Interdisciplinary Consensus Guidelines on Stuttering (Childhood-Onset Fluency Disorder): Addressing Issues in Diagnosis, Treatment, and Unmet Needs

Childhood-onset fluency disorder, commonly referred to as stuttering, has long been poorly understood within clinical practice, viewed as a transient developmental phase or a behavioral speech disruption. Contemporary evidence increasingly challenges this perspective, supporting a neurobiological model involving disruptions in neural timing, sensorimotor integration, and speech motor control.

In a first-of-its-kind multidisciplinary panel convened by the Stuttering Treatment and Research Society (STARS), 94% of experts agreed: Stuttering is a brain-based neuropsychiatric disorder on par with conditions that psychiatrists treat every day. The panel's findings go further, identifying overlapping genetic risk with autism and depression and flagging a clinical complication that psychiatrists may not see coming: Common medications for attention-deficit/hyperactivity disorder (ADHD) and depression that increase dopamine activity may be quietly worsening stuttering symptoms in patients who have them.

What Is Stuttering?

According to DSM-5, stuttering is characterized by involuntary disruptions in speech fluency, including repetitions, prolongations, and speech blocks, often accompanied by secondary behaviors such as physical tension or avoidance strategies. A diagnosis is warranted when these disruptions significantly impair academic, occupational, and/or social functioning.

Stuttering typically develops between the ages of 2 and 7 years and affects approximately 5% of individuals at some point during development. Although 70% to 80% of individuals recover by adolescence, persistent stuttering affects approximately 1% of the adult population. Males are disproportionately affected, with a ratio of approximately 2:1 in childhood that increases to 4:1 in adulthood.^1-3

Emerging evidence supports a genetic contribution to stuttering, with a recent large-scale analysis identifying multiple genomic regions and associated genes. Notably, several implicated genes overlap with those associated with neurodevelopmental and psychiatric conditions, including autism and depression.⁴ Consistent with this, neuropsychiatric comorbidities (eg, ADHD, obsessive-compulsive disorder, social anxiety disorder, and tic disorders) are commonly observed and may complicate clinical presentation and management (Figure 1).⁵ Similarly, stuttering is also associated with insomnia, and individuals who stutter report worsening symptoms when they experience sleep disturbances. Research also reveals that stuttering is associated with brain iron deposition, potentially providing a path toward a diagnostic/treatment biomarker.⁶ Speech therapy has historically been a primary form of treatment utilized by individuals who stutter, at least at some point in their lifetimes. However, its use is limited by high relapse and poor long-term adherence. Early intervention with speech therapy in children may show the most benefit, but efficacy claims cannot be reliably replicated given the natural recovery of many children. As such, most third-party payers do not reimburse for speech therapy. Perhaps as a result of these limitations in achieving sustained efficacy, the speech therapy field now has a contingent focused not on treating stuttering per se but having the individual learn to live better by embracing the differences of their neurologic disorder. Thus, effective and reliable stuttering treatments remain a challenge.

FDA-approved pharmacologic treatments can be used to address stuttering but are off-label for this indication. Available evidence suggests that agents with dopamine-modulating or dopamine-blocking activity may reduce stuttering symptoms in some individuals. The use of these agents in stuttering has been limited by a lack of knowledge of stuttering by the medical community and complicated by potential tolerability concerns. Other medication classes, including selective serotonin reuptake inhibitors (SSRIs), may show benefit for social anxiety but have not been demonstrated to yield efficacy for core stuttering symptoms. Benzodiazepines have not been associated with consistent long-term efficacy and carry concerns of dependence and withdrawal. Importantly, some commonly prescribed psychiatric medications for disorders highly comorbid with stuttering, including stimulants for ADHD, may exacerbate stuttering in select cases.^5,7

Beyond pharmacology and speech therapy, neuromodulation research is positively developing. Transcranial magnetic stimulation holds promise. Given that stuttering is likely related to subcortical transmission, deep brain stimulation may yield more benefit, but its risks, in its current technology, are too great for general application.^5,7

Despite advances in understanding its neurobiological underpinnings, stuttering remains underrecognized within medical practice. Diagnostic frameworks are inconsistent, and care between medicine and speech pathology is not integrated. To address these gaps, STARS convened an international multidisciplinary panel to establish consensus priorities for clinical care and research.

Building a Foundation

An international multidisciplinary clinical advisory panel (N = 35) representing psychiatry, neurology, speech-language pathology, and persons who stutter themselves participated in a structured consensus process. Although the panel included representatives from across the globe (with all continents except Africa represented), the majority of participants (65.7%) were based in the United States. Approximately half of participants had more than 20 years of experience in stuttering-related work, and 48.5% reported moderate to extensive experience with multidisciplinary care approaches.

