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

scalerscott1@earthlink.net 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

02468

101214

Janu

ary

April

July

Octob

erJa

nuar

yApr

ilJu

lyOct

ober

Janu

ary

Recovery Chronic Immediate concern

For further help and study info…

Contact: scalerscott1@earthlink.net

Contact: vsisskin@umd.edu

Questions?

scalerscott1@earthlink.netvsisskin@umd.edu

References and Resources

Alm, P.A. (2004). Stuttering and the basal ganglia circuits: a critical review of possible relations. Journal of Communication Disorders, 37, 325-396.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington DC.

Bellon-Harn, M.L., Harn, W.E. & Watson, G.D. (2007). Targeting prosody in an eight-year-old child with high- functioning autism during an interactive approach to therapy. Child Language Teaching and Therapy, 23, 157-79.

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,\

Greenspan, S. I. (2001). The Affect Diathesis Hypothesis: The role of emotions in the core deficit in autism and in the development of intelligence and social skills. Retrieved 8/07: www.floortime.org/downloads/affect_diathesis_hypothesis.pdf

Greenspan, S. I. & Weider, S. (1997). Developmental patterns and outcomes in infants and children with disorders in relating and communicating: A chart review of 200 cases of children with autistic spectrum disorders. The Journal of Developmental and Learning Disorders, 1, 87-14.

Hartfield, K. N., & Conture, E. G. (2006). Effects of perceptual and conceptual similarity in lexical priming of young children who stutter: Preliminary findings. Journal of Fluency Disorders, 31, 303-324.

Hietala, A. & Spillers, C. (2005, November). Disfluency patterns in children with autism spectrum disorders. Poster session presented at the Annual ASHA Convention, San Diego, CA.

Klin, A., Volkmar, F. & Sparrow, S. (Eds.) (2000). Asperger Syndrome. New York: The Guilford Press.

Logan, K. J. & Conture, E. G. (1995). Length, grammatical complexity, and rate differences in stuttered and fluent conversational utterances of children who stutter. Journal of Fluency Disorders, 20, 35-61.

Lord, C. & McGee, J.P. (Eds.), Educating children with autism. Washington, DC: National Academy Press. 2001.

Paul, R., Shriberg, L.D., McSweeny, J., Cicchetti, D., Klin, A., & Volkmar, F. (2005). Brief report: Relations between prosody performance and communication and socialization ratings in high functioning speakers with autism

spectrum disorders. Journal of Autism and Developmental Disorders, 35, 861-69.

Prizant, B.M., & Duchan, J.F. (1981). The functions of immediate echolalia in autistic children, JSHD, 46, 241-249.

Prizant, B. M. & Meyer, E. C. (2003, Sept). Socioemotional aspects of language and social-communication disorders in young children and their families. American Journal of Speech-Language Pathology, 56-71.

Quill, K.A. (1997). Instructional considerations for young children with autism: the rationale for visually cued instruction. Journal of Autism and Developmental Disorders, 27 (6), 697-714.

Scaler Scott, K., Grossman, H.L., Abendroth, K. J., Tetnowski, J.A. & Damico, J.S. (2006). Asperger Syndrome and Attention Deficit Disorder: Clinical disfluency analysis. Proceedings of the 5th World Congress on Fluency Disorders, Dublin, Ireland: International Fluency Association.

Shriberg, L.D., Paul, R., McSweeny, J.L., Klin, A,. Cohen, D.J., & Volkmar, F.R. (2001). Speech and prosody characteristics of adolescents and adults with high-functioning autism and asperger syndrome. Journal of Speech, Language, and Hearing Research, 44, 1097-1115.

Silverman, S., & Bernstein Ratner, N. (2002). Measuring lexical diversity in children who stutter: Application of vocd. Journal of Fluency Disorders, 27, 289-304.

Sisskin, V. (2006). Speech disfluency in Asperger’s Syndrome: Two cases of interest. Perspectives on Fluency and Fluency Disorders, 16(2), 12-14.

Sisskin, V. & Scaler Scott, K. (2007). Part I: Speech disfluency in autism spectrum disorders: clinical problem solving for autistic disorders. Retrieved November 12, 2007, from http://mnsu.edu/comdis/isad10/papers/sisskin10.html

Stribling, P., Rae, J., & Dickerson, P. (2007). Two forms of spoken repetition in a girl with autism. International Journal of Language and Communication Disorders, 42, 427-44.

Szatmari, P. (1991). Asperger’s Syndrome: Diagnosis, treatment and outcome. Psychiatric Clinics of North America, 14(1), 81-92.

Tager-Flusberg, H. (1995). Dissociation in form and function in the acquisition of language by autistic children.

In H. Tager-Flusberg (Ed.), Constraints on language acquisition: Studies of atypical children (pp. 175–194).Hillsdale, NJ: Erlbaum.

Tetnowski, J.A. (1998). Linguistic effects on disfluency. In R. Paul (Ed.), Exploring the speech-language connection (Vol 8, pp. 227-247). Baltimore, MD: Paul Brookes Publishing Co.

Van Borsel, J., Bontinck, C., Coryn, M., Paemeleire, F., & Vandemaele, P. (2007). Acoustic features of palilalia. Brain and Language, 101, 90-96.

Van Borsel, J.,& Tetnowski, J. A., Fluency disorders in genetic syndromes, Journal of Fluency Disorders (2007), doi:10.1016/j.jfludis.2007.07.002

Wagovich, S. A., & Bernstein Ratner, N. (2007). Frequency of verb use in young children who stutter. Journal of Fluency Disorders, 32, 79-94.

Yairi, E. & Ambrose, N.G. (2005). Early Childhood Stuttering: For Clinicians by Clinicians. Austin, TX: ProEd

Yaruss, J. S. (1999). Utterance length, syntactic complexity, and childhood stuttering. Journal of Speech, Language, and Hearing Research, 42, 329-344.

Zackheim, C. T. & Conture, E. G. (2003). Childhood stuttering and speech disfluencies in relation to children’s mean length of utterance: A preliminary study. Journal of Fluency Disorders, 28, 115-142.