Traits of attention deficit/hyperactivity disorder in school-age children who stutter

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  • Journal of Fluency Disorders 37 (2012) 242252

    Contents lists available at SciVerse ScienceDirect

    Journal of Fluency Disorders

    Traits owho st

    Joseph Da The Center foStatesb Department States

    a r t i c

    Article history:Received 10 MReceived in reAccepted 8 AuAvailable onlin

    Keywords:StutteringDisuenciesAttention De(ADHD)

    1. Introdu

    Attentioulate attenadulthood describes thin neurocoDauverman& McKeow

    CorresponE-mail add

    1 Tel.: +1 7

    0094-730X/$ http://dx.doi.of attention decit/hyperactivity disorder in school-age childrenutter

    onahera,, Corrin Richelsb,1

    r Childhood Communication, The Childrens Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United

    of Communication Disorders and Special Education (CDSE), Darden College of Education, Old Dominion University, Norfolk, VA 23529, United

    l e i n f o

    ay 2012vised form 6 August 2012gust 2012e 21 August 2012

    cit/Hyperactivity Disorder

    a b s t r a c t

    Purpose: The purpose of this study was to explore whether parents of CWS reported thepresence of ADHD symptoms that would warrant a referral to a psychologist to rule outthe disorder. This study also aimed to describe the characteristics of the sample in termsof gender, family history of stuttering, presence of neurological impairment, concomi-tant diagnoses, and stuttering severity. Finally, this study sought to explore the possiblestatistical relations among these same variables.Methods: Participants were 36 school-age CWS (32 males and 4 females) between the agesof 3.9 and 17.2 years (M = 10.4, SD = 4.0). Parent responses on the ADHD Rating Scale (Poweret al., 2001) were collected via a retrospective chart review.Results: For this sample 58% (n = 21), of the participants met criteria for needing referral foradditional evaluation for symptoms related to ADHD. A strong positive relation (r = .720,p < .001) was found between a reported family history of recovered stuttering and thepresence of a concomitant diagnosis.Conclusion: The results of the present study demonstrate the need for further training andeducation for SLPs working with CWS regarding ADHD.

    Educational objectives: The reader will be able to (1) describe the main characteristicsof ADHD, (2) discuss the evidence suggesting a possible relationship between ADHD andstuttering and (3) discuss how ADHD characteristics could impact clinical outcomes forCWS.

    2012 Elsevier Inc. All rights reserved.


    n Decit/Hyperactivity Disorder (ADHD) is a neurological disorder which impairs an individuals ability to reg-tion and/or behavior efciently. ADHD affects approximately 68% of children with symptoms persisting intoin approximately 70% of cases (DSM-IV-TR, 2000). In addition, the ever growing body of research on ADHDese individuals as having difculty with attention, excess motor activity, behavioral impulsivity and decits

    gnitive abilities across a wide range of domains (Goepel, Kissler, Rockstroh, & Paul-Jordanov, 2011; Oades,n, Schimmelmann, Schwartz, & Myint, 2010). ADHD often co-occurs with both affective disorders (Cuffe, Moore,n, 2005) and learning disability (Al-Yogan, 2009; Capano, Minden, Chen, Scharchar, & Ickowicz, 2008; Eden &

    ding author. Tel.: +1 215 590 7637; fax: +1 215 590 5641.resses: (J. Donaher), (C. Richels).57 683 5084; fax: +1 757 683 5593.

    see front matter 2012 Elsevier Inc. All rights reserved.rg/10.1016/j.judis.2012.08.002

  • J. Donaher, C. Richels / Journal of Fluency Disorders 37 (2012) 242252 243

    Vaidia, 2008; Mayers, Calhoun, & Crowell, 2000). This complex relationship between the core symptoms of ADHD andneurocognitive functioning has been shown to contribute to difculties with the efcient production of language (Blood,Blood, Maloney, Weaver, & Shaffer, 2007; Engelhardt, Corley, Nigg, & Ferreira, 2010; Engelhardt, Nigg, Ferreira, & Carr, 2008;Heitmann, Asbjrnsen, & Helland, 2004). These language-based issues can include excessive language production, poor topicmaintenancdisuenciesstops and stof ADHD traRiley, 1979

    The primthat would of the sampand stutteri

    1.1. Charac

    Accordindiagnosed wcriteria for domain (e.gfor more th

    There arhyperactiveare describesustained aing, etc.). Thsymptoms afor anythindriven by aconstitutesinattentive and commewas talking

    In a studInterview S4- to 17-yeproblems, pDifculties 1. Additioninto this subalso found tchildren alsDisease Confor ADHD a

    Bobb, Cabetween 193 genome-These authoassociationThe authorsdopamine sincluding an(1996) (as csymptom.

