The Effects of ADHD Medication Changes on a Child Who Stutters. Joseph Donaher Ph.D.

, CCC/SLP The Center for Childhood Communication The Childrens Hospital of Philadelphia University of Pennsylvania School of Medicine E. Charles Healey Ph.D., CCC-SLP Department of Special Education & Communication Disorders University of Nebraska-Lincoln Anneli Zobell B.A. Department of Special Education & Communication Disorders University of Nebraska-Lincoln Abstract: This case report describes a 10-year-old boy who presented with comorbid stuttering, ADHD and Tourette Syndrome. The focus of this case study is the childs favorable reaction to the non-stimulant Strattera versus the stimulant Adderall XR on stuttering behaviors. The family reported increased stuttering, tic behaviors, social anxiety and communication related frustration resulting in social isolation shortly after starting the stimulant medication. Consequently, the medical team discontinued the stimulant medication and prescribed the non-stimulant Strattera to manage the ADHD symptoms. After initiating the non-stimulant medication, the family reported an increased willingness to interact with peers and reduced aggressiveness while interacting with family members. Compared to the disfluency rate and speech patterning from the first evaluation, the child demonstrated a 63% reduction in disfluency rate and a 51% reduction in the proportion of speech behaviors typical of stuttering. However, the nonstimulant medication was linked with a noticeable increase in impulsivity and decrease in attention/focusing in the academic setting.

Donaher 2 Introduction: It is well established that the cause of stuttering is unknown but most experts agree that a complex interaction of multiple factors contribute to the onset and development of stuttering (Smith & Kelly, 1997). One factor that has been theorized to be a major contributing factor in maintaining stuttering in some people who stutter is increased levels of dopamine in the neural regions that modulate speech production (Wu, Maguire, Riley, Lee, Keator, Tang, Fallon, & Najafi, 1997). Pharmacological treatment studies have supported the role dopamine plays in maintaining stuttering by demonstrating a reduction in stuttering behaviors when dopamine blocking medications are prescribed (Wu et al, 1997; Maguire, Riley, Franklin, Maquire, Nguyen, & Brojeni, 2004; Burd, & Kebeshian, 1991; Lavid, Franklin, & Maguire, 1999).

Additional factors, which can contribute to the development and maintenance of stuttering, are coexisting disorders such as language/phonological disorders, learning disabilities, Tourette Syndrome, and Attention-Deficit Hyperactivity Disorder (ADHD). For example, for over a decade, considerable attention has been paid to the link between stuttering and ADHD. Biederman and colleagues (1993) reported an 18% incidence of stuttering in adults with ADHD and a 4% incidence of stuttering in children with ADHD. Interestingly, a 2007 study of 45 adults who stutter reported that 40% demonstrated behavioral traits consistent with ADHD but not at levels that merited the actual diagnosis (Alm & Risberg, 2007). The literature shows that the prevalence of ADHD among children who stutter ranges from 4% to 26% (Healey & Reid , 2003).

Donaher 3 Pharmacological management of ADHD with stimulant medication such as Adderall XR increases the concentration of dopamine in specific neural regions and remains the most effective, well-researched single intervention for ADHD (Zuyekas, Vitiello, & Norguist, 2006). However, managing ADHD through stimulant medication may come at the risk of increasing stuttering when the two disorders co-exist. The lack of wellcontrolled studies describing the effects of ADHD medications on stuttering makes it difficult to draw any conclusions regarding a possible relationship. Case reports have shown that stimulant medications can significantly increase stuttering behaviors in some individuals who stutter (Maguire et al, 2004; Burd et al, 1991). Conversely, there is some empirical evidence and anecdotal reports that nonstimulant medication such as Srattera used to control the symptoms of ADHD may not have this effect and may, in some cases, actually reduce stuttering behaviors (Maguire et al, 2004; Burd et al, 1991). The following case study illustrates the impact on stuttering when a child who stutters was taken off stimulant medication and switched to a non-stimulant medication to manage his ADHD.

Case Presentation: JV was a 10-year-old boy who presented with coexisting diagnoses of stuttering, ADHD and Tourette Syndrome. His medical history was significant for allergies, chronic ear infections, stuttering which began when he was 5 years of age and frequent phonic and motor tics. Family history was significant for persistent developmental stuttering demonstrated by his mother and maternal grandfather. JVs ADHD diagnosis was made when he was 7 years old and Tourette Syndrome was diagnosed when he was 9 years old.

