associated with a significant event, it is constant and uninfluenced by different speaking situations, and there is little awareness or concern shown by the speaker. differential diagnosis other disorders with symptoms resembling stuttering, or associated disorders include autism, cluttering, parkinson's disease, essential tremor, palilalia, spasmodic dysphonia, selective mutism, and social anxiety. treatment main article: stuttering therapy before beginning treatment, an assessment is needed, as diagnosing stuttering requires the skills of a certified speech–language pathologist (slp). while there is no complete cure for stuttering, several treatment options exist that help individuals to better control their speech. many of the available treatments focus on learning strategies to minimize stuttering through speed reduction, breathing regulation, and gradual progression from single-syllable responses to longer words, and eventually more complex sentences. furthermore, some stuttering therapies help to address the anxiety that is often caused by stuttering, and consequently worsens stuttering symptoms. this method of treatment is referred to as a comprehensive approach, in which the main emphasis of treatment is directed toward improving the speaker's attitudes toward communication and minimizing the negative impact stuttering can have on the speaker's life. treatment from a qualified s-lp can benefit stutterers of any age. speech language pathologists teach people who stutter to control and monitor the rate at which they speak. in addition, people may learn to start saying words in a slightly slower and less physically tense manner. they may also learn to control or monitor their breathing. when learning to control speech rate, people often begin by practising smooth, fluent speech at rates that are much slower than typical speech, using short phrases and sentences. over time, people learn to produce smooth speech at faster rates, in longer sentences, and in more challenging situations until speech sounds both fluent and natural. when treating stuttering in children, some researchers recommend that an evaluation be conducted every three months in order to determine whether or not the selected treatment option is working effectively. "follow-up" or "maintenance" sessions are often necessary after completion of formal intervention to prevent relapse. fluency shaping therapy fluency shaping therapy, also known as "speak more fluently", "prolonged speech", or "connected speech", trains people who stutter to speak less disfluently by controlling their breathing, phonation, and articulation (lips, jaw, and tongue). it is based on operant conditioning techniques. people who stutter are trained to reduce their speaking rate by stretching vowels and consonants, and using other disfluency-reducing techniques such as continuous airflow and soft speech contacts. the result is very slow, monotonic, but fluent speech, used only in the speech clinic. after the person who stutters masters these skills, the speaking rate and intonation are increased gradually. this more normal-sounding, fluent speech is then transferred to daily life outside the speech clinic, though lack of speech naturalness at the end of treatment remains a frequent criticism. fluency shaping approaches are often taught in intensive group therapy programs, which may take two to three weeks to complete. modification therapy the goal of stuttering modification therapy is not to eliminate stuttering but to modify it so that stuttering is easier and less effortful. the rationale is that, since fear and anxiety cause increased stuttering, using easier stuttering and with less fear and avoidance, stuttering will decrease. the most widely known approach was published by charles van riper in 1973 and is also known as block modification therapy. however, depending on the patient, speech therapy may be ineffective. electronic fluency device altered auditory feedback, so that people who stutter hear their voice differently, has been used for over 50 years in the treatment of stuttering. altered auditory feedback effect can be produced by speaking in chorus with another person, by blocking out the voice of the person who stutters while they are talking (masking), by delaying slightly the voice of the person who stutters (delayed auditory feedback) or by altering the frequency of the feedback (frequency altered feedback). studies of these techniques have had mixed results, with some people who stutter showing substantial reductions in stuttering, while others improved only slightly or not at all. in a 2006 review of the efficacy of stuttering treatments, none of the studies on altered auditory feedback met the criteria for experimental quality, such as the presence of control groups. mobile applications stuttering treatment using mobile application there are specialized mobile applications and pc programs for stutter treatment. the goal pursued by the applications of this kind is speech cycle restoration: i say, i hear, i build a phrase, i say, and so on, using various methods of stutter correction. the user interacts with the application through altered auditory feedback: they say something into the headset's microphone and listen to their own voice in the headphones processed by a certain method. the following stutter correction methods are typically used in applications: maf (masking auditory feedback). it is basically masking by white noise or sinus noises of the user's own speech. scientists believe that people who stutter can speak more smoothly when they do not hear their own speech. this method is considered old-fashioned and ineffective. daf (delayed auditory feedback). this method involves sending the user's voice from a microphone to headphones with a delay of fractions of a second. the goal of this method is to teach people who stutter to prolong vowels and reduce their speech rate. after speech correction with long delays, the application is adjusted at shorter delays which increase the speech rate until it becomes normal. faf (frequency-shifted auditory feedback). this method involves shifting the user's voice tone frequency that they are listening to compared to their own voice. the shift range can be different: from several semitones to half an octave. using metronomes and tempo correctors. rhythmic metronome strikes are used in this method. the effectiveness of the method is related to the fact that rhythm has positive effect on someone who stutters, especially when pronouncing slowly. using visual feedback. this method determines the user's speech parameters (for instance, speech tempo) and their representation on screen as visual information. the principal goal of the method is allowing the user to effectively manage