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Disfluency in Autism Spectrum Disorders: Treatment Considerations for the Clinician
Kathleen Scaler Scott, M.S., CCC-SLP Vivian Sisskin, M.S., CCC-SLP Board Recognized Specialist and Mentor, Fluency Disorders Board Recognized Specialist and Mentor, Fluency Disorders
University of Louisiana at Lafayette University of Maryland
[email protected] vsisskin @umd.edu
Questions we will not answer, but wish we could
What is the prevalence of stuttering/disfluency among the Autism Spectrum Disorder (ASD) population?
What is the prognosis for treating children who stutter with concomitant ASD?
If some reactive behaviors in stuttering reflect efforts to escape or avoid stuttering, would these behaviors be rare in children with limited perspective taking (Theory of Mind)?
And many, many others….
Our Goal Today
Summarize the limited research to date related to fluency/disfluency in children with ASD.
Speculate about the nature of these disfluencies based on current research and our combined clinical experience.
Provide you with a framework to develop an effective evaluation and treatment plan that is based in the literature as much as it can be.
Offer some examples from case histories to demonstrate considerations for treatment for some cases of concomitant disfluency and ASD.
What motivated this topic Lack of researchChildren with ASDs and disfluency/stuttering
And yet….
Clinical observations regarding disfluency in ASDsOur ownRecent increased questions and observations
on online discussion groups (Divisions 1, 16)
Types of DisfluenciesStuttering-like disfluencies
Single syllable whole word repetitions (I,I,I)
Sound, syllable repetitions (b-b-baby; may-may-, maybe)
Prolongations (ssssometimes)
Blocks
Non stuttering-like disfluencies
Multisyllable whole word repetitions (under, under)
Phrase repetitions (I want, I want some juice)
Revisions (I want apple, no, I mean orange juice)
Fillers, interjections (um, uh, well, like)
Background and Theoretical Perspective
What we know about language, disfluency and children with ASDs (Dobbinson, Perkins, & Boucher, 1998; Paul et al., 2005; Shriberg et al., 2001; Szatmari, 1991;Tager-
Flusberg, 1995) What we know about language,
disfluency and children who stutter (Bernstein Ratner & Sih, 1987; Logan & Conture, 1995; Tetnowski, 1998; Van Borsel & Tetnowski, 2007; Yaruss, 1999; Zackheim & Conture, 2003)
Patterns of stuttering/disfluency noted in individuals with Autism Spectrum Disorders
Klin, Volkmar, Sparrow (2000): “Dysfluencies are…common” (p. 378) in Asperger Syndrome” (AS)
Shriberg et al. 2001: 67% male speakers with AS and 40% with HFA: “inappropriate or nonfluent phrasing on more than 20% of utterances” (p. 1109)
“These data suggest that many speakers with autistic syndromes produce notably disfluent speech” (p. 1109)
Patterns of stuttering/disfluency noted in individuals with Autism Spectrum Disorders
Typical stuttering-like disfluenciesSound, syllable, word repetitions (Hietella
& Spillers, 2005; Paul et al. 2005; Scott, Grossman, Abendroth, Tetnowski & Damico, 2006; Shriberg et al. 2001; Sisskin, 2006)Prolongations (Paul et al., 2005; Shriberg
et al., 2001)Blocks (Paul et al., 2005; Scott et al.,
2006; Shriberg et al., 2001)
Patterns of stuttering/disfluency noted in individuals with Autism Spectrum Disorders
Less typical stuttering-like disfluenciesWhat are typical locations?Word final disfluencies (Hietella & Spillers,
2005; Sisskin, 2006)Word-medial blocks (Scott et al., 2006)Mid syllable insertion (“see-hee”) (Sisskin,
2006)
Patterns of stuttering/disfluency noted in individuals with Autism Spectrum Disorders
Typical NON stuttering-like disfluencies
Multisyllable whole word repetitions (possibly Paul et al. 2005; Scott et al., 2006; Shriberg et al., 2001)
Phrase repetitions (Scott et al., 2006; Sisskin, 2006)
Revisions (Hietella & Spillers, 2005; Paul et al., 2005; Shriberg et al., 2001; Sisskin, 2006)
Interjections (Hietella & Spillers, 2005; Scott et al., 2006; Sisskin, 2006)
Patterns of stuttering/disfluency noted in individuals with Autism Spectrum Disorders
Typical NON stuttering-like disfluencies
Multisyllable whole word repetitions (possibly Paul et al. 2005; Scott et al., 2006; Shriberg et al., 2001)
Phrase repetitions (Scott et al., 2006; Sisskin, 2006)
Revisions (Hietella & Spillers, 2005; Paul et al., 2005; Shriberg et al., 2001; Sisskin, 2006)
Interjections (Hietella & Spillers, 2005; Scott et al., 2006; Sisskin, 2006)
To sum up
What we know so far
Disfluency (more and less typical) and stuttering (more and less typical) happen in Autism Spectrum Disorders
The same patterns have been seen in different individuals in the contexts of reading (Hietala &
Spillers, 2005; Scott et al., 2006) repetition tasks (Scott et al.,
2006) and conversation (Dobbinson, Perkins, Boucher, 1998; Hietala & Spillers, 2005; Paul et al., 2005; Scott et al., 2006; Shriberg et
al, 2001; Sisskin, 2006) but there are individual differences as well
Awareness seems to be on a continuum
To sum up
Where the need for more research is:
Small study sizes (most 1-3 participants, largest had 30 participants)
All studies were descriptive in nature regarding disfluencies
Many focus on overall quality of speech rather than fine details of disfluencies
Need more information to see how much overlap there is between the type of ASD and type of disfluencies seen, if any; This can be tricky, given diagnostic difficulties
Assessment: What we want to know about the individual and Why
Cognitive level (Van Borsel and Tetnowski, 2007)
Age of onset of stuttering
Other presenting issues, such as language issues
Assessment Considerations: What we want to know about the disfluencies and Why
Linguistic contexts of disfluencies (more and less taxing—do the disfluencies change with context?)
