ADHD
“significantly impacts the ‘efficiency and fluency’ of speech” [1]
Some of the dysfluency may be stuttering. Some may be “excessive typical” or
“atypical” dysfluency. A detailed description of ADHD is beyond the
scope of this article. [2]
However, beginning with a few basics is essential to testing and treating
dysfluency in the presence of ADHD.
Joseph Donaher, Ph. D.,
describes ADHD as a condition in which a child focuses on too many things simultaneously.
A 13 year old student of his described
ADHD like this: “I have a billion ideas bouncing in my head and I have trouble
trying to figure out which one is most important.” Much of the information
about ADHD in this article is taken from Dr. Donaher’s presentation in the
Stuttering Foundation DVD No. 6700, ADHD
& Children Who Stutter. I highly
recommend it for parents and professionals.
The Huffington Post recently
reported that “Children with ADHD produce more vocal repetitions or word
fillers as they try to organize their thoughts, somewhat similar to a stammer…A
response in the classroom may be along the lines of, ‘It’s a story abou…um…a
story…um…um…it’s about…akidwhofliesakite...um.” In addition, these children
“frequently struggle to find the right words and put thoughts together quickly
and linearly in conversation. Errors in grammar as they compose sentences also may
occur, because of planning difficulties present even when underlying skills in
this area are intact.” The social use of language, called pragmatics, is also
affected. Children with ADHD may blurt out responses to questions, interrupt,
talk excessively, and speak too loudly. Distractibility, impulsiveness and poor
executive function skills may make basic conversational rules too difficult for
them to use. [3]
Dr. Donaher reports that ADHD
“can result in dysfluencies” for children who do not stutter and “exacerbates
dysfluencies “ in children who do stutter. He lists the characteristics of ADHD
Hyperactive/Impulsive and ADHD Inattentive types and, because both lists
include difficulties with language, the dysfluency of ADHD resembles
cluttering. Stuttering is characterized by part-word repetitions (p-p-p-play),
prolongations (sssssoccer), and blocks (d-og). Cluttering, on the other hand,
is characterized by whole-word and phrase repetitions, revisions ( I want to_ I
think that…), and fillers (um, ah, mmm).
“Like stuttering, cluttering is a fluency disorder,
but the two disorders are not the same. Cluttering involves excessive breaks in
the normal flow of speech that seem to result from disorganized speech
planning, talking too fast or in spurts, or simply being unsure of what one
wants to say. By contrast, the person who stutters typically knows exactly what
he or she wants to say but is temporarily unable to say it. To make matters
even more confusing, since cluttering is not well known, many who clutter are
described by themselves or others as "stuttering." Also, and equally
confusing, cluttering often occurs along with stuttering.”[4]
ADHD must be addressed prior
to speech therapy for best results. Stimulant medications seem to have a
greater impact on ADHD behaviors than non stimulant medications. Unfortunately,
stimulants are also linked to “the onset and exacerbation of disfluencies and
stuttering.” Behavior management of ADHD symptoms requires a lot of work collaborating
professionals across settings and is most effective in combination with
medication. It looks to me like concepts
of behavior management for ADHD may help almost any child working on speech
change.
“ADHD represents a deficit in
executive function, a skill set that includes attention, impulse control…and
far more. Seen as a disorder of self-regulation, ADHD potentially impacts
anything that requires planning and coordination, from sleep and eating habits
to laying out a long-term science project all the way to how someone speaks and
listens in conversation.”[5]
That
said, we can understand Dr. Donaher’s conclusion: children with ADHD are unable
to do something without appropriate support.
This concept of providing
support, or “scaffolding,” is critical. A recent book dedicated to moving
beyond “the absurdity of public school IEPs and their bizarre, fuzzy-wuzzy
language,”[6]
describes many ways for adults to support children so they may achieve
short-and long-term goals. For children with ADHD, this is support for
executive functioning skills. I will refer to concepts presented in the workbook
Executive Skills in Children and Adolescents [7]
now as I write about speech therapy goals.
Dawson
and Guare report that the first executive functioning skill to emerge in
childhood is called behavioral inhibition. This skill begins to appear at 5-12 months of age and lays the
groundwork for subsequent skills. Behavioral inhibition has 3 properties: 1. the ability to delay or prevent a
response, 2. the ability to stop ongoing behaviors, and 3. the ability to manage
distractions. Behavioral inhibition reminds me of a fluency enhancing strategy
called pausing. [8]
Pausing
appears in speech therapy for clients of all ages. Sheryl Gottwald lists pause
time as a conversational strategy adults can use with young children who
stutter.[9]
Linda Cochran illustrates the value of wait time with a simple concise drawing
anyone will understand. [10]
Coleman and Weidner encourage adults to divide long complex sentences with pauses when reading aloud to young children. [11],[12]
I've also read about 'the power of the pause' in reference to public speaking. A
short pause gives a speaker extra time to organize ideas, retrieve vocabulary,
formulate grammatically correct sentences, create a speech motor program, and articulate
intelligibly. It also provides time for listeners to process information.
