Does this scenario sound familiar? A teacher (or parent) asks you to “take a look” at a student because they think the child 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 they are feeling when they speak. They aren't aware of any disfluencies. and they say they don’t feel any tension in their speech muscles!
So, you are left to wonder…Is this child stuttering? It doesn’t look like “real” stuttering! The student is certainly disfluent. But it's not stuttering and it's not cluttering!
What to do???
We have had this clinical discussion with our colleagues for many years now. Unfortunately, SLPs still lack confidence in assessment and therapy 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 their speaking environments. We need help! In this blog, I hope to provide some clarification and resources that can help.
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 experiencing was different from both stuttering and cluttering, but the research was just beginning to get off the ground.
The study paired Dr. Scaler-Scott's team of researchers at Misericordia University with a volunteer cohort of clinicians at Frisco Independent Schools in Texas. The study was designed to look at atypical disfluencies in the speech of students with autism. These students were assessed and diagnosed with atypical disfluencies and no coexisting fluency differences.
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 students didn’t seem to be aware that disfluencies were happening until it was brought to their attention, and many students in the study truly did not care. They communicated confidently in their real-life settings.
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, these types of disfluencies seem to occur predominantly in children with autism. However, studies and clinical evidence are also showing atypical disfluencies in students with high degree of ADHD as well as some students without (diagnosed) co-existing 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 help students that demonstrate these disfluencies? THAT is the million-dollar question!
As you have no-doubt discovered, research and suggested therapy practices are behind the clinical anecdotal evidence that many of us see I now. The good news is, there are amazing SLPs trying to catch up! (see resources below).
For now, we must support these children with the evidence-based practice we have. 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 the district and in my practice, once we “upped our game” of differential diagnosis with this population, we took what we knew to be evidence-based from other fluency disorders to help these children begin to recognize and then reduce the breaks in their fluency.
Self-Monitoring
If you think about students with autism and those with ADHD, you know that self-monitoring can be challenging. 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 "identification" activities are those that we use for our students who stutter, adapted to the needs of our students with atypical disfluencies.
Pausing/Phrasing
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.
Cancellation
Another evidence-based 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 skill is part of the "stuttering more easily" techniques we use with students who stutter. You can see cancellation in action in our video series of speech handling strategies.
As you may already have surmised, therapy is individualized, and the suggestions above are in no way presented as a programmed approach for therapy!
Parent/Teacher Education
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 not just because they exist, but because they have negative impact on the child's communication.
I hope this brief overview has given you some direction in your work with this population. I wish we have definitive answers and a packet of handouts and therapy activities that you could use, but unfortunately this something that we can work toward in the future.
In the meantime, you will find a list of the resources (see below) that can give more clarity in assessment and therapy for children with 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 finding a deeper understanding of these students, and a more effective and efficient way to support their communication.
As always, don’t hesitate to reach out to us with questions and comments at info@stutteringtherapyresources.com.
Current resources for working with atypical disfluencies
Eichorn, N., & Donnan, S. (2021). Word-final disfluencies in a school-age child: Beneath the tip of the iceberg. Language, Speech, and Hearing Services in Schools, 52(4), 967–977.
Scaler Scott, K. (2017). Fluency Plus: Managing fluency disorders in individuals with multiple diagnoses. Routledge.
Sisskin, V. (n.d.) Autism Spectrum Disorders and Stuttering (includes information about Atypical Disfluencies).
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.
Sisskin, V., & Wasilus, S. (2024). Word-final disfluency: Clinical data from a single therapy protocol. Perspectives of the ASHA Special Interest Groups, 9(2), 308–319.
Sisskin, V., & Wasilus, S. (n.d.). Demystifying word-final disfluency [Streaming video].Stuttering Foundation.
Sutkowski, S., Scaler Scott, K., & Kisenwether, J. (2023). Comparative analysis of the temporal aspects of word-final disfluencies, stuttering-like disfluencies, and nonstuttering-like disfluencies. Perspectives of the ASHA Special Interest Groups, 8(5), 913–924.
Tetnowski, J., Richels, C., Shenker, R., Sisskin, V., & Wolk, L. (2012). When the Diagnosis Is Dual, The ASHA Leader, Vol. 17, 10-13.