How Can You Tell if Childhood Stuttering is the Real Deal?

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One of the more challenging clinical decisions that confront speech-language pathologists is what to do with a young child who stutters. Do we recommend intervention? Do we wait and see if the child recovers without formal therapy? A recent study published in Pediatrics by Reilly and colleagues has generated a significant amount of press, with headlines declaring that preschool children who stutter will “do just fine.”

Even though this message does not appear to be the intent of the authors (as per their more detailed podcast on StutterTalk), it is the message the media chose to run with in their headlines. There are several key points about the Reilly article, preschool stuttering, and our current research base that need to be evaluated before we make claims such as those put forward by the media.

First, the Reilly et al. study used temperament and behavior scales, which were not designed to assess reactions to stuttering or communication. In fact, of the three scales used, only one had a question relating to communication, and it was not about stuttering. So, while it certainly may be true that young children who stutter may exhibit normal temperament and behavior (a finding we should not be surprised by), this study did not actually assess reactions to stuttering or communication, as the misleading media headlines have suggested.

This brings us to the second point of discussion, which is the difference between early stuttering and normal disfluencies. For a child with normal disfluencies, a “wait and see” approach is much more acceptable than for a child with early stuttering. We often use the term “emergent” to describe skills that are developing, but have not fully emerged. Children with normal disfluencies have emergent fluency. Their skills are developing in this area. Children who exhibit signs of early stuttering are much more at risk for continued stuttering, without proper intervention. As such, the question for parents, physicians, SLPs and others, is “How do we know the difference?”

The chart below describes some characteristics of “normal disfluency” and “stuttering.”
Normal Disfluency (less risk)                               Stuttering (higher risk)
Phrase Repetitions Sound                                                Syllable Repetitions
Interjections                                                                          Prolongations
Revisions                                                                                 Blocks
Multi-syllabic Whole Word Repetitions                     Tension/Struggle
No tension or struggle                                                       Changes in pitch/loudness
No secondary behaviors                                                   Secondary behaviors
No negative reaction or frustration                             Negative reaction/frustration
No family history of stuttering                                       Family History of stuttering

 

 

This can be a starting point to help determine risk. In addition, the child’s gender (boys are at a higher risk), time since onset (greater than 6 to 12 months is higher risk), age of onset (children who start stuttering at age 3 ½ or later are at higher risk), overall speech and language skills (it is important to assess all areas of speech and language), and level of parent concern also need to be considered.

Third, much of the problem that persists in our understanding the risk of early stuttering lies in the difference between population studies and clinical studies. Studies that have looked at recovery rate have been population studies, and thus likely captured many children who were experiencing “emergent fluency” rather than “stuttering.” The research does not translate well into clinical settings. While up to 80 percent of children in population studies may outgrow their “stuttering,” that number is far lower in a clinical setting.

Of the children seen in a clinical setting, many have several of the above risk factors that would put them at higher risk for continued stuttering without proper intervention. Children in a clinical setting are not a random sample of the population, but a specific subgroup with an identified concern (usually on the part of the parents) about stuttering. As such, speech-language pathologists need to be careful about discussing recovery rates with parents that may not apply to their child.

Finally, a “gold-standard” that allows us to predict with 100 percent accuracy which children need intervention does not currently exist. As such, we have to rely on current best practice: the integration of research evidence, clinical experience, and client values. Even if we assume that waiting to intervene will result in a similar outcome later, the reality is we do not know if waiting has a negative impact on social skills, self-confidence, and peer relationships.

Given the above information, what do we recommend to parents, physicians and SLPs? Parents are often the most reliable judge of their children. When they come to us with concern, it is warranted in most cases. Parents should trust their instincts. If they are concerned about their child’s stuttering, they should discuss those concerns with the child’s pediatrician and advocate for a consultation with a speech-language pathologist. Parents do not need a referral for an SLP. They can contact an SLP on their own (go to ASHA’s ProSearch directory of clinicians to find one in their area) or go through their public school or Child Find.

