊

＊
＊
＊

＊

＊
＊
＊
＊

＊
＊

＊
＊
＊
＊
＊
＊
＊
＊

＊
＊
＊
＊
＊

＊
＊

＊
＊
＊

＊
＊

＊
＊

3

7

4

10

5

0

5

5

1

127

0

1

0

1

0

Hara Y. et al.

is also seen in children who do not stutter, so that it may
not be considered as stuttering.
The expression, "The first word does not come out"
was difficult to determine whether or not it was dur to thechild being poor at word recall, a thinking difficulty, ormutism; therefore, it was necessary to change theexpression. "Difficulty with uttering first words andrequiring physical effort to speak, despite having
something to say, sometimes with a facial grimace"
although a bit long, was determined to help avoid
evaluating children as stuttering who are not actually
stuttering. For the purposes of the present study, it wasthought that by carefully selecting three simple
expressions as items that could adequately reveal core
symptoms, that it would be easier and more accurate touse those for the actual screening. In addition, stuttering
repeatedly fluctuates and changes in its manifestations;
therefore, it is necessary to check whether or not thesymptoms are only manifested for a short period of time.

children with speech difficulties and especially those who
stutter. Awareness of the kinds of support necessary forchildren who stutter and how to give them that support
remain important issues for future studies.

Acknowledgments
We thank Inagaki Masumi, MD, PhD, of the National
Center of Neurology, for his support. This work wasalso supported by JSPS KAKENHI (No. JP1717001B).
Conflicts of Interest: None

References
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Accessed January 10, 2020.
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Limitations and Conclusions
This preliminary study aimed to develop items that could
accurately identify children who stutter at the ages of 5
or 6 years old. Children at around the age 5 years old orolder often become aware of any differences in their own
speech as compared with that of their mother, father,siblings, or friends. On the other hand, if professionals(e.g., NTs and/or STs) notice multiple items regardingchildren's speech that may be deviant from the norm,
they can pay extra careful attention to those children andmay be able to address these concerns and suggest
professional treatment before the children enter
elementary school. One limitation of this study was thesmall sample size. Further evaluations of larger
populations using this screening scale with various cases
including more cases of actual stuttering are warranted
to clarify the validity of this present study. It will also benecessary to identify more issues using such screening
items to better determine a child's speech difficulties
including disfluency and stuttering.
Nursery school and kindergarten teachers are key
persons who are with a child for extended periods oftime, can listen to their utterances in various situations,are aware of any of the child's speech difficulties, andcan take the appropriate action to help them. The
screening items in the present study will enable teachers
to distinguish children who stutter and thereby provide
opportunities to give them the necessary support theyneed. In the course of this study, it became surprisingly
evident that most nursery school and kindergarten
teachers know relatively little regarding how to support
128

Screening items for stuttering

12. Ozawa E, Hara Y, Suzuki N, et al. Standardized test
for stuttering. Tokyo: Gakuensha; 2013 (inJapanese).
13. Van Riper C. The nature of stuttering, 2nd edition.
Long Grove, IL: Waveland Press, Inc.; 1982.
14. Kubo M, Kikuchi Y. A research study on mothers
and preschool teachers of children who stutter. Jpn
J Commun Disord 2018; 35: 80-4 (in Japanese).

15. Hara Y, Inagaki M. Study on development and spreadof assessment tools for early extraction ofcharacteristics of developmental disorders that are
difficult to manifest. KAKEN report 2017 (inJapanese).
16. Hayashi C. Multidimensional quantification withthe applications to analysis of social phenomena. Ann
Inst Stat Math 1953; 5: 121-43.
17. Tanaka Y. Review of the methods of quantification.
Environ Health Perspect 1979; 32: 113-23.

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