A Synopsis of Cluttering and Its Treatment
About the presenters: Kenneth O. St. Louis, Ph.D. (West Virginia University, Morgantown, West Virginia) and Florence L. Myers, Ph.D. (Adelphi University, Garden City, New York) have both published widely in the areas of cluttering and stuttering. They have collaborated on a number of professional presentations and research or clinical articles on cluttering (including one book and one special journal edition), each bringing a different emphasis or perspective on the problem. Dr. St. Louis has emphasized the essential symptoms and diagnosis of cluttering and Dr. Myers, the treatment of the disorder, although they both have made contributions in other areas of focus in this mysterious fluency disorder. Both authors are associate editors for the Journal of Fluency Disorders. Dr. St. Louis was instrumental in founding the International Fluency Association and has served on several key ASHA committees and task forces relating to specialty recognition and terminology in fluency disorders. Dr. Myers has collaborated on two editions of a textbook on stuttering and has extensive knowledge and experience in linguistically-motivated and motorically-motivated disfluency.
A Synopsis Of Cluttering And Its Treatment
by Kenneth St. Louis and Florence Myers
Virginia and New York, USA
Definition And Symptoms
Like stuttering, cluttering is a fluency disorder, but the two disorders are not the same. Cluttering involves excessive breaks in the normal flow of speech that seem to result from disorganized speech planning, talking too fast or in spurts, or simply being unsure of what one wants to say. By contrast, the person who stutters typically knows exactly what he or she wants to say but is temporarily unable to say it, thus repeating or prolonging sounds or syllables, blocking, and/or using accessory (secondary) devices like eye-blinks, synonyms for difficult words, or abnormal facial postures. To make matters confusing, since cluttering is not well known, many who clutter are described by themselves or others as "stuttering." Also, and equally confusing, cluttering often occurs along with stuttering.
The definition of cluttering adopted by the fluency disorders division of the American Speech-Language-Hearing Association is: Cluttering is a fluency disorder characterized by a rapid and/or irregular speaking rate, excessive disfluencies, and often other symptoms such as language or phonological errors and attention deficits. To identify cluttering, one must listen to the nonstuttered speech of the speaker. Evidence for a fluency disorder (one that is not stuttering) and excessive disfluencies, is present in a speaker who: does not sound "fluent," (i.e., does not seem to be clear about what he or she wants to say or how to say it); manifests excessive levels of "normal disfluencies," such as interjections (e.g., "um, you know") and revisions (e.g., "We went over....we started to go to grandma's."); manifests little or no apparent physical struggle in speaking; and has few if any accessory or secondary behaviors. A rapid and/or irregular speaking rate would be present in a speaker who has any or all of the following: talks "too fast," based on an overall impression or actual syllable per minute counts; sounds "jerky"; or has pauses that are too short, too long, or improperly placed.
These fluency and rate deviations are the essential symptoms of cluttering. In addition, however, there are a number of symptoms that may or may not be present but add support to a diagnosis of cluttering. Accordingly, the clinical picture of a typical cluttering problem would be enhanced if the person in question had or manifested any of the following optional characteristics: confusing, disorganized language or conversational skills, often with word-finding difficulties; limited awareness of his or her fluency and rate problems; temporary improvement when asked to "slow down" or "pay attention" to speech (or when being tape recorded); mispronunciations, slurring of speech sounds, or deleting nonstressed syllables in longer words (e.g., "ferchly" for "fortunately"); speech that is difficult to understand; several blood relatives who stutter or clutter; social or vocational problems resulting from cluttering symptoms; learning disabilities not related to reduced intelligence; sloppy handwriting; distractibility, hyperactivity, or a limited attention span; difficulty with organizational skills for daily activities; and/or auditory perceptual difficulties.
Diagnosis
Before seeking or providing therapy, it is important that someone suspected of cluttering be diagnosed accurately by a speech-language pathologist. The assessment process is often quite extensive and may require two or more sessions. It may also require contributions or reports from other professionals, such as classroom teachers, special educators, psychologists, or (possibly) neuropsychologists. The evaluation should obviously include consideration of the fluency problem, but also any coexisting oral-motor, language, pronunciation, learning, or social problems. If the suspected clutterer is in school, it may be a good idea to get a comprehensive academic achievement test (e.g., mathematics, writing, and reading) and even an intelligence test.
The diagnosis should specify whether or not cluttering is present and also what other problems are present, such as stuttering, a language disorder, or a learning disability. It is important to note that if a stutterer also clutters; sometimes the cluttering will not be noticed until the stuttering diminishes, either on its own or from speech therapy.
Therapy
Therapy for clutterers generally addresses the contributing problems first before focusing directly on fluency. Ordinarily, one of the first goals of therapy is to reduce the speaking rate, although this may not be easy for the clutterer to achieve. Some clutterers respond well to "timing" their speech to a delayed auditory feedback (DAF) device; some do not. Another technique that has been found helpful with younger clutterers is to use the analogy of a speedometer wherein rapid speech is above the "speed limit" and "speeding tickets" are given for exceeding the "limit."
