My client isn’t fluent – but is it stuttering?

Atypical Disfluency - Part 2
 
By Vivian Sisskin, M.S., and Nan Bernstein Ratner, Ed.D.
University of Maryland
 
In the last column, we began to tackle the increasingly reported cases of children who are referred for “stuttering,” but whose fluency profiles do not comfortably fit conventional definitions. We started by discussing children who seem to have language formulation problems, rather than stutter, and apparently touched a nerve, since Nan’s inbox basically flooded with reader reports of children with exactly this type of profile. Unfortunately, as many noted, performing a good differential diagnosis and qualifying the child for services seemed problematic, let alone developing an appropriate treatment plan. 
 
We agree that it is currently challenging to find appropriate tasks or tests to use in these cases and are compiling a list of potential resources to include in our next column. In the meantime in this issue, we will discuss another increasingly reported fluency concern: children whose disfluencies are strikingly unlike stuttering, primarily because of location within words and clauses. The most frequently remarked atypical disfluency is final repetition of sounds or utterance components. 
 
What do we know?
 
Atypical disfluencies are generally not seen in the majority of children with developmental stuttering (child onset fluency disorder). While uncommon, more and more cases are being reported through online communities by speech-language pathologists seeking guidance for treatment. The most common atypical disfluency of concern is word-final repetition (“home-ome”; “playground-ayground”), though there are increasing reports of mid-word insertions, described as an insertion of /h/ or a glottal stop mid-vowel (“we-he”; see- ʔee).
 
Historically, final-word repetition has been documented in cases of acquired stuttering and in children with neurological impairment (Ardila & Lopez, 1986; Bijleveld, Lebrun & Leleux, 1985; Lebrun & Van Borsel, 1990; Lebrun & Van Dongen, 1994; Van Borsel, Van Coster, Van Lierde, 1996). In terms of developmental disfluency, some documented cases reported rapid remission in young children (Camarata, 1984; Mowrer, 1987; Rudman, 1984). Atypical disfluencies have been documented in case studies of typically developing children (Humphrey, 1997; McAllister & Kingston, 2005), as well as with children who present with features of autism spectrum disorder (Scaler Scott, Grossman, Abendroth, Tetnowski, Damico, 2006; Scaler Scott, Tetnowski, Flaitz, Yaruss, 2014).
 
At this point, the nature and origin of these disfluencies are not clear. Case studies conjecture that these may be perseverative behaviors, a form of covert repair, a form of palilalia, symptoms of efforts to self-regulate, or perhaps a subtype of developmental stuttering. 
 
Although there are growing numbers of published case reports, there are only a few published treatments (Sisskin & Wasilus, 2014; Van Borsel, Geirnaert, Van Coster, 2005) for decreasing the frequency of atypical disfluencies. As with other communication disorders without clear etiologies, the above case studies demonstrate positive outcomes through behavioral treatments; we can successfully treat some disorders without understanding their cause or how they emerge.
 
What is the diagnostic profile?
 
What does the multi-dimensional assessment profile look like for these cases? Among the neurotypical children (children without ASD), we have seen average to above-average language skills, and in some cases, vocabulary levels in the superior range. The profile among the children with autism is less consistent. In terms of disfluency, most of the children displayed stuttering-like disfluency (part-word and whole word repetition) and between-word disfluency (interjections and phrase repetitions) in addition to atypical disfluency, but at a lower frequency. No secondary physical concomitant behaviors were noted and while awareness varied, there was minimal concern, anxiety, or reactive behavior on the part of the child. Scores on The Overall Assessment of the Speaker’s Experience of Stuttering for School-Age Children (OASES-S) has typically indicated a higher life impact than what would be expected from children who do not stutter, but from our experience, it was possible that the children with atypical disfluency were judging their experience as communicators more generally, as some of these children had co-existing pragmatic language concerns.
 
What are some potential treatment ideas?
 
Individual case studies show good promise for treating atypical disfluency. In one case where the frequency was initially very high and speech was difficult to follow, frequency of word-final disfluency was brought down to less than 2% of spontaneous speech, in all speech contexts, even several years post-therapy (Sisskin & Wasilus, 2014). In other cases we have treated, involving final-word repetition or mid-word insertion, atypical disfluency became unnoticeable to the unfamiliar listener. 
 
