We have recently been inundated with questions about children who are being referred for speech services due to “audible inhalations” that occur when they are engaged in conversational speech. We hope to bring some relief to these questions by parsing out three potential scenarios that have been reported by our colleagues.
What's going on?
First, let us acknowledge that research has not yet caught up with the observations of clinicians on the ground—there are no studies that we’re aware of to guide us about how to handle these unique speech disruptions. Still, we can find some clarity through careful differential diagnosis of these breathing patterns, so that we can understand whether the breathing patterns are part of our scope of practice
Where Do I Start?
The first step is to gain clarity about what the child is doing and feeling. Thus, before we launch into the scenarios, we want to highlight the importance of discovering—from the perspectives of the students themselves—IF they notice the breathing differences and WHY they think they are doing this!
Yes, we need to observe and document, and we need to gather information from the students’ caregivers and teachers and others, but we cannot stop there! Don’t just observe as a listener and surmise—discover from the speaker’s experience so you can know more at a deeper level!
Of course, some children will not have awareness of what they are doing, or they may not have the language capabilities to describe their awareness. Some children simply may not know why they are breathing in these unique ways. Just because a child may not be able to tell us the ifs and whys doesn’t mean we shouldn’t probe for deeper understanding.
Differential Diagnosis
With that said, here are some thoughts about what we know—for now—and about how we are approaching this in our own diagnostic and clinical practices.
1. Audible inhalations in children already diagnosed with stuttering
In a recent blog post, Scott discussed the all-too-frequent practice of clinicians and others trying to change breathing patterns in people who stutter. His rant emphasized one of the main the problems with telling people who stutter to “take a deep breath” – that these deep breaths can turn into exactly the type of audible inhalations that we are focusing on here.
Here’s a link to that post: https://www.stutteringtherapyresources.com/blogs/blog/its-almost-never-breathing
In other words, the inhalations may simply be a reflection of a habitual over-emphasis on breathing differently (and, yes, that includes others giving the student advice about diaphragmatic or belly breaths, big breaths, deep breaths, relaxation breaths, and all the rest!).
If you see that a child who stutters is taking breaths in the middle of or between words, first assess whether the child is changing breathing because they have been told to do so, perhaps by SLPs or well-meaning but misguided caregivers.
You will also want to explore whether the breathing pattern might be a result of their attempts to not stutter (that is, a “secondary behavior”). It is quite common for people who stutter to try to avoid stuttering or to hide their stuttering, and one way they try to do this is to change their breathing. (Again, probably due to frequent recommendations to breathe.)
If the breathing changes are related to attempts to avoid stuttering, then there is much that we can do to help speakers change that. We have written three blog posts on the topic of secondary characteristics…here are links:
Addressing Secondary Characteristics
Even More Secondary about Secondary Characteristics
How Do I Work on Secondary Characteristics in Therapy?
2. Audible inhalations in children who are exhibiting atypical disfluencies
In another recent blog post, Nina outlined the characteristics of students who are demonstrating breaks in fluency that are not typical for stuttering nor cluttering. These occur in students who are presenting with what we understand as atypical disfluencies.
In this case, the students are definitely experiencing a fluency issue, but it’s not stuttering or cluttering. Still, some of these students are observed to exhibit audible inhalations (AI) within words. (e.g., ba-AI-aby).
For these students, the breathing differences seem to be a part of the overall fluency difference, not a separate issue, and we need to treat the breathing within the context of the atypical disfluencies themselves.
Here’s a link directly to that post so that you can learn more: https://www.stutteringtherapyresources.com/blogs/blog/what-about-those-atypical-disfluencies
3. Audible inhalations that are not co-occurring with any observed or reported speech fluency condition (such as stuttering, cluttering, atypical disfluencies)
Now, what about those students who aren’t stuttering or cluttering or disfluent in any other way, but they’re still exhibiting audible gasps between words?
As noted above, we start by attempting to gain insight from those around the children and from the children themselves, about what is going on. Then, we can seek to determine what our role will be—if indeed we will have any role at all.
Here are some of the questions we ask ourselves:
• Does the person’s breathing seem to be normal aside from the audible inhalations?
• Does the person’s breathing seem to be normal when they are not speaking?
• Does the person exhibit any speech, language, or voice concerns that might be related to breathing (e.g., vocal cord dysfunction, paradoxical vocal fold movement)?
• Does the person have a history of any developmental or medical issues that may relate to the observed breathing patterns (e.g., asthma, Down syndrome)?
• Could there be an associated neurological condition that exacerbates respiratory function? (e.g., Myasthenia Gravis, Cystic Fibrosis)
In many cases, determining the answers to these questions and following best practices in assessment will require collaborating with the students’ caregivers and other professionals.
If it turns out that the abnormal breathing is not related to speech production and not interfering with the person’s communication, then referral to and intervention from an SLP is not indicated.
Nevertheless, many students who demonstrate audible inhalations during speaking will likely end up in our space because of the likely impact on communication. Our role may be a supportive one, when other professionals take the lead in treating primary breathing issues. Still, we need to be ready to intervene in order help students whose communication is affected by abnormal breathing patterns, regardless of the cause.
Intervention might involve providing education about the speech production mechanism and about typical breathing for speech. (Continue to resist the urge to teach atypical breathing patterns like taking deep breaths before speaking—that’s just now how people talk!) And, this might involve providing guidance about appropriate times to breath, such as before beginning an utterance or between phrases within an utterance. The concepts of appropriate, natural pausing and phrasing may be of help as well. Some of these strategies are commonly used with people who stutter, so you can draw from your existing knowledge to help!
Sum it up, please!
The bottom line is that we must prepare ourselves to feel comfortable and confident in our differential diagnosis of fluency disorders and breathing issues related that might be related to them. We also must increase our comfort in knowing when to refer or suggest outside medical perspectives to evaluate respiration issues that do not speech pathology services.
As indicated, this is an area in which knowledge is still developing. We frankly don’t know why we are seeing so many inquiries about abnormal breathing. We do know, however, that we are stronger together in our search for increased education and understanding of these and other complicated cases.
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