In direct speech therapy, the student enlists
behavioral inhibition to find a new kinesthetic
(sensory) feeling of easier speech. He or she pauses long enough to find this
feeling while saying single sounds, syllables and then isolated words at first.
Gradually, the student uses this new feeling of speech production on tasks of
increasing difficulty, called a hierarchy. There is absolutely no expectation
that a student can enlist behavioral inhibition in everyday conversation until much
later in therapy. Everyday conversation is very demanding and will not provide enough
support to ensure success. However, speech homework is different. Homework games will have supportive rules, such as requiring
pause time from every player.
Wise
adults know that children learn through imitation. Without launching into a
discussion of nature vs. nurture, let's agree that modeling is one way we
nurture our children. How fortunate that the speech language pathologist (SLP) demonstrates
the behaviors she is training! When the SLP says, "Let me think…;"
and, "I feel confident because...;" and, "First I'll make a plan…;"
and "What if...;"[13]
followed by a brief pause, that SLP is
modeling verbal mediation. Verbal mediation is about putting thoughts, feelings and choices
into words – prior to, during, and after a behavior. Verbal mediation is
essential to any kind of speech homework. To transfer a new skill, the parent
and the child will need verbal mediation to decide when, where, and how to
follow through with an agreed upon plan. Evidence based practice requires the
family actively participate in this way. [14]
If you ask a child what he does in speech therapy,
I can almost guarantee he will say something like 'I don't really know. We play
games.' This anecdote represents what happens when children practice new speech
skills. A child has to remember the new speech behavior as he is multi-tasking other
communication demands. It seems to me that adult support frees up a child’s working memory so that he can be successful. This support can
take the form of a linguistic hierarchy because one way to make a task easier
is to simplify language. Also, controlling for pragmatic language leads to
first practicing in choral speech, then immediate imitation, and delayed
imitation before moving on to very simple elicited and spontaneous language tasks.
Simple, repetitive homework games require minimal language processing and
interruption so that a child can remember to use his new speech skill. Children
find it easier to use a new skill when working memory is not overwhelmed.
Many small successes culminate in large achievements.
Remember, the small successes take place in supportive
situations. This is where the executive skill called planning comes in. Math curriculums plan addition and subtraction before
multiplication and division. Similarly, SLPs plan speech work along a continuum
of difficulty. To take this analogy further, we provide maximum instruction
when introducing a new math concept and expect children to solve real-life
mathematical problems only gradually. Similarly, we plan short- and long- term
speech goals that respect the student's ability to inhibit behavior and juggle
communication demands in working memory.
Once a lesson is presented, the student must do
it. I find a child must pay careful attention to a specific activity for about 10-20
minutes at the very least. This is called sustained attention. During sustained attention, the student chooses the new behavior
and remembers to use it repeatedly while relying upon the conditions set up for
his success. The child cannot interrupt the planned activity by leaving his
seat, talking about his favorite TV show, or giving up. He needs to engage his
brain in feeling, hearing, experiencing and comprehending the consequences of a
new behavior. Neurons in the brain need to record and retain the multi-sensory
experience of a new way of speaking. “Concept cells link perception to memory…their
elegant coding scheme allows our minds to leave aside countless unimportant
details and extract meaning that can be used to make new associations and
memories.” [15]
Sustained attention is required at each step of a linguistic and transfer
hierarchies.
Metacognition is the ability to observe one's own behavior. I
find this an especially tricky concept in speech change because sounds are
fleeting. Now you hear it - now you don't. Furthermore, the SLP does not see
nor experience production of the new speech goal. She is unlikely to hear
subtle moments of stuttering or appreciate the student’s internal thoughts and feelings. This is
problematic because the speaker needs feedback to know when she has made an
appropriate change. Listening to an audio recording or observing digital
analysis of her speech may help. This requires a sense of separateness, an
ability to look at speech as something distinct from her inherent identity. Speech
becomes something to study and manipulate.
Perhaps this next executive functioning skill should
have come earlier : regulation
of affect. A child needs to feel comfortable talking about stuttering before
he can examine and experiment with speech change. Fear and embarrassment assume
many disguises. For example, when a second grader crawled under the table as
soon as I moved beyond introductory pleasantries and began talking about
stuttering, I knew affect would be an important therapy issue. In the
children's story Hooray for Aiden a young girl avoids school activities so
that her peers will not hear her stutter. Her sadness and anxiety are
overwhelming until a classroom visitor models self-respect and acceptance. A
policeman visits her classroom to explain his job and as he talks, he stutters.