Treatment strategies involved identification and correction of atypical disfluency. In contrast to stuttering, where “suppression” might lead to escape or avoidance behaviors, no replacement behaviors or covert concealment strategies resulted. Identification involved active monitoring in game formats. Initially, monitoring of non-speech behaviors needed to be taught directly, gradually leading to self-monitoring of the target behavior. Correction involved “canceling” the entire word followed by fluent repetition. Initially, verbal contingencies were used, eventually moving to self-correction. 
 
Special attention and care was taken to program for carryover and generalization. This required active parent participation and home assignments to spend time each day on games to reinforce new behaviors. We might go as far as to say that the most important components of the therapy for these cases included implementation of creative teaching strategies (catering to the learning style of the client), individualized counseling (as some children questioned the rationale for reducing atypical disfluency in their speech); and attention to behavioral principles that lead to long term change.
 
What’s next?
 
We must emphasize that the information we provided here is based on individual therapy cases of children with atypical disfluency. We need further research to determine if these cases differ fundamentally from developmental stuttering, or might be a subtype among other subtypes. We have a good deal of anecdotal evidence from speech pathologists that commonly used fluency strategies have not been successful in treating most of these cases. 
 
To be honest, we have both been rather surprised by the outpouring of feedback on the first column on this topic, and more frequent postings of reports of atypical disfluency on professional listservs. It is clear we need more research, assessment development and intervention reports on these clinical cases. 
 
If you would like to help us explore the dimensions and characteristics of clients presenting with atypical disfluency, please complete a short anonymous survey at https://umdsurvey.umd.edu/SE/?SID=SV_5j7YxjpAOWSj4ln 
 
Knowing your concerns about clients with difficult to characterize fluency profiles will greatly help us explore what is needed to best address their problems. We will share results of this survey in an upcoming column.
 
Do you have questions for Researcher Corner? Email Dr. Ratner at nratner@umd.edu.
 
References
Ardila A, Lopez MV. Severe stuttering associated with right hemisphere lesion. Brain Lang 1986; 27(2):239–246 
Bijleveld H, Lebrun Y, van Dongen H. A case of acquired stuttering. Folia Phoniatr Logop 1994;46(5):250–25321 
Camarata SM. Final consonant repetition: a linguistic perspective. J Speech Hear Disord 1989; 54(2):159–162 
Humphrey BD. Unusual disfluency: repetitions in final position in an adolescent boy: a poster publication. Fl J of Comm Dis 1997;17:41–42 
Lebrun Y, Leleux C. Acquired stuttering following right-brain damage in dextrals. J Fluency Disord 1985;10:137–141 
Lebrun Y, Van Borsel J. Final sound repetitions. J Fluency Disord 1990;15:107–113 
McAllister J, Kingston M. Final part-word repetitions in school-age children: two case studies. J Fluency Disord 2005;30(3):255–267 
Mowrer DE. Repetition of final consonants in the speech of young child. J Speech Hear Disord 1987; 52(2):174–178 
Rudmin F. Parent’s report of stress and articulation oscillation as factors in a pre-schooler’s disfluencies. J Fluency Disord 1984;9:85–87 
Scaler Scott K, Grossman H, Abendroth K, Tetnowski J, Damico J. Asperger syndrome and attention deficit disorder: clinical disfluency analysis. Proceedings of 5th World Congress on Fluency Disorders. International Fluency Association. July 25, 2006; Dublin, Ireland 
Scaler Scott K, Tetnowski JA, Flaitz JR, Yaruss JS. Preliminary study of disfluency in school-aged children with autism. Int J Lang Commun Disord 2014;49(1):75–89
Sisskin V, & Wasilus S. Lost in the literature, but not in the caseload: Working with atypical disfluency from theory to practice. Sem Sp Lang 2014;35 (2):144-152
Van Borsel J, Van Coster R, Van Lierde K. Repetitions in final position in a nine-year-old boy with focal brain damage. J Fluency Disord 1996;21:137–146 
Van Borsel J, Geirnaert E, Van Coster R. Another case of word-final disfluencies. Folia Phoniatr Logop 2005;57(3):148–162 
 
From the Summer 2015 Newsletter