If only a stammer was all that stammerers have to contend with, says Trudy Stewart, a speech and language therapist for Leeds health authority. But difficulty speaking soon becomes overlaid with anxiety and avoidance that can permeate all of a child's life.
"A stammer can be amazingly serious. Children will compromise the words they use, the situations in which they speak, even the people they are.
They will make choices about their relationships, hobbies and careers, based on an anticipation of stammering. 'I can't say that word, I can't speak in that situation, I can't do that job, because I can't speak.'"
STAMMER OR STUTTER
The words stammer and stutter are interchangeable. Both mean jerky, hesitant speech, accompanied by tension in speaker and listener. Children who stammer may trip over certain sounds or syllables - the classic "p-p-p" - but they may also elongate words, block out certain words completely, or disguise their stammer with filler words, like "yah" and "like".
Some will distract attention from their stammer by bad behaviour or self-effacement. Some will betray their tension by avoiding eye contact when speaking, or by blinking, grimacing or foot-tapping.
Children of all intellectual abilities stammer. Stammering runs in families: studies show non-standard brain activity among stammerers, which may explain both their speech patterns and their apparently heightened emotional sensitivity. This is less true of the numerous under-5s - about one in 20 - who stammer. They are simply going through a phase when the simultaneous muscular and emotional control they need for talking is beyond them. At this stage, girls and boys are equally likely to stammer; bilingual children slightly more so.
By school age, boy stammerers outnumber girls five to one. Just over one in 100 children aged 5-18 stammer - virtually the same prevalence as among adults.
Since four-fifths of nursery-age children grow out of stammering, it might be argued that help for stammerers is best delayed until 5 or 6, when long-term problems can be identified.
In fact, says Cherry Hughes, former secondary head and education adviser to the British Stammering Association (BSA), the reverse is true.
"Intervention with under-5s is crucial. Oral language skills are a precursor to literacy: if children have trouble speaking it will have a dramatic effect on their academic achievement later."
Recent research has picked out danger signals among those nursery children likely to continue stammering. These include having another stammerer in the family, tension when speaking, and fragmenting words, rather than repeating whole words or phrases.
Children as young as 4 can show the psychological side effects that make stammering so potentially serious, says Jackie Turnbull, also a speech therapist in Leeds. "Children will say, 'My words won't come out right.' I am seeing a 4-year-old at the moment who talks about 'my brother' because he can't say his brother's name. I've had children who can't say their own name. That can be very difficult: some adults change their names rather than struggle to say them."
Most stammerers have good and bad days. Most can sing without stammering.
Many can speak in funny voices or regional accents without stammering. Many have times and situations when they barely stammer, and others when they can barely speak. The variation depends on who they are talking to, the complexity of what they are trying to say, and how stressful the situation is.
Such unpredictability is extremely disconcerting, says Cherry Hughes. "It's frightening for the child, because they can talk perfectly fluently to their hamster in the morning, get to school and totally block. It's also discomfiting for teachers, particularly if they see the same child who couldn't speak in the lesson talking away to their friends in the playground. I've had teachers say to me, "Could he be putting it on?'"
SAFE TO STAMMER
But children cannot put on a stammer, and most of them do not grow out of it. So what they need most is a school atmosphere in which they feel safe to stammer.
That means, says Cherry Hughes, a school where communication is openly discussed: where teachers talk about and model patient listening, taking turns, and not interrupting or finishing off other people's sentences.
Children also need to know that they will not be forced to speak, and that if they do not speak they will not be criticised. Lunchtime staff should not necessarily expect every child to say thank you, she explains.
"There has to be a whole-school policy. When the caretaker stops a child in the corridor to ask for help moving chairs, he needs to be trained to understand that this child who seems to be evading answering may have a communication problem. If the child stands and looks at him, he needs to wait for the child to speak."
Stammering children have particular difficulty if they are nervous with anticipation, if they are taken by surprise, if they are ashamed about what they are going to say or reluctant to say it, and if they feel they have nothing to say. All those situations may arise in school: in circle time, in reading aloud in the classroom, in class discussions, in performances, in oral testing, and above all at register time, where insistence on formal replies, strict alphabetical order or even a register every lesson can be torture for a child.
Secondary school children in particular can become skilled in avoiding tense situations, says Trudy Stewart. They do so by long-windedness, by pretending they have literacy difficulties, by disruptive behaviour, by needing to go to the toilet or by upsetting a glass of water when it is their turn to speak.
