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developmental pattern, which is reflected in the age norms of standardized tests. It is not unusual for typically developing children to use developmental processes for shortening words and syllables as they are learning to talk, but their progression in mastering speech sound production should result in mostly inteUigible speech by age 3 years. Children with speech sound disorder continue to use immature phonological simplification processes past the age when most children can produce words clearly.

Most speech sounds should be produced clearly and most words should be pronounced accurately according to age and community norms by age 7 years. The most frequently mis- articulated sounds also tend to be learned later, leading them to be called the ''late eight" (/, r, s, z, th, ch, dzh, and zh). Misarticulation of any of these sounds by itself could be considered within normal limits up to age 8 years. When multiple sounds are involved, it may be appro­ priate to target some of those sounds as part of a plan to improve intelligibility prior to the age at which almost all children can produce them accurately. Lisping (i.e., misarticulating sibi­ lants) is particularly common and may involve frontal or lateral patterns of airstream direc­ tion. It may be associated with an abnormal tongue-thrust swallowing pattern.

Most children with speech sound disorder respond well to treatment, and speech dif­ ficulties improve over time, and thus the disorder may not be lifelong. However, when a language disorder is also present, the speech disorder has a poorer prognosis and may be associated with specific learning disorders.

Differential Diagnosis Normal variations in speech. Regional, social, or cultural/ethnic variations of speech should be considered before making the diagnosis.

Hearing or other sensory impairment. Hearing impairment or deafness may result in abnormalities of speech. Deficits of speech sound production may be associated with a hearing impairment, other sensory deficit, or a speech-motor deficit. When speech deficits are in excess of those usually associated with these problems, a diagnosis of speech sound disorder may be made.

Structural deficits. Speech impairment may be due to structural deficits (e.g., cleft palate). Dysarthria. Speech impairment may be attributable to a motor disorder, such as cerebral palsy. Neurological signs, as well as distinctive features of voice, differentiate dysarthria from speech sound disorder, although in young children (under 3 years) differentiation may be difficult, particularly when there is no or minimal general body motor involve­ ment (as in, e.g., Worster-Drought syndrome).

Selective mutism. Limited use of speech may be a sign of selective mutism, an anxiety disorder that is characterized by a lack of speech in one or more contexts or settings. Se­ lective mutism may develop in children with a speech disorder because of embarassment about their impairments, but many children with selective mutism exhibit normal speech in "safe" settings, such as at home or with close friends.

Childhood-Onset Fluency Disorder (Stuttering) Diagnostic Criteria 315.35 (F80.81)

A. Disturbances in the normal fluency and time patterning of speech that are inappropri­ ate for the individual’s age and language skills, persist over time, and are characterized by frequent and marked occurrences of one (or more) of the following: 1. Sound and syllable repetitions. 2. Sound prolongations of consonants as well as vowels.

3. Broken words (e.g., pauses within a word). 4. Audible or silent blocking (filled or unfilled pauses in speech). 5. Circumlocutions (word substitutions to avoid problematic words). 6. Words produced with an excess of physical tension. 7. Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”).

B. The disturbance causes anxiety about speaking or limitations in effective communica­ tion, social participation, or academic or occupational performance, individually or in any combination.

C. The onset of symptoms is in the early developmental period. (Note: Later-onset cases are diagnosed as 307.0 [F98.5] adult-onset fluency disorder.)

D. The disturbance is not attributable to a speech-motor or sensory deficit, dysfluency as­ sociated with neurological insult (e.g., stroke, tumor, trauma), or another medical con­ dition and is not better explained by another mental disorder.

Diagnostic Features The essential feature of childhood-onset fluency disorder (stuttering) is a disturbance in the normal fluency and time patterning of speech that is inappropriate for the individual's age. This disturbance is characterized by frequent repetitions or prolongations of sounds or syllables and by other types of speech dysfluencies, including broken words (e.g., pauses within a word), audible or silent b lo cl^ g (i.e., filled or unfilled pauses in speech), circumlocutions (i.e., word substitutions to avoid problematic words), words produced with an excess of physical tension, and monosyllabic whole-word repetitions (e.g., 'T-I-I-I see him"). The disturbance in fluency interferes with academic or occupational achieve­ ment or with social communication. The extent of the disturbance varies from situation to situation and often is more severe when there is special pressure to communicate (e.g., giv­ ing a report at school, interviewing for a job). Dysfluency is often absent during oral read­ ing, singing, or talking to inanimate objects or to pets.

Associated Features Supporting Diagnosis Fearful anticipation of the problem may develop. The speaker may attempt to avoid dys­ fluencies by linguistic mechanisms (e.g., altering the rate of speech, avoiding certain words or sounds) or by avoiding certain speech situations, such as telephoning or public speaking. In addition to being features of the condition, stress and anxiety have been shown to exacerbate dysfluency.

Childhood-onset fluency disorder may also be accompanied by motor movements (e.g., eye blinks, tics, tremors of the lips or face, jerking of the head, breathing movements, fist clenching). Children with fluency disorder show a range of language abilities, and the relationship between fluency disorder and language abilities is unclear.

Deveiopment and Course Childhood-onset fluency disorder, or developmental stuttering, occurs by age 6 for 80%- 90% of affected individuals, with age at onset ranging from 2 to 7 years. The onset can be insidious or more sudden. Typically, dysfluencies start gradually, with repetition of initial consonants, first words of a phrase, or long words. The child may not be aware of dysflu­ encies. As the disorder progresses, the dysfluencies become more frequent and interfering, occurring on the most meaningful words or phrases in the utterance. As the child becomes aware of the speech difficulty, he or she may develop mechanisms for avoiding the dys­ fluencies and emotional responses, including avoidance of public speaking and use of short and simple utterances. Longitudinal research shows that 65%-85% of children re­