Disfluency in Autism Spectrum Disorders: Treatment Considerations for the Clinician

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Disfluency in Autism Spectrum DisordersTreatment
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_at_earthlink.net vsisskin _at_umd.edu

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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.

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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.

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What motivated this topic

• Lack of research
• Children with ASDs and disfluency/stuttering
• And yet.
• Clinical observations regarding disfluency in
  ASDs
• Our own
• Recent increased questions and observations on
  online discussion groups (Divisions 1, 16)

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Types of Disfluencies

• Stuttering-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)

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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, 1991Tager-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)

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Patterns of stuttering/disfluency noted in
individuals with Autism Spectrum Disorders

• Klin, Volkmar, Sparrow (2000) Dysfluencies
  arecommon (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)

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Patterns of stuttering/disfluency noted in
individuals with Autism Spectrum Disorders

• Typical stuttering-like disfluencies
• Sound, 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)

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Patterns of stuttering/disfluency noted in
individuals with Autism Spectrum Disorders

• Less typical stuttering-like disfluencies
• What 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)

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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)

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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)

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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

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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

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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

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Assessment ConsiderationsWhat we want to know
about the disfluencies and Why

• Linguistic contexts of disfluencies (more and
  less taxingdo the disfluencies change with
  context?)
• Types of disfluencies (non and stuttering-like,
  typical and atypical)
• Locations of disfluencies (typical or atypical)
• Durations of disfluencies

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Assessment Considerations

• Awareness of disfluencies
• Responses to disfluencies
• Impact of disfluencies on overall communication
  effectiveness
• Other related behavioral patterns (e.g.
  perseveration, interaction style, etc.)

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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).

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Example 2

• Age 7
• Aspergers 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

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Example 3

• Age 16
• Aspergers Syndrome
• Notable features of communication
• Final part-word repetition (with and without
  mid-syllable insertion)
• Interjections
• Pedantic, intellectualized manner
• No awareness (defensive)

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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.

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Treatment ConsiderationsWhat 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

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Treatment ConsiderationsHow 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

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Speculation and future research

• The link between engagement, self-regulation
  (executive functioning) and development of fluent
  speech
• Gertner, Rice, Hadley (1994)Prizant Meyer
  (1993)
• Greenspan (2001) Greenspan Weider (1997)
• Treatment implications and case illustrations

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Speculation and future research

• The 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

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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

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Echo Breakdown by Functional CategoriesAdapted
from Prizant Duchan,1981
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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

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• Weighing the odds

More concern

• Family history of chronic stuttering
• Male
• Stable or increasing pattern of Stutter-Like
  Disfluencies (SLD's) over 12 mos.
• Stuttering onset after 36 months
• Relatively poorer speech/language performance

• No family history or history of recovered
  stuttering
• Female
• Decrease in SLD's over 12 months
• Early onset of symptoms
• Strong speech/language skills

Less concern
Note Severity of symptoms do not appear to be a
risk factor
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Patterns to monitor
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For further help and study info

• Contact scalerscott1_at_earthlink.net
• Contact vsisskin_at_umd.edu

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Questions?

• scalerscott1_at_earthlink.net
• vsisskin_at_umd.edu

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References and Resources

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