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JV attended a regular education classroom with no support services. He had never received speech therapy and had no knowledge of strategies to reduce his stuttering behaviors. His ADHD and Tourette Syndrome diagnoses were made by a pediatric neurologist who subsequently prescribed Adderall XR (20mg) to manage the ADHD symptoms.

During a routine follow-up with their neurologist, the family complained of increased stuttering behaviors over the past two weeks since starting the stimulant medication. Additionally, JV complained of increased tic behaviors, increased levels of social anxiety and communication related frustration resulting in social isolation. JV was referred for a stuttering evaluation, which was completed on that same day by the first author, a licensed speech language pathologist and board recognized specialist in fluency disorders (BRS-FD) by the American Speech-Language-Hearing Association (ASHA).

During the initial speech evaluation while JV was still taking stimulant medication, a 491-word speech sample was obtained from a wordless picture book to determine the frequency and severity of stuttering. The childs utterances during the picture book description were transcribed verbatim by the third author and independently verified by the second author, a licensed speech-language pathologist and an ASHA BRS-FD. An analysis of the disfluent speech behaviors revealed a 21.5% disfluency rate, of which 58.4% were typical of stuttering (i.e., single word and syllable repetitions and audible/silent sound prolongations). Given the familys report of increased stuttering

Donaher 5 behaviors following the introduction of stimulant medication, the medical team discontinued the stimulant medication and prescribed the non-stimulant Strattera (10mg) to manage JVs ADHD symptoms.

During a routine follow-up neurology appointment approximately eight weeks after initiating Strattera, JVs mother reported a significantly reduced degree of stuttering and an increased willingness and desire to socialize with his peers. JV requested several play dates with a new friend and began using the telephone to interact with peers outside of the school setting. JVs mother reported that he was less aggressive during interactions with family members and appeared to quarrel less with his younger sister. It should be noted that JV had still not received treatment for his stuttering at this point and the only apparent change was the switch from a stimulant to a non-stimulant medication for his ADHD behaviors.

In order to determine whether JVs fluency had improved since being placed on Strattera, a 606 word speech sample was obtained using a wordless picture book. The sample was analyzed by the same individuals and in the same way as the previous sample. The results revealed an 8% disfluency rate, of which 28.5% of the behaviors were typical of stuttering. Compared to the disfluency rate and speech patterning from the first evaluation, this represented a 63% reduction in disfluency rate and a 51% reduction in the proportion of speech behaviors typical of stuttering.

Donaher 6 However, when the stimulant medication was discontinued and the nonstimulant medication was implemented, JVs teachers witnessed a noticeable increase in his impulsivity and decrease in his ability to attend and focus in the classroom. This finding is compatible with studies suggesting that non-stimulant medications are less effective at treating the core symptoms of ADHD.

Discussion: This case report described a favorable reaction to a non-stimulant versus a stimulant medication on stuttering in a 10-year-old boy who presented with comorbid stuttering and ADHD. The non-stimulant medication was linked with decreased speech related apprehension, increased socialization, and decreased stuttering behaviors. However, these improvements came at the cost of increased impulsivity, reduced attention and reduced performance in the academic setting.

The importance of this case report relates to the relative frequency with which clinicians report similar issues and the paucity of published research on this topic. Alm (2005) discussed two early studies evaluating the effects of stimulant medication on stuttering. Fish and Bowling (1965) reported that stimulant medication led to reduced stuttering in 50% of subjects who stuttered with coexisting mental retardation. Interestingly, for the subjects that did not initially improve with stimulant medication, a dopamine receptor blocker was administered. The results indicated that 67% of these subjects experienced reduced stuttering. In a separate study, Langova and Moravek (1964) reported that stimulant medication increased fluency in 88% of their subjects who stuttered. However,

Donaher 7 they reported that stimulant medication increased stuttering in 79% of the cases presenting with stuttering-cluttering or pure cluttering. In the cases identified as stuttering-cluttering or pure cluttering, 79% demonstrated increased fluency on dopamine receptor blockers.

Further research is needed to better understand the relationship between stimulant medication and stuttering. Unfortunately, the nature of this single case report prevents generalizing the results prior to replication with a larger sample. With a larger sample, future studies may be able to identify subgroups of PWS based on reaction patterns to specific medications. This could provide insight into the underlying neuropathology and etiological basis of stuttering. Given that both stuttering and ADHD begin in childhood, and that the majority of studies on this topic have involved adults who stutter, future studies should include CWS to determine whether they demonstrate similar responses.