Pediatricians should refer to an SLP when any of the following are present in a child who is stuttering:

  • A family history of stuttering
  • Child has been stuttering for more than six months
  • Child exhibits any negative reactions toward stuttering
  • Child exhibits physical tension or secondary behaviors (e.g., eye blinking, head nodding, etc.) associated with stuttering
  • Other speech/language concerns are also present
  • Parents are concerned
  • Child is experiencing negative reactions from other family members or peers

Through a collaborative effort between the parents, physicians, SLPs and others in the child’s community, we can make a significant difference for children who stutter.

 

Craig Coleman, CCC-SLP, BRS-FD, is assistant professor at Marshall University and president of the Pennsylvania Speech-Language-Hearing Association. He is an affiliate of ASHA Special Interest Groups 4, Fluency and Fluency Disorders, and 18, Telepractice. 

Handling Verbally Disruptive Behavior in Patients With Dementia

dementia

Verbal behavior that others consider disruptive is common in later-stage dementia. This behavior can range from a man who follows his nurse around asking repetitive questions, to the woman who sits in her chair and screams loudly for no apparent reason, to the man who lies curled up in bed, moaning softly through the night.

And there are many other variations on these themes. It has been estimated that 25 percent of those with dementia who still live in the community, and 50 percent of those who reside in long-term care facilities, exhibit this type of behavior at any given time. As many as 90 percent of those with dementia will demonstrate such behaviors at some point.

There are a number of different types of dementia-producing illnesses that can lead to screaming and other verbally disruptive behaviors. These include Alzheimer’s type dementias, vascular, Lewy Body, and frontotemporal, as well as the less common prion diseases, metabolic imbalances, and other degenerative conditions. Disinhibited behaviors are often associated with frontotemporal dementia, but they can be due to other diseases as well.

Often, sadly, the typical response to these disruptive individuals is to administer some medication intended to calm the person and make the behavior more manageable. However, in most cases there are non-pharmaceutical interventions that not only work much better, but also produce fewer side effects. I have heard it said that up to 95 percent of behaviors in people with dementia are actually a form of communication. When one considers the loss of verbal language production that inevitably occurs in dementia’s latter stages, it is no surprise that people with this disease resort to whatever means they can to communicate with the outside world.

The messages they seek to convey tend to fall into a few common categories: 1.) “I’m in pain,” 2.) “I’m lonely/frightened/bored,” 3.) “I don’t want to be here,” and 4.) “I need/want something.” At times, it is readily apparent what the person is trying to say. But, more often than not, the person’s caregivers need to do a little detective work to decipher the meaning behind the verbal outburst.

When I work with a nursing home resident with dementia and  consistently problematic behavior, I first attempt to define the behavior more clearly. What exactly does the resident do? What times of day does this occur? Are there any other events and circumstances associated with the behavior—occurring immediately before or after the behavior, for instance? What else is going on in the environment? It is also helpful to know what interventions have been attempted in the past for dealing with the behavior, and whether these interventions have proven at all beneficial. I try to learn as much as I can about the resident’s medical, family and occupational history. It is important to remember that this verbal agitation or disruption is a symptom and not a disease or condition in itself.

Pain, often related to conditions such as arthritis, compression fractures, limb contracture, and constipation, is responsible for perhaps as much as 50 percent of verbal disruptions. Because people with advanced dementia may lose the ability to ask for pain relief, administering a daily maintenance dose of Tylenol or a similar medication can be helpful.

In addition, I recommend doing the following to assess what might be causing discomfort:

  • Conduct a physical evaluation. Has the resident recently been placed on a new medication, or taken off one? Is there any sign of infection, injury or other medical issues? Is there pain related to arthritis, a toothache, constipation, etc.? Is the resident hungry or thirsty or in need of a change in bedding?
  • Survey the person’s environment to determine if any changes may have prompted the behavior. This could be a change in the routine, a new caregiver or a new roommate. Perhaps the hustle and bustle of getting the unit ready for Christmas is too much for the person to handle. Has there been an upsetting visit from a family member? (Also be aware that understimulation can be just as problematic.)
  • Assess the caregivers in this particular situation. Caregivers, both professionals in long-term care facilities, and family members in a home environment, are subject to a great deal of stress. This stress may not be directly related to the situation at hand. It could be that a nurse has had to place her own husband in the hospital, or has just learned that a son is having trouble in school. And if the caregiver is feeling stressed, it is likely that her charges will pick up on this as well.

