Below continues our examination of disfluencies in Autism Spectrum Disorders, as introduced in Part I of this paper. In Part II, we examine two additional diagnoses within the autism spectrum.

Case Three: Pervasive Developmental Disorder, Not Otherwise Specified

Background:
C3 was a 5-year-old male who was referred to a private speech and language clinic by his mother with concerns regarding social interaction. C3 was recently diagnosed with Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS) by a neurodevelopmental pediatrician. Cognitive testing revealed scattered skills, with particular needs in the area of perceptual performance. C3 was noted by his preschool teacher to like to be "in charge," and to have difficulty accepting other children's ideas for play themes. He was also noted to have difficulty transitioning between activities.

Disfluency Profile:
Speech and language skills were assessed via standardized testing and spontaneous speech samples collected in the clinic and from an audiotape of home play activities. Disfluencies were mild and consisted only of final part-word repetitions in the middle of sentences (e.g. "Thomas the Tank-ank Engine is a train-ain that is sold in stores-ores everywhere."). Disfluencies were noted during tasks requiring language formulation such as expository narratives, and at the end of sentences when no further language formulation was required, such as during sentence repetition tasks. C3 was aware of his disfluencies only when they were taped and played back for him, but otherwise denied them in general. His teacher reported that the disfluencies did impact intelligibility minimally, until she became accustomed to listing to C3's speech pattern.

Language Profile:
Language skills were within the average range on standardized testing. C3 was noted to have difficulty accurately reading and responding to nonverbal communication. He was also reported to have stereotyped interests, such as topic focus upon "Thomas the Tank Engine" in conversation. He could provide an organized narrative, but his conversation skills were characterized by monopolizing conversational topics and turns, and abruptly shifting from a topic presented by his partner back to a topic of his choosing.

Discussion:
Given C3's pattern of presentation, we need to examine what we know about his relevant symptoms in the areas of speech, language, and behavior; that is, his word-final disfluencies (WFDs), language formulation skills and flexibility skills. In terms of speech, C3's pattern of disfluencies was not typical of developmental stuttering, where disfluencies generally occur in the initial rather than in the final position of words or phrases (Humphrey & Van Borsel, 2001). To date, WFDs have been most commonly reported in individuals with disorders of executive functioning and/or communication, such as traumatic brain injury (LeBrun & Leleux, 1985) and mental retardation (Stansfield, 1995).

In terms of language, C3 presented with no known language difficulties, either in standardized testing or conversational speech. He did, however, tend to exhibit WFDs when formulating expository narratives. Expository narratives have been found to result in more mazing behaviors (defined by Loban (1976) as disrupted flow of speech due to excessive repetitions, revisions, and/or filled pauses) than general narratives in children with and without language disorders, and therefore to present more challenge in formulation (Scott & Windsor, 2000). Recent work in stuttering has suggested that young children who stutter may present with subtle differences in speed and accuracy of lexical retrieval (Hall, 2004; Hartfield & Conture, 2006; Pellowski & Conture, 2005). It is possible, then, that C3 had some subtle differences in higher-level language formulation, which may have been related to the presence of the WFDs.

In terms of speech, C3 also exhibited WFDs when no language formulation was required. Van Borsel (2005) suggests that such patterns may be similar to palilalia, and describes these as "compulsive repetitions." It is reasonable, then, to speculate that a "compulsive repetition" might be some type of perseverative behavior. From a behavior standpoint, perseveration has been clearly documented in ASDs (see Pennington & Ozonoff, 1996 for a review). C3's difficulties in transitioning and flexibility with peers and possible perseverative behaviors suggest difficulties within the larger category of executive functioning (EF) skills. In brief, EF skills involve planning, goal-setting, organizing, evaluating, shifting set, and regulating behaviors in order to accomplish a task and to function efficiently and effectively in one's environment (Singer & Bashir, 1999).

Researchers have documented WFDs in the preschool population (Camarata, 1989; Mowrer, 1987; Rudmin, 1984). In these instances, the occurrence of the WFDs was fleeting and disappeared within a few months without any treatment, suggesting a possible phase in normal preschool development. In addition, compulsive and repetitive behaviors increase in normally developing children after one year of age and gradually decline after four years of age (Evans, et al., 1997). Leekman, et al. (in press) found repetitive behaviors to fall on a continuum in typically developing two-year-olds. Turner (1997) found a correlation between perseveration and reports of repetitive verbal behaviors, such as echolalia, among individuals with autism. Although repetitive verbal behaviors such as WFDs have not yet been studied specifically, it is possible to speculate from these findings that C3's WFDs were part of overall delays in development, and may remit on their own.

Treatment Considerations:
Just as we have no means to predict with certainty who will recover from typical stuttering, we have even less information about who will recover from C3's atypical type of stuttering. Therefore, from a clinical standpoint, we need to determine treatment priorities based upon functional concerns. In C3's case, difficulties with social interaction were C3's mother's initial concerns, and therefore such pragmatic issues need to be addressed. Fluency appears to be mildly impacted without evidence of tension, struggle, or communicative avoidance, and intelligibility of speech is only minimally affected. It seems logical, then, that a focus upon executive functioning skills as they relate to social interaction would be of primary interest. Whether addressing executive functioning skills also improves fluency remains to be seen through follow-up evaluations. WFDs would continue to be monitored for warning signs that further intervention may be warranted.