Types of disfluencies (non and stuttering-like, typical and atypical)
Locations of disfluencies (typical or atypical)
Durations of disfluencies
Assessment Considerations
Awareness of disfluenciesResponses to disfluenciesImpact of disfluencies on overall
communication effectivenessOther related behavioral patterns (e.g.
perseveration, interaction style, etc.)
Example #1
Age: 8
Autistic Disorder
Clip at onset and 3 months post onset
Notable features of communication
SLD (up to 15-20 iterations.
Physical concomitant behaviors: lowering head; jerking torso
No awareness
Imitated(echolalia and scripts) and some spontaneous utterances (requests).
Example #2
Age: 7
Asperger’s Syndrome
Notable features of communication:
Initial part-word repetition
Final part-word repetition (with and without mid-syllable insertion)
Revision; phrase repetition
No awareness
Monologue on narrow circumscribed interest
Scripted language
Unusual prosody, pitch, volume
Example #3
Age: 16
Asperger’s Syndrome
Notable features of communication
Final part-word repetition (with and without mid-syllable insertion)
Interjections
Pedantic, intellectualized manner
No awareness (defensive)
Example #4
Age: 20
Autistic Disorder with intellectual impairment
Stereotypical behavior; compulsive rituals
Notable Features of Communication
Whole word repetition
Part-word repetition
Strings of both (above) with variation on sound production.
No awareness
One- and two-word utterances for behavior regulation (requesting & protesting). Disfluency mostly on highly motivated requests.
Treatment Considerations: What to Treat
Impact on communication
Intelligibility
Distracts from intent/meaning
Functional concerns
Impacts communication intent/function
Impacts learning (language, academic, prevocational)
Impacts socialization (home, school, community)
Prognosis for best functional outcomes
Goals that make the greatest difference
Treatment Considerations: How to Treat
The triad of symptoms and learning style associated with ASD
Behavioral approaches (Lord et al., 2001)
Concrete, rule-based, visual learners (Bellon- Harn et al., 2007; Quill, 1997)
Hypothesis related to the nature of the symptoms (slides #23,24,25,27)
Motivation
For change
For practice
Speculation and future research
The link between engagement, self- regulation (executive functioning) and development of fluent speechGertner, Rice, & Hadley (1994);Prizant &
Meyer (1993)Greenspan (2001); Greenspan & Weider
(1997)
Treatment implications and case illustrations
Speculation and future researchThe link between linguistic level and
development of fluent speech (Bernstein Ratner & Sih, 1987; Hartfield & Conture, 2006; Logan & Conture, 1995; Silverman & Bernstein Ratner, 2002; Wagovich & Bernstein Ratner, 2007; Yaruss, 1999; Zackheim & Conture, 2003)
Zackheim and Conture (2003)
Mazing behaviors; planning, retrieval (Hartfield & Conture, 2006; Pellowski & Conture, 2005; Hall 2004)
Treatment implications and case illustration
Speculation and Future Research
The link between core symptoms of ASD and less typical speech disfluency
“Restricted, repetitive, and stereotyped patterns of behavior (DSM-IV, 1994)
Palilalia, verbal perseveration, and compulsive repetition (Alm, 2004; Van Borsel et al.,2007; Stribling et al. 2007)
Verbal repetition strategies as a pragmatic function (Prizant and Duchan, 1981).
Treatment implications and case illustration
Echo Breakdown by Functional Categories Adapted from Prizant & Duchan,1981
Functional Category % of Category Relative to Total Echolalia Summarized from 4 children
Non-focused 3.97 Turn-taking 33.30 Declaratiave 25.67 Rehearsal 13.48 Self-regulatory 13.18 Yes-answer 5.15 Request 5.25
Speculation and Future Research
Concomitant childhood stuttering and ASD
Onset at later chronological ages that coincide with spurt in language growth (see slide #24 for references).
May follow common patterns of persistence and recovery (Yairi & Ambrose, 2005).
May respond to indirect methods of treatment.
Treatment implications and case illustration
Weighing the odds
More concern
Less concern
Family history of chronic stutteringMaleStable or increasing pattern of Stutter-Like Disfluencies (SLD's) over 12 mos.Stuttering onset after 36 months
Relatively poorer speech/language performanceNo family history or history of recovered
stutteringFemaleDecrease in SLD's over 12 monthsEarly onset of symptomsStrong speech/language skills
Note: Severity of symptoms do not appear to be a risk factor
Patterns to monitor
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Recovery Chronic Immediate concern
Questions?
[email protected]@umd.edu
References and Resources
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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington DC.
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Bernstein Ratner, N., & Sih, C. (1987). Effects of gradual increases in sentence length and complexity on children’s dysfluency. Journal of Speech and Hearing Disorders, 52, 278–287.
Dobbinson, S., Perkins, M. R., & Boucher, J. (1998). Structural patterns in conversations with a woman who has autism. Journal of Communication Disorders, 31, 113-134.
Gertner, B. L., Rice, M. L., & Hadley, P. A. (1994). Influence of communicative competence on peer preferences in a preschool classroom. Journal of Speech and Hearing Research, 37, 913-923,\
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