their voice through achieving the defined targeted parameters. it is supposed that the user sees visual representation of both current and targeted parameters (such as speech tempo) on the screen while pronouncing. medications although no medication is fda approved for stuttering, several studies have shown certain medications to have beneficial effects on reducing the severity of stuttering symptoms. although different classes of medications have been investigated, those with dopamine blocking activity have been shown in numerous trials to have positive effects on stuttering. these medications are fda approved in the united states and hold similar approval in most countries for other conditions and their safety profiles are well established in these disorders. the best studied medication in stuttering is olanzapine, whose effectiveness as of 2004 had been established in replicated trials. olanzapine acts as a dopamine antagonist to d2 receptors in the mesolimbic pathway, and works similarly on serotonin 5ht2a receptors in the frontal cortex. at doses between 2.5 and 5 mg, olanzapine has been shown to be more effective than placebo at reducing stuttering symptoms, and may serve as a first-line pharmacological treatment for stuttering based on the preponderance of its efficacy data. however, other medications are generally better tolerated with less weight gain and less risk of metabolic effects than olanzapine. as of 2000, risperidone and haloperidol had also shown effectiveness in the treatment of stuttering. however, haloperidol in particular often result in poor long-term compliance due to concerning side effects such as movement disorders and prolactin elevation, which can also occur with risperidone. other dopamine active medications reported to positively treat stuttering include aripiprazole, asenapine, lurasidone, which tend to be better tolerated than olanzapine with less weight gain. all these medications as well as olanzapine can carry the potential risk of a long-term movement disorder known as tardive dyskinesia. the investigational compound, ecopipam, is unique from other dopamine antagonists in that it acts on d1 receptors instead of d2, owing little, if any risk, of movement disorders. a 2019 open label study of ecopipam in adults demonstrated significantly improved stuttering symptoms with no reports of parkinsonian-like movement disorders or tardive dyskinesia which can be seen with d2 antagonists. in addition, ecopipam had no reported weight gain, but instead has been reported to lead to weight loss. in a preliminary study, it was well tolerated in subjects, effectively reduced stuttering severity, and was even associated in a short-term study with improved quality of life in persons who stutter. further research is still warranted, but this novel mechanism is showing promise in the pharmacologic treatment of stuttering. support with existing behavioral and prosthetic treatments providing limited relief and pharmacologic treatments in need of fda approval for widespread use, support groups and the self-help movement continue to gain popularity and support from professionals and from people who stutter. self-help groups provide people who stutter a shared forum within which they can access resources and support from others facing the same challenges of stuttering. one of the basic tenets behind the self-help movement is that since a cure does not exist, quality of life can be improved by not thinking about the stammer for prolonged periods. psychoanalysis has claimed success in the treatment of stuttering. hypnotherapy has also been explored as a management alternative. support groups further focus on the fact that stuttering is not a physical impediment but a psychological one. psychological approach cognitive behavior therapy has been used to treat stuttering. also sociological approaches has been explored regarding how social groups maintain stuttering through social norms. diaphragmatic breathing several treatment initiatives, for example the mcguire programme and the starfish project, advocate diaphragmatic breathing (or costal breathing) as a means by which stuttering can be controlled. prognosis among preschoolers with stuttering, the prognosis for recovery is good. based on research, about 65% to 87.5% of preschoolers who stutter recover spontaneously by 7 years of age or within the first 2 years of stuttering, and about 74% recover by their early teens. in particular, girls seem to recover well. for others, early intervention is effective in helping the child overcome disfluency. prognosis is guarded with later age of onset: children who start stuttering at age 3½ years or later, and duration of greater than 6–12 months since onset, that is, once stuttering has become established, and the child has developed secondary behaviors; only 18% of children who stutter after five years recover spontaneously. stuttering that persists after the age of seven is classified as persistent stuttering, and is associated with a much lower chance of recovery. however, with treatment young children may be left with little evidence of stuttering. for adults who stutter, there is no known cure, though they may make partial recovery or even complete recovery with intervention. people who stutter often learn to stutter less severely, though others may make no progress with therapy. emotional sequelae associated with stuttering primarily relates to state-dependent anxiety related to the speech disorder itself. however, this is typically isolated to social contexts that require speaking, is not a trait anxiety, and this anxiety does not persist if stuttering remits spontaneously. research attempting to correlate stuttering with generalized or state anxiety, personality profiles, trauma history, or decreased iq have failed to find adequate empirical support for any of these claims. epidemiology the lifetime prevalence, or the proportion of individuals expected to stutter at one time in their lives, is about 5%, and overall males are affected two to five times more often than females. however, there is not much information known about the underlying cause for such a skewed sex ratio. most stuttering begins in early childhood, and studies suggest that 2.5% of children under the age of 5 stutter. as seen in children who have just begun stuttering, there is an equivalent number of boys and girls who stutter. still, the sex ratio appears to widen as children grow: among preschoolers, boys who stutter outnumber girls who stutter by about a two to one ratio, or less. this ratio widens to three to one during first grade, and five to one during fifth grade, as girls have higher recovery rates. due to high (approximately 65–75%) rates of early recovery, the overall prevalence of stuttering is