The Link Between ADHD and Stuttering: A Closer Look
About the presenters: E. Charles Healey is a professor of speech-language pathology in the Department of Special Education and Communication Disorders at the University of Nebraska-Lincoln. He has been a faculty member at the University of Nebraska for the past 21 years. He has published and presented numerous papers on fluency disorders in children and adults. He is an ASHA Fellow.
Robert Reid is an Associate Professor of Special Eductation at the University of Nebraska-Lincoln. He is an internationally known scholar in special education and a recognized expert on children with ADHD. He has published many articles on ADHD and presented workshops on the topic throughout the United States.
The Link Between ADHD and Stuttering: A Closer Look
by E. Charles Healey and Robert Reid
from Nebraska, USA
Attention deficit hyperactivity disorder (ADHD) affects approximately 3-5% of school-age children (APA, 1994). One aspect of ADHD which has received some attention is the relationship between ADHD and communication disorders. There are reports that from 16% to 37% of children with specific language impairment also have ADHD (Baker & Cantwell, 1987). Additionally, children who exhibit ADHD have been shown to have high rates of articulation disorders (Baker & Cantwell, 1987, 1992) and display an increased number of speech disfluencies when compared to children without ADHD (Zentall, Gohs, & Culatta, 1983).
A review of the literature on stuttering reveals very few studies have been published on the relationship between fluency disorders and ADHD. Molt (1996) found that three children with cluttering possessed some form of attention deficit disorder. In a recent survey by Arndt and Healey (in press), it was found that about 4% of 109 children who stuttered were suspected of having an attention deficit hyperactivity disorder (ADHD). Interestingly, even though a small subset of the population of children who stutter appears to possess ADHD as concomitant disorder, very little has been written on this topic.
The main purpose of this paper is to take a closer look at the possible link between stuttering and ADHD. Specifically, we will: 1) provide some of the general characteristics of ADHD in school-age children, 2) offer suggestions on how stuttering can be treated when a child stutters and has ADHD, and 3) ask for feedback from clinicians about our recommendations, particularly from those who presently or in the past have treated a child who stutters and who has ADHD.
General Characteristics of ADHD
ADHD is now one of the most commonly diagnosed disorders of childhood (Barkley, 1998). Children with ADHD typically exhibit problems with inattention, hyperactivity, and impulsivity. This is manifest by difficulty attending (or persisting) to task, remaining seated, resisting distractions, and generally impulsive behaviors. Additionally, these children are often noncompliant, aggressive, and disruptive. Problems with socialization and appropriate socials behaviors are also common.
There are three different types of ADHD diagnoses (APA, 1994): ADHD Predominantly Inattentive, ADHD Predominately Hyperactive/Impulsive, and ADHD Combined Type (children who exhibit both Predominantly Inattentive and Predominantly Hyperactive/Impulsive. Below is a brief description of the characteristics of the first two types of ADHD diagnoses. The third type is simply a combination of characteristics associated with the first two types.
ADHD Predominately Inattentive
This type of ADHD may often occur in academic, occupational, or social situations. It is characterized by failure to give close attention to details or careless mistakes in schoolwork or other tasks. Written work is often messy and performed carelessly and thoughtlessly. These children appear as if their mind is elsewhere or simply are not listening to what has just been said. They may shift frequently between activities often without completing any one task. Tasks that require organization or those that require sustained mental effort are usually unpleasant or aversive for these types of children. As a result, children often attempt to avoid these types of tasks. This avoidance must be due to the person’s difficulties with attention and not due to an oppositional attitude. In social situations, inattention problems may result in frequent (and inappropriate) shifts in conversation, not monitoring conversations, or attending to others.
ADHD Predominately Hyperactive/Impulsive
This type of ADHD condition is characterized by inappropriate levels of motor activity. Common problems include fidgeting or squirming in one’s seat, not remaining seated when expected to do so, excessive running or climbing in situations where it is inappropriate. It is also difficult for these children to play quietly and they tend to talk excessively. Usually, these children are labeled as "on the go" or "acting like they are driven by a motor." For some children, problems with hyperactivity decreases markedly by adolescence (DuPaul & Stoner, 1994). In older children, symptoms of hyperactivity may take the form of feelings of restlessness and difficulty engaging in quiet sedentary activities.
Impulsivity is demonstrated by impatience, difficulty in delaying responses, providing answers before questions have been completed, difficulty awaiting one’s turn, and frequently interrupting or intruding on others to the point of causing social, academic, or occupational challenges. Children with impulsivity problems will often make comments out of turn, fail to listen to directions, initiate conversations at inappropriate times, grab objects from others, touch things they aren’t supposed to touch, and clown around. All of this can lead to potentially dangerous activities without consideration of possible consequences.