Any form of intervention ultimately depends on the cause of the outburst.  Treating acute medical issues—and addressing dehydration or hunger—should take precedence over anything else.  Next,  consider environmental modifications, such as using softer lighting or music, establishing a routine that can provide a calming influence, and so on.

Music is associated with reduced agitated behavior, especially during bathing or meals. Light physical exercise can prove to be a pleasant distraction for the person. Other possible interventions can include pet therapy, massage, white noise, photographs of family or familiar people and places, and attention to any personal needs the person may have.

If you’ve tried all these strategies, and the person with dementia continues to be disruptive, possibly posing a risk of self harm or harm to others, then antidepressants, mood stabilizers and antipsychotic agents may provide some benefit. But, given that the side effects can be severe, opt for such agents only after careful consultation with the person’s physician and family.

Jami L. Hede, MS, CCC-SLP, is a private practitioner and affiliate of  ASHA Special Interest Group 15, Gerontology. This post was adapted from her blog, “Exploring Dementia.” 

The Signs Of The Times

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Announcing the launch of ASHA’s Identify the Signs, a public education campaign broader in reach, scope, and array of ASHA member-oriented tools than anything we have done in the recent past.

Identify the Signs spotlights the importance of early detection of communication disorders and the ability of certified speech, language and hearing professionals to provide quality treatment and help. Altogether, it is a unique and promising opportunity for everyone in the ASHA community to be involved at every level, working in concert to raise the profile of our professions and most importantly, the needs of those we serve.

Nationally, the campaign features English and Spanish television, radio and print public service announcements that highlight the importance of early detection and encourage the public to learn the early warning signs. We also will engage broadcast, print and digital media outlets to bolster the campaign and direct the public to our new campaign website, IdentifyTheSigns.org. The website has helpful, easy to understand information about the early warning signs of communication disorders that will enable the public identify potential communication issues and seek treatment.

But here is a truly exciting part: Identify the Signs is designed to be equally active and effective at the grassroots. In the coming months, outreach to local media markets will be conducted, and we anticipate that it will result in opportunities to feature ASHA members. In recent years, numerous members have been very effective media sources and our new campaign represents a golden opportunity to increase the number who serve in that role, spreading the word about our discipline and the important work we do. Interested ASHA members are invited to indicate their interest by sending in a brief email to pr@asha.org. They will then be contacted as appropriate media opportunities arise.

Apart from that, there are a variety of campaign assets for ASHA members to use to raise awareness in their practices, their schools and their wider communities. Along with the public-focused website, ASHA has developed a member toolkit that includes print and digital posters, social media badges and more to educate people about the early warning signs of communication disorders and highlight speech-language and hearing professionals as the best sources for treatment. Also, products and brochures that complement the campaign are now available in the ASHA store.

We encourage ASHA members to visit the campaign site and use the outreach tools there in their communities. They are also invited to send feedback about the campaign, its resources, and their involvement to pr@asha.org. The Identify the Signs effort will extend over the next year, and such input will be helpful guidance for the future.

Patty Prelock, PhD, CCC-SLP, is the current president of ASHA and the dean of the College of Nursing and Health Sciences and professor of communication sciences and disorders at the University of Vermont. patricia.prelock@uv.edu.

Why Suspected Childhood Apraxia of Speech Requires Careful Assessment

toddlerpointing
Recently I got one of those phone calls that speech-language pathologists often dread. It went something like this:

Parent: Hi. I am looking for a speech therapist who uses PROMPT [Prompts for Restructuring Oral Muscular Phonetic Targets] to treat my son’s childhood apraxia of speech. Are you PROMPT-certified?

Me: I am PROMPT-trained and I do treat motor speech disorders but perhaps you can first tell me a little bit about your child? What is his age? What type of speech difficulties does he have? Who diagnosed him and recommended the treatment?