In a safe school, adds Cherry Hughes, teachers will reduce the need for such avoidance. "What does harm is when teachers show they aren't comfortable with the stammer, when they interrupt or finish the child's sentences or say things like, 'Perhaps it's better if you don't speak unless you feel you won't stammer.' Don't create a sense of shame. What teachers need to do is acknowledge the difficulty, and show they understand; to say, 'That was a bit of a struggle, wasn't it?'"
There is no reliable cure for a stammer. Speech therapy for the child, often in short intensive courses, such as those run by the London-based Michael Palin centre, can make a significant difference. But speech therapists are keen to transfer strategies the child learns on these courses into schools, and also to come into school and help teachers and children find ways of living comfortably with stammering.
The kind of activities that learning support assistants in particular can use with stammering children include playing games involving taking turns, so the child learns to cope with waiting and anticipation more comfortably.
At Michael Palin, children learn "tortoise talking": slowing down the overall speech rate, and in particular making sure the child gets through the whole vowel sound. Once a child knows how to do this, teachers and assistants can remind them. Role play, list-making, counting aloud, speaking in rhythm (for example in nursery rhymes) and reading aloud in a group all aid fluency and build confidence.
But the most practical help a school can give a stammering child, say experts, is finding positive solutions to stressful situations. Bend or crouch down to the child's level in a conversation, rather than towering over them. Simplify your language. Try not to keep them waiting long to speak (though no child can be allowed to talk whenever they want to).
Model clear, steady speech yourself, and talk about thinking before speaking: put your finger on your cheek to show that you are thinking. Talk about attentive listening, too: many children in the class will benefit from greater confidence that they will be heard out, as well as from being reminded not to rush the stammerer.
At register time, allow children to put up their hands, use various phrases or respond while everyone gets their books ready: any solution to prevent the child feeling exposed. In circle time welcome even the briefest contribution, like "I think so, too."
Above all, teachers should ask the child's advice on what to do, says Alison Nicholas, speech therapist at the Michael Palin centre. "Each child will want to handle it differently, and maybe even differently in different lessons. And if there's a situation where the child stammers, go back to the child and say, I didn't quite know what to do then, what should I do next time?"
Teachers may worry that a child will not want to speak publicly at all.
That is difficult for the teacher, agrees Cherry Hughes. "The teacher has to say you are an able pupil, you are learning like other pupils, there are lots of ways you can develop your confidence, and then take a step-by-step approach."
More common, says Jackie Turnbull, is that the child is less anxious than the adults and children around them. "Very young children in particular want to perform. The problem we have is teachers over-protecting children, saying, 'I didn't choose them for that part because I thought they would find it too difficult.' I've had children say, 'I wish they would let me do it.'
"I think that's part of the negotiation between child and teacher. They need to say: 'What if your talking is a bit bumpy? Would you like help? Would you like someone to say it with you?' The child might say, 'I might get stuck but if you just wait for me I'll be all right.'
Regular one-to-one meetings with the form tutor or pastoral head are useful for stammering children who find it difficult to ask for help. Children who stammer are vulnerable to teasing and bullying; this is part of their protection. But particular attention may be needed as GCSEs approach, with planning the oral components of both English and foreign languages.
The BSA produces a CD Rom on this subject. (See resources, below). The principle, says Cherry Hughes, is the same as always: be flexible and ask the child what they want. Practice is important and word limits rather than time limits are helpful. Examination boards will allow stammerers extra time.
Changing the audience can also make a huge difference. Hughes recalls one boy who was paralysed making a speech in front of his GCSE English class, but completely fluent giving a talk on football as coach to a Year 7 team.
Doing assessed talks within lessons is convenient for the school, but shy children and stammerers can boost their grades by changing context.
Adults and children regularly skirt around stammerers and stammering, not mentioning the problem, half-aware of their own feelings of anxiety and embarrassment. Often they look away when the stammerer is speaking. It takes courage for schools to deal openly with it.
"It's possible to generate this fear of stammering, which is more of a problem than the stammering itself," says Hughes. "There's something people find frightening about stammering, particularly if it's accompanied by facial movements like eye-rolling or tics. It seems to make us anxious about the fragility of our own speech. But why shouldn't people stammer?"
TRAINING AND RESOURCES
* The British Stammering Association is at www.stammering.org. Its helpline is 0845 6032001. Education officer Cherry Hughes is on 01606 77374. It produces three CD Rom guides to good practice with pupils who stammer for primary and secondary schools and GCSE English oral work. A copy of each was sent to all English state schools in 2004. Additional copies cost pound;12.99 each * Stammering: A Practical Guide for Teachers and Other Professionals by Rustin et al, is published by David Fulton, pound;19.
* The Michael Palin Centre (Association for Research into Stammering in Childhood) is at www.stammeringcentre.org. It offers courses for children and training for teachers.