2/6/13

ADHD, Stuttering, and Executive Functioning


          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.

It seems to me that concepts of executive functioning apply to speech therapy for children with and without ADHD. The latest catalogue from LinguiSystems arrived in my mail yesterday. I see there are four products for executive functioning and the Executive Functions Training workbooks are “Bestsellers”. [18]I’ll add them to my wish list! In the mean time, I see it’s a beautiful sunny though chilly February day. Time to stop typing and soak up some sun. As usual, I’ll need to rearrange my to-do list , and tap my executive functioning skills, to make this change in my plan for the day! Wishing you plans with flexibility!









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.
[4] The Stuttering Foundation: http://www.stutteringhelp.org/cluttering
[5] M. Bertin, (1/16/13)
[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
[14] Evidence Based Practice http://www.asha.org/members/ebp/
[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, www.hooraypublishing.com 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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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.