A premeeting survey assessed key domains, including diagnosis, treatment, unmet needs, and research priorities. Survey items included Likert-scale agreement statements as well as multiple-choice and open-ended responses.

Following completion of the survey, the advisory panel met in person for a 2-day structured meeting involving evidence review, moderated discussions, and breakout sessions. Consensus statements were developed through iterative discussion and voting.

The Consensus Statements

"Stuttering should be recognized by the broader medical community as a heterogeneous biological brain-based disorder."

Survey responses demonstrated strong consensus that stuttering should be conceptualized as a brain-based disorder, with 94% of respondents expressing the highest level of agreement. Most respondents (80%) identified stuttering as a disorder, whereas smaller proportions described it as a condition (37.1%) or a variant of diverse speaking (17.1%).

When classified within medical domains, stuttering was most frequently identified as neuropsychiatric (60%), followed by neurologic (34.3%), with minimal support for purely psychiatric classifications. Additionally, 91.4% of respondents agreed that stuttering is a heterogeneous disorder.

Although the etiology and risk factors for persistent stuttering need further attention, the panel agreed that there seems to be a genetic link, as evidenced by familial connections. A minority of cases seem to be linked to autoimmune origin consistent with disorders classified as pediatric autoimmune neurologic syndrome.

Together, these findings support a neurobiological framework characterized by clinical variability. The panel also emphasized the resulting need for individualized clinical frameworks rather than uniform approaches. Specifically, because stuttering has different causes and presentations, treatment approaches need to be individualized.

"A comprehensive approach is needed to diagnose childhood-onset fluency disorder, and physicians and other medical professionals are central to the process.”

Respondents endorsed a comprehensive diagnostic approach incorporating developmental history, speech measures, family history, and patient-reported outcomes alongside neurological and psychiatric evaluation. Despite agreement on these elements, substantial gaps were identified. A majority of the board (65.7%) disagreed that clear standards exist for defining stuttering severity. Additional limitations included the absence of validated biomarkers, lack of standardized subtyping systems, and limited ability to predict persistence vs recovery. Underrecognition of comorbidities and insufficient differentiation of clinical profiles were also noted.

"The current state of available and accessible treatments is limited as are the tools to appropriately assess treatment efficacy. Nonetheless, early intervention is crucial."

Despite the availability of multiple treatment modalities (eg, speech therapy, psychotherapy, pharmacologic interventions, and emerging neuromodulation techniques), the overall treatment landscape was widely perceived as inadequate, with nearly 90% rating it as fair or poor. According to the panel, speech therapy currently remains the cornerstone of care, with 91.4% endorsing its high historic use base and 88.6% recommending regular involvement of speech-language pathologists. Discussions also highlighted the need for better controlled trials of speech therapy, especially in regard to long-term maintenance of response. Approximately three-quarters of the panel also endorsed evidence for the integration of behavioral and off-label pharmacological approaches. There was less enthusiasm for neuromodulation and device-based treatment, with just under half of the panel (45.7%) affirming the evidence base, but consensus was for further exploration.

Among individuals who stutter, treatment experiences reflected these patterns. Speech therapy and psychotherapy (85% and 77%, respectively) were most commonly reported. Pharmacologic treatment was heterogeneous, with approximately half of the panel reporting use of dopamine receptor blocking agents. Benzodiazepines, SSRIs, and β-blockers were less frequently used among those on the panel who stutter (23%, 15%, and 15%, respectively). Neuromodulatory interventions were used less frequently overall, with transcranial direct current stimulation reported by approximately 15% of respondents and other modalities rarely used.

The advisory panel noted the clear need for effective and accessible treatment. Much like issues in diagnosis, the panel, particularly psychiatrists, neurologists, and individuals who stutter, noted that the lack of a validated tool to measure symptomology impedes treatment research and the development of clear guidelines for treating clinicians.

"Interdisciplinary care should be considered standard for individuals with stuttering, including relevant specialties of medicine, eg, family medicine, pediatrics, psychiatry, neurology, as well as other health care professions such as speech-language pathology and psychology."

More than 90% of respondents endorsed interdisciplinary care as the standard for persistent stuttering. Specifically, they noted that stuttering is best addressed in an interdisciplinary, collaborative environment involving health care professionals from medicine, speech-language pathology, and psychology.

Unfortunately, they also recognized barriers exist to ideal care, identifying limited access to trained providers, lack of awareness, and financial constraints as main issues. These findings highlight a gap between recommended care models and real-world implementation.