    1.2. ADHD

    The pheCuffe et al.,within monhave also de and difculty with sequencing and organization. These issues often result in a speech pattern with excessive, including lled pauses (i.e. uh or um), repetition of a word or string of words and repairs where the speakerarts the intended message over (Engelhardt et al., 2010). Furthermore, for individuals who stutter, the presenceits has been shown to negatively impact therapeutic outcomes and their ability to manage their speech (Riley &

    , 2000).ary purpose of this study was to explore whether parents of CWS reported the presence of ADHD symptoms

    warrant a referral to a psychologist to rule out the disorder. This study also aimed to describe the characteristicsle in terms of gender, family history of stuttering, presence of neurological impairment, concomitant diagnoses,ng severity. Finally, this study sought to explore the possible statistical relations among these same variables.

    teristics of ADHD

    g to the Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR, 2000), children are generallyith ADHD using questionnaires given to teachers and/or caregivers as well as parent report. In order to meet the

    ADHD, children must show impairment in social, academic, or occupational functioning across more than one., school/daycare and home). The impairment has to have been present prior to 7-years-old, must have persistedan 6-months and should not be due primarily to another diagnosis/disorder (DSM-IV-TR, 2000).e three subtypes of ADHD: (1) ADHD predominately inattentive type (ADHD-IA), (2) ADHD predominantlyimpulsive type (ADHD-HI), and (3) ADHD combined type (ADHD-C) (DSM-IV-TR, 2000). Inattentive symptomsd as difculties with basic organization (e.g., frequently loses or forgets items), avoidance of tasks that require

    ttention or mental effort (e.g., reading), and high levels of distractibility (e.g., notices small noises, changes in light-e DSM-IV-TR (2000) indicates that 40% of children with ADHD will present with ADHD-IA. Hyperactiveimpulsivere described as children who talk excessively, dget and move continuously, or generally have difculty waiting

    g (e.g., turns, teachers to nish asking questions, etc.). These children are often described as being on the go or motor. The DSM-IV-TR (2000) indicates that 50% of children with ADHD will present with ADHD-HI. ADHD-C

    only 10% of the remaining children diagnosed with ADHD and is, as its name implies, a combination of bothand hyperactiveimpulsive symptoms. These children may be described as the child who notices every soundnts on it, loses the items in his or her desk because they put them in his or her neighbors desk while the teacher.y of 10, 255 children balanced for age and gender, Cuffe et al. (2005) used data taken from the National Healthurvey to investigate the prevalence and correlates of ADHD, gender, race, and comorbid symptoms in childrenars-old. Comorbid symptoms were divided into disorders indicating emotional problems, conduct/behavioraleer relationships, and prosocial behavior using the National Institute of Mental Health (NIMH), Strengths andQuestionnaire (SDQ). Results indicated that the proportion of males to females with ADHD is approximately 4 toally, females tend to be diagnosed with ADHD-IA with upwards of 92% of females diagnosed with ADHD ttingtype (Weiler, Bellinger, Marmor, Rancier, & Waber, 1999 as cited by Cuffe et al., 2005). Females with ADHD wereo have greater comorbid emotional problems and learning disabilities. In their sample, approximately 65% of theo had conduct problems. Results of Cuffe et al. (2005) are consistent with statistics reported by the Centers fortrol and Prevention (CDC, 2005) who reported that males were more likely to be diagnosed with and medicatedcross all age ranges. Increasingly, evidence of a genetic or familial transmission of ADHD is growing.stellanos, Addington, and Rapoport (2006) summarized the literature on molecular genetic studies of ADHD91 and 2004 and found more than 100 genetic studies of ADHD. These authors reviewed 113 articles, includingwide linkage studies, and association studies of 94 polymorphisms in 33 different candidate genes (p. 551).rs and others (Hawi et al., 2010) describe ADHD as a highly heritable disorder. The authors categorized genetic

    s according to those studies that effect the dopamine system, serotonin system, and the noradrenaline system. indicate that at least 4 genes have accumulating evidence of association with ADHD, 3 of which are part of theystem and the other is in the serotonin system. The serotonin system plays a crucial role in affective disordersxiety and depression. ADHD frequently has comorbidity with affective, anxiety, and conduct disorders. Cantwellited by Cuffe et al., 2005) reported that up to 67% of children with ADHD have at least one other psychiatric

    and stuttering

    nomenological proles of ADHD and stuttering share many commonalities (Bloodstein, 1995; Bobb et al., 2006; 2005; Klotz, Johnson, Wu, Isaacs, & Gilbert, 2011). For example, both disorders have higher concordance ratesozygotic twin pairs than within dizygotic twin pairs, suggesting a primary genetic transference. Twin studiesemonstrated that both disorders demonstrate a large environmental component, because a number of identical