Although there is no treatment efficacy research available for C3's disfluency profile, we can consult research from other disciplines to keep our treatment grounded in evidence-based practice (Bernstein Ratner, 2005). Treatment efficacy has been demonstrated for addressing social skills and peer interaction through a combination of conversational skills training and peer coaching skills in context (Bierman & Furman, 1984). A review of the social skills literature has found that manipulations of antecedents to and consequences of behaviors have been effective strategies for social skills training with those of lower cognitive levels, while coaching, modeling and self-control training have been more effective for higher cognitive levels (Gresham, 1981). Use of a floortime approach has also been shown to be effective for individuals with PDD-NOS (Greenspan & Weider, 1997). Singer and Bashir (1999) have documented effectiveness of pause time for an individual with formulation and executive functioning issues. Given that the presenting symptoms for language formulation, if they are symptoms at all, are subtle, adaptive contextualized strategies such as use of pause time are more appropriate than intense exercises addressing formulation of expository narratives (Singer & Bashir, 1999).

Case Four: Asperger Syndrome

Background:
C4 was a 10-year-old female who was diagnosed with Asperger Syndrome by a neuropsychologist. All scores on the Weschler Intelligence Scale for Children-III were in the superior range of performance, with the exception of average performance for working memory and processing speed. C4's classroom teacher reported difficulties with transitions and flexibility when things did not go as she expected. She also experienced teasing from peers in response to her poor self-monitoring of offensive habits.

Disfluency Profile:

Speech and language skills were assessed via language sampling in home and classroom environments, and via interview, checklists and standardized testing. Stuttering was moderate. Part-word repetitions were noted at the beginning, middle and ends of words and syllables. Prolongations (1 second duration) and blocks (1-3 second duration) were also noted. Tension and audible inhalation were noted during moments of blocks. However, no other secondary behaviors, affective or cognitive components were noted. C4 exhibited excessive non-stuttered disfluencies, including phrase revisions and interjections. C4 was aware of her disfluencies in general but could not identify them during specific moments of occurrence.

Language Profile:
Language scores on standardized tests were within the above average range of performance. Similar to C3, C4 had difficulty with shifting topic and monopolizing conversation; however, unlike C3, C4 also had difficulty organizing verbal narratives, demonstrating an excessive number of verbal mazes in her conversational speech.

Discussion:
Following the same analysis pattern used with C3, and given what we know about EF and language development from the literature, we use what we see and know to make treatment recommendations for C4. Many of the issues are similar for this client as for C3. However, given C4's disorganization in narrative, this area seems to require more intense work than just adaptive strategies. While difficulties with formulation may or may not be related to C4's disfluencies, these are communication needs which must be addressed for C4 to function as an effective communicator. C4's audible inhalation in response to moments of stuttering suggested that she was in need of more effective fluency strategies to help her regain control of her speech.

Treatment Considerations:
It was recommended that C4's clinician work with her on use of fluency strategies, pausing, and formulation strategies in conversational contexts. Because her difficulties with formulation and fluent speech were more severe than C3's, she would likely require more direct work on foundation skills in addition to application of skills in functional contexts.

Given her EF difficulties, and what the literature says regarding treatment strategies for those with higher cognitive levels, direct teaching and practice following conversational rules were recommended for C4. She would also need direct teaching and practice using strategies to keep herself organized (e.g. transition words in verbal and written activities). In terms of EF skills, work on self-monitoring behavior was recommended. It is hoped that such self-monitoring would carry over to monitoring of speech; however, given the social stigma attached to some of her behaviors, monitoring of these be would be a priority regardless of a carryover effect to fluency. Habit self-monitoring may be more appropriately addressed by a school counselor, or, if the behaviors are found to be related to sensory issues, by an occupational therapist.

Given that C4 had more than the possible language formulation issues of C3, C3's strategy of pausing to give him time to formulate may have helped C4, but may also have resulted in increased stuttering, since most people who stutter experience difficulties with initiation of phonation (Logan, 2003). Therefore, it was recommended that C4 work on coordination of traditional fluency strategies such as easy starts, pullouts, and continuous phonation with pausing to buy time for formulation.

Pulling it all together

In summary, there are a number of considerations when planning a treatment path for speech disfluencies in ASDs. Factors the clinician might consider include the characteristics of the disfluencies (stutter-like or atypical, duration of disfluencies, and number of reiterations), reactivity to and awareness of disfluency, linguistic context of disfluencies, and impact on communication. Treatment decisions in the cases presented here also took into account the overall communicative abilities of the child, predictors of chronicity and recovery, presenting symptoms of concomitant disorders, and hypotheses related to the cause or nature of disfluent speech. In all four cases, the authors evaluated the profile and needs of the individual child in determining treatment priorities.

Although the treatment research regarding fluency disorders in the ASD population is limited, the clinician can examine evidence from research in related disciplines for guidance in making evidence-based treatment decisions. We have provided a non-exhaustive list of research at the end of Parts I and II as starting points.

References

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Discussion for either or both Part I and Part II