Does this scenario sound familiar? A teacher (or parent) asks you to “take a look” at a student because they think he may be stuttering. You observe the student, but what you see in the child’s disfluencies is unexpected. You start to dig deeper, even asking the student about what you are observing. He isn’t aware of his disfluencies. When you ask him about how his speech feels, he says he doesn’t feel any tension in his speech muscles!
So, you are left to wonder…Is this child stuttering? It doesn’t look like “real” stuttering! He is certainly disfluent. But he’s not stuttering and he’s not cluttering!
What to do???
We have heard this clinical discussion for the better part of a decade now. Unfortunately, clinicians still lack confidence in assessment and treatment of what is being termed “atypical disfluencies.”
As professionals, we are left to our own clinical decision-making process to determine if atypical disfluencies are impacting a child’s ability to communicate in his speaking environments. We need help! I hope to provide some clarification and resources in this entry.
I was in involved in a research study with Dr. Kathleen Scaler-Scott on this very topic. Even at that time (2007-08), clinicians and researchers realized what these students were doing was different than both stuttering and cluttering, but the research was just beginning to get off the ground.
The study paired her wonderful researchers at Misericordia University with a volunteer cohort of clinicians at my wonderful Frisco Independent Schools in Texas. The study was designed to look at atypical disfluencies in the speech of students on the autism spectrum. These students were assessed and diagnosed with atypical disfluencies and no other fluency disorders.
Our trial therapy in this study was based on working memory, as some theorize that for students on the spectrum who present with these disfluencies, there could be a formulation issue preceding some of the difficulties in moving forward with communication. Like cluttering, the children didn’t seem to be aware that it's happening until it was brought to their attention, and many students in the study truly did not care.
What we know for now IN BRIEF
- First, let’s clarify the types of disfluencies we are discussing as atypical:
- MWB: Mid-Word Break [be-come]
- MWR: Mid-Word Repetition [be-e-come]
- BSI: Sound Insertion (in-word or between-words) [be-uh-come]
- FSR: Final Sound (or syllable) Repetition [become-m-m] [become-ome-ome]
- FSP: Final Sound Prolongation [become-mmm]
- Next, let’s be clear that these types of disfluencies seem to occur predominantly in children on the autism spectrum. However, studies and clinical evidence are also showing atypical disfluencies in students with high degree of ADHD as well as some students without co-occurring disorders.
- And finally, it is important to realize that a student may present with atypical disfluencies AND stuttering, or atypical disfluencies AND cluttering, so differential diagnosis will be key.
What do we do?
Having said all this, once we have a correct assessment and diagnosis, how do we treat students who are showing these patterns? THAT is the million-dollar question!
As you have no-doubt discovered, research and treatment procedures are a little behind the clinical anecdotal evidence that many of us have right now. The good news is, there are people out there trying to catch up! (see resources below).
For now, we must treat these children with the evidence-based practice we have, which is in all areas of fluency disorders. In these situations, I always remember a quote by Dr. Nan Bernstein-Ratner. Paraphrasing her, “Use what you already know (as long as it's evidence-based).”
In my district and in my practice, once we “upped our game” in differential diagnosis of this population, we took what we knew to be evidence-based in other fluency disorders to help these children begin to recognize and then reduce the breaks in their fluency.
If you think about students on the autism spectrum and those with ADHD, you know that self-monitoring can be an issue. We work on mindful attention of communication based upon the child's level of awareness, motivation, and ability to self-monitor their messages-at least in the structured therapy setting. These activities are those that we use for our students who stutter, adapted to the needs of each student.
Once there has been some success with self-monitoring of atypical disfluencies, we move on to helping these students by smoothing out their messages using appropriate pausing. These are the same activities we use with students who stutter and/or clutter, and we adapt them as necessary for each child.
Another evidence-based fluency disorder activity that has shown some promise in students who are able to recognize their atypical disfluencies after they have occurred is the strategy known as cancellation. This Van Riper based strategy is part of the stuttering management techniques we use with students who stutter. You can see cancellation in action in our video series of speech handling strategies.
Because success is not guaranteed, we spend much of our time educating parents and teachers about communicative impact as we work to increase the effectiveness of each student’s overall communication. This includes working on the atypical disfluencies if they have a moderate level of negative impact on the child's communication.
I hope this have given you some direction and help in your quest to work with this population. We wish we had definitive answers and research, and a packet of worksheets and handouts that you could use, but unfortunately that's a little farther off in the future.
In the meantime, here is a list of the resources I have used to increase my efficacy in assessment and treatment of atypical disfluencies. Most of these resources discuss children on the autism spectrum. If you have a student who demonstrates atypical disfluencies, but is not diagnosed with a co-existing disorder, the information presented in these resources is STILL valid! Don’t let titles or subject-types keep you from moving into a deeper understanding of these students and a more effective and efficient way to enhance their communication.
As always, don’t hesitate to reach out to us with questions and comments at firstname.lastname@example.org.
Current resources for working with atypical disfluencies
Scaler-Scott, K. (2018) Fluency Plus: Managing Fluency Disorders in Individuals with Multiple Diagnoses. Slack Incorporated: NJ.
Scaler Scott, K., Grossman, H., Abendroth, K., Tetnowski, J.A. & Damico, J.S. (2006). Asperger’s Syndrome and Attention Deficit Disorder: Clinical disfluency analysis. Proceedings of the 5th World Congress on Fluency Disorders. Dublin, Ireland: International Fluency Association.
Shriberg, L.D., Paul, R., McSweeny, J.L., Klin, A,. Cohen, D.J., & Volkmar, F.R. (2001). Speech and prosody characteristics of adolescents and adults with High-Functioning Autism and Asperger’s Syndrome. Journal of Speech, Language, and Hearing Research, 44, 1097-1115.
Sisskin, V. (2006) Speech Disfluency in Asperger’s Syndrome: Two Cases of Interest, SIG 4 Perspectives on Fluency and Fluency Disorders, 16, 12-14. (https://doi.org/10.1044/ffd16.2.12)
Sisskin, V. (2012) Autism Spectrum Disorders and Stuttering (includes information about Atypical Disfluencies). (https://www.stutteringhelp.org/training/autism-spectrum-disorders-and-stuttering)
Sisskin, V., & Bernstein Ratner, N. (2015) My Client Isn’t Fluent, but Is It Stuttering? Part 2. Stuttering Foundation. (https://www.stutteringhelp.org/My-client-isnt-fluent-but-is-it-stuttering)
Sisskin, V. & Wasilus, S.(2014). Lost in the Literature, but Not the Caseload: Working with Atypical Disfluency from Theory to Practice, Seminars in Speech Lang 2014; 35(2): 144-152.