Parent: He is turning 3. He was diagnosed by a neurodevelopmental pediatrician a few weeks ago. She recommended speech therapy four times a week for 30 minutes, using PROMPT.

Me: And what did the speech therapy evaluation reveal?

Parent: We did not do a speech therapy evaluation yet.

Sadly, I get these types of phone calls at least once a month. Frantic parents of toddlers ages 18 months to 3+ years call to inquire about PROMPT therapy based on a neurodevelopmental pediatrician’s diagnosis. The speech-language diagnosis, method of treatment and treatment were typically specified by the physician in the absence of a comprehensive speech language evaluation and/or past speech-language therapy treatments.

The conversation that follows is often uncomfortable. I listen to the parent’s description of the symptoms and explain that the child needs a comprehensive speech language assessment by a certified SLP before being treated. I explain to the parent that, depending on the child’s age and the findings, the assessment may or may not substantiate CAS because symptoms are similar in a number of other speech and communication disorders.

Parents react in a number of ways. Some hurriedly thank me for my time and resoundingly hang up. Some stay on the line and ask me detailed questions. Some request an evaluation and become clients. A number of them find that their child never had CAS! Past misdiagnoses have ranged from autism spectrum disorder (CAS was suspected because of imprecise speech and excessive jargon) to severe phonological disorder to dysarthria secondary to cerebral palsy.

CAS is a disorder that disrupts speech motor control and creates difficulty with volitional, intelligible speech production. Research indicates that while children with CAS have difficulty forming words and sentences at the speech level, they also struggle with areas of receptive and expressive language. In other words, “pure” apraxia of speech is rare.

This condition needs to be diagnosed by an SLP. In fact, due to the disorder’s complexity, it is strongly recommended that parents seek an assessment by an SLP specializing in assessment and treatment of motor speech disorders. Here’s why.

  • CAS has a number of overlapping symptoms with other speech sound disorders, such as severe phonological disorder and dysarthria.
  • Symptoms that may initially appear as CAS may change during the course of intervention, which is why diagnosing toddlers under 3 years of age is problematic. Instead, a “suspected” or “working” diagnosis is recommended in order to avoid misdiagnosis.
  • Diagnosis of CAS is nuanced, complex and challenging, though a new instrument—Dynamic Evaluation of Motor Speech Skill (DEMSS)—shows promise with respect to differential diagnosis of severe speech impairments in children.

When children with less severe impairments, SLPs need to determine where the breakdown is taking place by designing tasks assessing:

  • Automatic versus volitional control.
  • Simple versus complex speech productions.
  • Consistency of productions on repetitions of same word.
  • Vowel productions.
  • Imitation abilities.
  • Prosody.
  • Phonetic inventory before and after intervention.
  • Types and levels of cuing required for response.

Given the complexity of CAS assessment and treatment described here, you can see that the PROMPT approach may not even be applicable to some children. Thus, I strongly urge developmental clinicians to first refer a child for a speech language assessment—and refrain from making recommendations for specific types and frequencies of treatment—when difficulty with speech production is observed.

For more information on childhood apraxia of speech, please visit the Childhood Apraxia of Speech Association of North America website or visit the ASHA website to find a professional specializing in the diagnosis and treatment of CAS near you.

 

Tatyana Elleseff, MA, CCC-SLP, is a bilingual speech-language pathologist with Rutgers University Behavioral Healthcare and runs a private practice, Smart Speech Therapy LLC, in Central New Jersey. This post is adapted from a post that originally appeared on her blog, Smart Speech Therapy LLC. She specializes in working with multicultural, internationally and domestically adopted children and at-risk children with complex communication disorders. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education, 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, and 16, School-Based Issues.

Early Speech and Language Development of Children

Elizabeth-Crais_PodcastPodcast: Episode 27
How can you tell the difference between a child who may have a speech or language disorder and a “late bloomer?” What are the benefits of early intervention? SLP and ASHA Fellow Elizabeth Crais answers these and other key questions as part of ASHA’s “Identify the Signs” campaign. Read the transcript.