General Considerations for Treating Children Who Stutter Who Also Have ADHD
At present, a multi-modal treatment to ADHD is the most widely accepted approach (e.g., Barkley, 1998; DuPaul & Stoner, 1994). The model includes four major areas in which intervention may be addressed: (a) educational accommodations, (b) promoting appropriate behavior, (c) medical management, and (d) ancillary support services for children and parents (e.g. counseling, parental support groups). Educational accommodations focus on manipulating the classroom environment (or antecedents) in an attempt to prevent behavior problems from occurring. The goal is to alter the school and classroom environment to better fit the needs of the child. Focusing on antecedents offers the advantage of being proactive rather than reactive. Changing antecedents often results in a swift and sizable positive change in behavior, thus, antecedent manipulation potentially offers a great deal of return on a teacher’s investment of time and effort.
The purpose of behavior management is to decrease inappropriate behavior and increase appropriate replacement behaviors that will help the student to better function in the classroom (Reid & Maag, 1998). It is not sufficient to reduce or eliminate undesirable behavior. Unless the student is given an appropriate behavior in place of an inappropriate one, problems will reoccur or a different set of problem behaviors will emerge. There are no interventions or techniques that are specific to children with ADHD. Behavior modification techniques and other commonly used techniques, which work with other groups of student with behavior difficulties, will also typically work well with children with ADHD.
Medication is the most widespread treatment by far. For children identified by medical/health professionals, the odds are that 9 out of 10 children will receive medication for at least some period. The most commonly prescribed medications are psycho-stimulants such as methylphenidate (Ritalin). Stimulant medication produces immediate and positive changes in behavior (e.g. reduced activity, improved compliance) and improvement on tests requiring concentration and attention in about 75% of children with ADHD. However, the documented long-range effects of stimulant medication on academic achievement or social competence are unknown. Although stimulant medication positively influences the attention deficit symptoms, it has no direct impact upon children's academic performance or social skills.
Ancillary support services are also important since many children will profit from psychological counseling and special instruction in areas such as social skills. Providing support for the parent may also be critical. Speech language services are one important support service for many children with ADHD and because some children with ADHD have been diagnosed as speech/language impaired, the ancillary support services of a speech-language pathologist are important.
Suggestions for Treating Children Who Stutter Who Have ADHD
Given the above general recommendations for treating children with ADHD, the treatment of children who stutter who have ADHD would have to be adapted to meet most treatment objectives. There are a number of techniques which have proven themselves effective within the context of the general education classroom (e.g. Reid, 2000); however, there is little or no information extant on the treatment of children with ADHD for stuttering. Thus, we offer suggestions for treating this type of child based on our knowledge of the general education classroom setting and how it might relate to what is generally known about treating children who stutter.
Medication. There is a good chance that if a child has received an ADHD diagnosis, he or she will be on medication (Reid, Maag, & Vasa, 1994). The most common form of medication is the psycho-stimulant methylphenidate (Ritalin). Proper levels of medication will be help the child to be more attentive, persist longer at a task, and/or modify inappropriate motor activity. Medication will not directly help a child learn or acquire new skills. Rather, it will help the child be more receptive to learning. One critical aspect of medication is knowledge of the window within which the child will function best. Medication will typically take around 30 minutes before its effects become apparent. Approximately 1 hour after ingestion, medication will peak and the positive effects will be maximized. This period of maximum effectiveness will last approximately 2 hours. After this time, the medication will be metabolized out of the bloodstream and its effects will diminish. During this time, some children experience "rebound" effects such as increased motor activity, emotional outbursts, and moodiness. This is normal. To receive optimum results, it’s best if treatments are scheduled from 1 to 3 hours after medication is ingested.
Environment. Because children with ADHD are often easily distracted, it’s best practice to minimize or eliminate any environmental distractions. Children with ADHD should be taught in a room with four walls, with a minimum of objects on the walls. Open classroom environments or a corner of a classroom will likely result in problems maintaining attention.
Instruction. There are a number of common-sense practices that will help children with ADHD. The first consideration might be grouping. Children with ADHD often do well in one-to-one situations or very small groups. If possible, individual instruction is recommended . If this is not feasible, we recommend placing the child with ADHD in as small a group as possible with the best behaved students. The length of lessons is also important. It’s important to match the length of instruction to attention span (i.e. don’t schedule a 20 minute lessor for a child with a 15 minute attention span). It may be better, to schedule treatment for short periods of time (i.e., 10-15 segments) rather than one lengthy session (i.e., 30 minute sessions). If longer sessions must be used, or the student tolerates longer sessions, it’s a good idea to break up the activities with the session. For example, rather than doing two 15-minute activities, it would be better to do four 7-minute activities and allow brief breaks in between. Creating activities that utilize game type formats and infusing novelty can also help maintain attention and effort.