From a clinical management perspective, this case illustrates the importance of the coordinated multidisciplinary management of children who present with complex medical profiles encompassing multiple diagnoses. Further exploration of how various management strategies for coexisting diagnoses can impact the efficacy of other interventions is warranted. This knowledge may serve to reinforce or refute the popular clinical perception that stimulant medication increases stuttering behaviors for a large proportion of CWS. Unfortunately, this belief, which remains unsubstantiated in the literature, has resulted in many professionals counseling families against ADHD

Donaher 8 medications even at times when the attention/focusing issues are the predominant impairment.

REFERENCES Alm, P.A. (2005). On the Causal Mechanisms of Stuttering. Lund University, Sweeden, 2005. Alm, P. A., & Risberg, J. (2007). Stuttering in adults: The acoustic startle response, temperamental traits, and biological factors. Journal of Communication Disorders. 40, 1-41. Biederman, J., Faraone, S.V., Spencer, T., Wilens, T., Norman, D., Lapey, K.A., Mick, E., Lehman, B.K., Doyle, A. (1993). Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. American Journal of Psychiatry. Dec; 150(12): 1792-8. Burd, L. & Kebeshian, J. (1991). Stuttering and stimulants. Journal of Clinical Psychopharmacology. 11, 72. Guitar, B. (2006). Stuttering: An Integrated Approach to Its Nature and Treatment, 3rd Edition. Baltimore, MD: Williams and Wilkins. Healey, E.C. & Reid , R. (2003). Tutorial on Stuttering and ADHD. Journal of Fluency Disorders. Volume 28, Number 2. Lavid, N., Franklin, D., L., & Maguire, G., A. (1999). Management of child and adolescent stuttering with Olanzapine: Three case reports. Journal of Clinical Psychiatry. 11, 233-236. Maguire, G.A., Riley, G.D., Franklin, D.L., Maquire, M.E., Nguyen, C.T., & Brojeni,

Donaher 9 P.H. (2004). Olanzapine in the treatment of developmental stuttering: a doubleblind, placebo-controlled trial. Annals of Clinical Psychiatry, Apr-Jun;16(2):6367. Smith, A. & Kelly, E. (1996). Stuttering: A dynamic multifactorial model. In Curlee, R. and Siegel, G. (Ed.) Nature and treatment of stuttering: new directions, (2nd ed.) (pp. 204217) Needham Heigts, MA: Allyn & Bacon. Wu, J.C., Maguire, G.A., Riley, G.D., Lee, A., Keator, D., Tang, C., Fallon, J., & Najafi, A. (1997). Increased dopamine activity associated with stuttering Neuroreport, 8: 767-770. Zuyekas, S., Vitiello, B., & Norguist, G. (2006). Recent trends in stimulant medication use among U.S. children. American Journal of Pyschiatry. April; 163(4): 574-577.

CONTINUING EDUCATION QUESTIONS 1. The most effective, well-researched single intervention for ADHD is: A. Behavior modification B. Biofeedback C. Pharmacological management D. Cognitive Behavioral Therapy

2. Pharmacological treatment studies exploring a possible link between stuttering and ADHD have demonstrated: A. Consistent findings suggesting stimulant medications are never appropriate for CWS

Donaher 10 B. Inconsistent findings making it difficult to draw any conclusions C. Consistent findings which implicate the neurotransmitter norepinephrine D. Inconsistent findings suggesting no relationship exists

3. Speech and language intervention for CWS with coexisting diagnoses should include: A. Neuroimaging B. Transdisciplinary management C. Pharmacological treatment D. Multidisciplinary management

4. Pharmacological treatment studies have suggested that stimulant medications may increase the frequency of stuttering for some PWS by altering: A. The level of impulsivity, attention and focusing B. The level of serotonin in the neural regions that modulate speech production C. The level of dopamine in the neural regions that modulate speech production D. The level of speech related anxiety and social phobia

LEARNING OBJECTIVES 1. To discuss the evidence base related to whether medications commonly prescribed for ADHD could have an effect on the speech skills of children who stutter 2. To determine the most appropriate treatment practices for children who stutter based on their individual patterning 3. To coordinate intervention with other professionals when CWS present with complex medical profiles encompassing multiple diagnoses and/or clinical management approaches

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