Policeman Dave tells the class, “There’s n-n-nothing wrong with speaking the
way that Aiden and I speak. When we get stuck on a word, it’s call stuttering.
People who stutter are just r-r-regular people.” [16]
The National Stuttering
Association brings hope and empowerment to children and adults who stutter, their
families, and professionals. Visit www.westutter.org
for more information.
To shorten the length if this article, I will group together the
executive skills called organization, time management & task initiation.
All three apply to speech
homework. I admit that I have never, in my 30 years as an SLP, been able to
convince anyone to consistently complete homework . Finally I realized the
obvious; this was not my job. I can talk with parents about playing speech
games in the car, combining speech work with school work, arranging teacher
conferences, requesting teacher feedback, completing take-home exercises, and
on and on. Ultimately, it is the parent or child who organizes the family
schedule to include speech homework - according to a lesson plan that
respects the child's abilities and provides adequate scaffolding to
ensure success. This is not easy given the pressures of our busy culture. But
speech change does not happen without a commitment to work outside the SLP's
office.
The
final executive skills I’ll mention are goal-directed persistence
& flexibility.
I wish I could find another
copy of a decorative wall hanging I've given as holiday gifts to two students.
It was a simple painted sign that read "never, never, never give up."
Stuttering is a peculiar condition. It is somewhat similar but always different
from person to person. It seems to be affected by so many different factors and
universally responsive to no single therapy method. "Progress" takes
many forms [17]
and therapy week-to-week is dependent upon the client's experience with
previous lessons and homework. As quality of life improves, clients feel their
communication skills are 'good enough' and they leave therapy. Or, they drop
out for a variety of other reasons. So, I never really know how my students
fare over the long haul. I can only hope to have given them something of what
they needed at the time we worked together. Persistence and flexibility over
many weeks, months, or years is one key to success.
Judy
[1] J. Donaher (2012) ADHD and Fluency Disorders in School-Aged
Children, Case Studies in Fluency
Disorders, Rockville, MD: American Speech Language Hearing Association
Online Conference, May 9-12, slide 11.
[2] I recommend visiting websites
such as Children and Adults with
Attention Deficit / Hyperactivity Disorder (http://www.chadd.org/) for more information.
[3] M. Bertin,
M.D. (January 16, 2013) That’s ADHD again? You Don’t Say! Listen Closely and
Hear the Effects of ADHD on Communication, HUFFLIVE, HUFF POST PARENTS.
[6] D.
Twachtman-Cullen & J. Twachtman-Bassett (2011) The IEP from A to Z: How
to Create Meaningful and Measurable Goals and Objectives, San Francisco,
CA: Jossey-Bass, p. XV
[7]
P. Dawson
& R. Guare (2010) Executive Skills in Children and Adolescents: A Practical
Guide to Assessment and Intervention, 2nd Edition, NY, NY: The
Gilford Press.
[8] D. Daley (2010) The Power of the
Pause, http://www.mnsu.edu/comdis/ica1/papers/nuggets/dalyc.html
[9] S. Gottwald (2010) Moving from
Assessment to Intervention Planning , DVD No. 6300, www.stutteringhelp.org.
[10] S. Cochrane ( 2011 ) "Brain Time" - A clinical technique for
children to aid in reducing impulsivity to speak and for a "preparation
time" prior to speaking http://www.mnsu.edu/comdis/isad15/papers/therapy15/cochrane15.html
[12] C. Coleman & M. Weidner (2009) Using Stories to Teach Fluency
Strategies to Young Children, http://www.mnsu.edu/comdis/isad12/papers/therapy12/coleman12.html
[13]
K. Chmela (2004 ) Working with
Preschoolers Who Stutter: Successful Intervention Strategies, DVD No. 0162, www.stutteringhelp.org
[15] R. Q. Quiroga et al. (February, 2013) Brain Cells for
Grandmother: Each concept – each person or thing in our everyday experience –
may have a set of corresponding neurons assigned to it, NY, NY: Scientific
American, pp. 31-35.
[16]
Karen
Hollett (2010) Hooray for Aiden, Yellowknife, NT, Canada: Hooray Publishing, broken link p.20
[17] J. S. Yaruss et. al. (2012) Stuttering in School-Age
Children : A Comprehensive Approach to Treatment, Language, Speech, and Hearing Services in Schools, (43) pp.
536-548.
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