Behavior modification. There are two main goals for behavior modification: increase positive behavior and decrease or eliminate inappropriate behavior. The most common means of increasing behavior is positive reinforcement. That is, providing the student a reward after the behavior is performed. Here’s how it might work in practice. Typically, the first stage of any stuttering therapy program is for the child to identify and learn difference between normal-like and stuttering-like disfluencies. A reward system could be established for children when they correctly identify the difference between various types of disfluencies from a clinicians model and later, in their own speech. Each time the student correctly identifies a disflunecy, she or he receives a token. These tokens later can be redeemed for reinforcers such as toys or preferred activities. Throughout the course of treatment, a clinician would also want to be sure to assist and reward the child on producing utterances with reduced linguistic complexity. Beginning at a simple linguistic level and gradually increasing the complexity of an utterance as fluency skills are learned is appropriate for the ADHD child as well as any other child who stutters. It’s important to remember that children with ADHD require a great deal of reinforcement initially. Reiforcers should be provided frequently.
Once correct identification and understanding of disfluent speech is achieved, a clinician could begin teaching some form of improved strategy for talking with less stuttering through fluency shaping and/or stuttering modification techniques. These might include teaching the child fluency shaping techniques such as a continuous phonation pattern, a reduced speaking rate, and the use of easy onsets of phonation. Pullouts, cancellations or an easy repetition pattern during a disfluent moment could be taught as ways to stuttering modification techniques (Guitar, 1998). Perhaps, a variety of these techniques could be taught to the child before deciding on one or two that assist the child in the greatest speech improvement.
Language training. Because many children with ADHD are socially impaired by the disorder, it would seem important to teach the child some of the essentials of good communication. This would include being a good listener, taking conversational turns, maintaining the topic of discussion, and using good eye contact with the speaker. A communication program outlined by Dodge (2000) could be adapted for use with ADHD children. Thus, one of the main focuses of a program for a child who stutters who also has ADHD would be to assist them in becoming good communicators as well as more fluent speakers.
Questions and Feedback
In an attempt to provide the field with better information than is currently available for helping clinicians treat children who stutter and have ADHD, we ask for feedback from those who read this paper. We are particularly interested in knowing a number of things about treatment with this population and encourage all readers to give us feedback by responding to the threaded discussion that is part of the papers on this website or by sending an email to chealey1@unl.edu. You can respond with specific information/comments or make general comments. Any information will assist us in gathering responses from practicing clinicians. The questions are as follows:
1). What are some general characteristics of children you have treated who stutter who are also ADHD?
2). How have you treated children who stutter who also have ADHD?
3. What particular problems have you encountered while treating these types of disfluent children?
4. Any other information that you would like to share about treating this subgroup of the population of children who stutter.
References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorder. (4th ed.). Washington, DC: Author.
Baker, L. & Cantwell, D. P. (1987). A prospective psychiatric follow-up of children with speech/language disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 545-553.
Baker, L. & Cantwell, D. P. (1992). Attention deficit disorder and speech/language disorders. Comprehensive Mental Health, 2, 3 — 16.
Barkley, R. A. (1998). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (2nd ed.). New York: Guilford Press.
Barkley, R. A., DuPaul, G. J., & McMurray, M. B. (1990). A comprehensive evaluation of attention deficit disorder with and without hyperactivity as defined by research criteria. Journal of Consulting and Clinical Psychology, 58, 775-789.
Dodge, E. (2000). The survival guide for school-based speech-language pathologists. San Diego, CA: Singular Publishing Group Thomson Learning.
DuPaul, G., & Stoner, G. (1994). ADHD in the schools: Assessment and practice. New York: Guilford Press.
Guitar, B. (1998) Stuttering: An integrated approach to its nature and treatment. 2nd Ed. Baltimore, MD: Williams and Wilkins.
Hartsough, C. S. & Lambert, N. M. (1985). Medical factors in hyperactive and normal children: Prenatal, developmental, and health history findings. Amerivan Journal of Orthopsychiatry, 55, 190-210.
Hamlett, K. W., Pelligrini, D. S., & Conners, C. K., (1987). An investigation of executive processes in the problem-solving of attention deficit disorder-hyperactive children. Journal of Pediatric Psychology, 12, 227-240.
Levy, F., Hay, D., McLaughlin, M., Wood, C., & Waldman, I. (1996). Twin-sibling differences in parental reports of ADHD, speech, reading and behaviour problems. Journal of Child Psychology and Psychiatry, 37, 569-578.
Reid, R., Maag, J. W.,Vasa, S. F., & Wright, G. (1994) Who are the children with ADHD: A school-based survey. Journal of Special Education, 28, 117-137.
Riccio, C. A., & Jemison, S. J. (1998). ADHD and emergent literacy: Influence of language factors. Reading and Writing Quarterly, 14, 43-58
Zentall, S. (1985). A context for hyperactivity. In K. D. Gadow & I Bialer (Eds.) Advances in learning and behavioral disabilities (Vol 4, pp. 273-343). Greenwich, CT: JAI Press.
Zentall, S., Gohs, D. & Culatta, B. (1983). Language and activity of hyperactive and comparison children during listening tasks. Exceptional Children, 50, 255ff
September 7, 2000