  • 244 J. Donaher, C. Richels / Journal of Fluency Disorders 37 (2012) 242252

    twin pairs were discordant. Both ADHD and stuttering occur in boys more than girls by a ratio of roughly 5:1. Both disordershave symptoms occurring during childhood and are exacerbated by stress, increase in severity over time and can be managedor controlled, at least temporarily when the child uses skills taught in behavioral interventions. Finally, ADHD and stutteringhave both been associated with functional and structural neural differences in white/gray matter volume and with thecircuitry ofbasal ganglthe regulati

    These sireports esti(Riley & Rillarge data bpertaining 140 childrechildren wiindicated ththe controlmay be ind

    Alm andtive assessmgroup differndings conHammer, 2

    Using a stutter, Arn10 states. Ra larger surpathologistand colleagyears-old awere no sihad scoresresponses.

    In a direThe ndingis comprisethe same grof successfuoutcomes bThese ndin2007; Bossh

    The resuand stutterof the diagnto attentionresearch quchildren; (2to whetherneurologica

    2. Method

    2.1. Particip

    ParticipaSD = 4.0). Eitheir initialwithin a six& Landau, 2of either imduring pareIn an attem the basal ganglia (Alm, 2005; Caruso, 1991; Klotz et al., 2011; Nakao, Radua, Rubia, & Mataix-Cols, 2011). Theia, due to its location, functioning and interconnections throughout the cerebral cortex, plays a signicant role inng of motor behaviors, emotions and cognition.milarities led researchers to further explore the possible relationship between ADHD and stuttering. Preliminarymate the comorbidity of ADHD and stuttering range from a low of 4% (Arndt & Healey, 2001) to a high of 26%ey, 2000). ADHD has been identied as a risk factor for stuttering in adults based on a secondary analysis of aase (Ajdacic-Gross et al., 2010). Biederman and colleagues (1993) conducted structured self-report interviews

    to a variety of academic, medical and psychological concerns with 84 adults with a clinical diagnosis of ADHD,n with a clinical diagnosis of ADHD from an earlier study and matched controls. Results indicated that 4% of theth ADHD reported a signicant history of stuttering as compared to the 2% reported by the control group. Resultsat 18% of the adults with ADHD reported a signicant history of stuttering as compared to the 3% reported by

    group. These ndings indicate that ADHD with stuttering tends to be more persistent than ADHD alone. Thisicative of more widespread neurodevelopmental pathology.

    Risberg (2007) administered The Wender Utah Rating Scale, a 25-item self-report questionnaire for the retrospec-ent of ADHD symptoms, to 32 adults who stutter and 28 nonstuttering controls. Results indicated signicantences with adults who stutter reporting signicantly higher ratings of ADHD-like traits during childhood. Thesetinue to be consistent in children who stutter (CWS) as well (Arndt & Healey, 2001; Blood, Ridenhour, Qualls, &

    003; Riley & Riley, 2000).cross-sectional survey design to describe the occurrence of comorbid conditions in school-age children whodt and Healey (2001) reported on data obtained from 241 speech-language pathologists sampled from acrossesults indicated that 4% of the 262 school-age children with a veried uency disorder also had ADHD. Invey study with a similar purpose, Blood and colleagues (2003) analyzed results from 1184 speech-languages. Results indicated that 6% of the 2628 school-age CWS presented with comorbid ADHD. More recently, Bloodues (2007) investigated performance on the CPT II in a group of 19 CWS between the ages of 9- and 11-nd a control group of 19 children who did not stutter in the same age range. Results indicated that theregnicant differences between the groups for this task. However, the authors report that as a group, CWS

    on the risk-taking subscale that suggested that the children who stuttered were more impulsive in their

    ct evaluation of CWS, Riley and Riley (2000) evaluated 50 school-age CWS using their Revised Components Model.s indicated that 26% of their sample presented with an Attending Disorder which, from the authors description,d of high impulsivity, poor attention and hyperactivity consistent with ADHD. Interestingly, an earlier work byoup suggested that the presence of an Attending Disorder prior to therapy signicantly decreased the likelihoodl therapy outcomes (Riley & Riley, 1979). Additionally, it was shown that clinicians could increase therapeuticy addressing the attending issues prior to the initiation of speech modication therapy (Riley & Riley, 1979).gs are relevant as evidence accumulates on the association between stuttering and attention skills (Blood et al.,ardt, 2006; Engelhardt et al., 2008, 2010; Heitmann et al., 2004).lts of these studies strongly support the need for continued exploration of the links between ADHD characteristicsing. As mentioned above, DSM-IV-TR (2000) stipulates that parents or caregiver report is a necessary componentostic process...


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