"Because stuttering can impact all aspects of life, assessment must go beyond fluency."

All respondents agreed that stuttering can affect multiple aspects of life. Outcomes such as verbal communication confidence, social participation, emotional well-being, and occupational functioning were identified as critical.

Importantly, the panel noted the misconception that stuttering is related to lower IQ. Unfortunately, this myth persists and results in negative consequences in educational and business settings, with individuals who stutter being overlooked for opportunities and treated unfairly as not intelligent. This also has tremendous impact on individuals’ overall well-being and success.

Significant barriers to care were identified, including lack of trained professionals, limited access, and insufficient long-term treatment options. Respondents also noted misalignment between current care models and patient needs, including overemphasis on fluency and insufficient attention to psychosocial factors.

"Additional formal education is needed for physicians and allied health care professionals."

There was near unanimous agreement on the need for expanded education among clinicians and allied health professionals (97.3% and 97.1%, respectively). Research priorities included neurobiological mechanisms, genetic contributions, biomarkers, and development of targeted pharmacologic and neuromodulatory treatments. Respondents also emphasized the importance of public education to reduce stigma. Importantly, 85.7% of respondents disagreed that individuals who stutter and their families have access to sufficient, high-quality information.

"Additional research is essential to improve diagnosis, assessment, and treatment."

Participants identified multiple areas requiring further investigation, including etiology, biomarkers, pharmacologic treatments, neuromodulation, and subtyping frameworks. The panel agreed that greater research is needed with double-blind, randomized, placebo/sham-controlled trials of stuttering treatment across various interventions, including psychotherapy, speech therapy, neuromodulation, and pharmacotherapy. Collectively, these priorities indicate a field moving toward a more mechanistically driven and precision-oriented model, with a focus on translating neurobiological insights into clinically actionable frameworks, improving diagnostic specificity, and enabling the development of targeted, individualized treatment strategies.

Moving the Consensus Road Map Forward

Despite an increasing understanding of the neurobiology of stuttering, the advisory panel concluded there are significant gaps in diagnosis, treatment, and clinician education. These challenges parallel those previously observed in other neuropsychiatric disorders (eg, ADHD and Tourette syndrome), and lessons can be learned from these examples.

The findings of this consensus effort highlight the need for a coordinated, interdisciplinary, and biologically informed approach to care (Figure 2). They determine that future priorities need to include development of standardized diagnostic frameworks, validated outcome measures, and accessible treatment pathways.

Beyond this consensus, the advisory panel committed to initiatives to further support individuals who stutter, their families, and their clinicians, including the development of resources for the following: educators, schools, and families negotiating the education system; employers (to ensure they understand the potential asset of individuals who stutter as well as how to address their unique needs); foundations and ideals for additional research, especially the development of assessment tools and pharmacological research; and fundamentals for setting up training programs in medical schools and allied health educational institutions.

Acknowledgments

The authors are grateful to medical residents Lorenzo Medina, MD; Sharmila Thiagarajan, MD; Dragos Turturica, MD; Yves-Smith Benjamin, MD; and individuals with lived experience. Their time, expertise, and lived perspectives enriched the development of this consensus statement. Special thanks to Ernie Canadeo for his encouragement and unwavering belief in this effort.

Dr Maguire is director of residency training and chair of psychiatry at College Medical Center in Long Beach, California; founder of STARS; and a member of the Psychiatric Times editorial board.

Dr SheikhBahaei is an Empire Innovation Program assistant professor of neurobiology at Stony Brook University, State University of New York.

Dr Kikuchi is assistant professor in the Department of Otorhinolaryngology–Head and Neck Surgery at Kyushu University Hospital in Fukuoka, Japan.

Dr LaSalle is professor at California State University, Monterey Bay in Seaside.

Dr Valente is chief medical officer at LifeStream Behavioral Center in Florida.

Dr Bohnen is president of the Brazilian Fluency Institute and an international expert on fluency disorders.

Dr Santos is pediatric neurologist at Hospital de Santa Maria in Lisbon, Portugal.

Mr Leal is cofounder and clinical director of Speechcare/iStutter (Portugal, Spain, United Arab Emirates).

Dr Binder is an associate professor in residence in the Department of Biomedical Sciences at the University of California, Riverside.

Dr Alva is the medical director of ATP Clinical Research in Costa Mesa, California, and the mood disorders section editor for Psychiatric Times.

Dr Mattingly is associate clinical professor of psychiatry at Washington University School of Medicine in St Louis and CEO of Midwest Research Group.

References

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