The analogy of an engine that is racing too fast has been helpful to some clutterers. It is as if their entire being is too energized and unharnessed, thus making it difficult for them to monitor and to modulate their speech, language, and thought. Having the clutterer speak softly helps to "calm down" the system as well as fostering a quieting effect on all aspects of communication. A clinician may ask a clutterer to reflect on how it feels during these moments and to recapture these feelings when the speech reverts to a rapid, nonfluent manner of delivery. Often he or she must be taught to pause deliberately. If the person is unaware of where to pause, it may be useful to write down the unintelligible sentences (from a tape recording) that he or she actually has said, first without spaces between words and then with normal spacing. Seeing the difference can often assist in learning to discriminate appropriate pause locations. Listening to a segment of one's cluttered speech can also be very beneficial. And after the clutterer becomes acquainted with specific symptoms, he or she might well make a list of those symptoms that are most compromising to his speech.
As many clutterers have limited awareness of their rapid and irregular speech rate, it can be helpful if they are directed to count silently with their fingers or raise and lower their forearm to coincide with pauses. The clinician should start with deliberate movements and be firm about maintaining deliberate, slow, and consistent marking of pauses. This technique serves two purposes. First, the nonverbal gestures impose pauses without interfering with the semantic intentions of the speaker's message. Second, the added sensory awareness accompanying the motoric gestures may increase awareness of pausing. In time, the clutterer may either increase the rate of the movements or rely on his or her own "sense of time" to modulate the duration of each pause. In fact, any technique that helps the clutterer to segment thoughts, linguistic units, and articulatory gestures at appropriate junctures can be immensely helpful.
Pronunciation (articulation) and language problems are often reduced if the clutterer can achieve a slower rate. Sometimes, however, these problems need to be addressed directly. One technique involves practice first in using short, highly structured utterances (e.g., "Hi. My name is John. I live at 148 Third Street. I work at the drug store on Main Street.") and then progressing to more normal language (e.g., "Hi. I'm John. I live on Third Street, three blocks from the drug store where I work on Main Street.") It may also be helpful for clutterers to learn to exaggerate stressed syllables in longer words while being sure to include all the unstressed syllables (e.g., "par-tic-u-lar," "con-di-tion-al," or "gen-er-o-si-ty"). Stressing a syllable in a multisyllabic word adds duration as well as increases both loudness and pitch of that syllable. The accentuation of a syllable often helps to organize the articulatory gesture, as if to provide the clutterer a "center of gravity" or focal point in his speech. Even speakers who do not clutter may need several tries at pronouncing a long or unfamiliar word if they are not sure where to place the stress. The analogy of the broadjump athlete can be used. If the athlete mistimes his steps or is haphazard as to which leg to use to initiate the jump (analogous to the accented syllable), the execution of the entire jump will be amiss.
Some clutterers benefit from planning both the content (the "what") of a message as well as the delivery (the "how"). For example, the "what" can be taught as formulating a telegram (e.g., "Car won't start. I pump accelerator. Carburetor gets flooded."). The "how" then focuses on filling in the appropriate small words (e.g., "My car often won't start after it sits for a few minutes. I pump the accelerator a few times before trying again. Often, the carburetor gets flooded.") Having the older clutterer first outline his narrative can also be very helpful even though coming up with the logical sequence for an outline may be difficult. However, once the outline is in print, it is easier for the clutterer and clinician to pinpoint and rectify spots which are unclear or illogical. And when the outline is satisfactory, the clutterer should be asked to speak from the outline, a practice used by many public speakers. Following a topical outline just prepared undoubtedly will increase confidence and enhance delivery.
Many clutterers also stutter, and often the cluttering is masked by the stuttering. In some of these individuals, the cluttering emerges as the individual gets control of the stuttering or begins to stutter less. Yet, whether or not the clutterer also stutters (or previously stuttered), any therapy techniques that focus attention on fluency targets such as easy onset of the voice, more prolonged syllables, or correct breathing can also help the person to manage many of the cluttering symptoms. The important thing is that the clutterer learn to pay attention to--or monitor--his or her speech and do anything that makes it easier to remember to do so.
Lack of awareness is a particularly vexing problem. Many clutterers appear to be genuinely unaware of the extent of their cluttering behaviors. They must be taught to be astute observers of listener feedback, e.g., a look of bewilderment on the listener's face or frequent requests for clarification or repetition. Some older clutterers are better able to monitor if they listen daily to a tape with a short sample of their disorganized cluttered speech and, immediately following, a sample of their clear, monitored speech. Many of these individuals even find it helpful to listen to and compare these "wrong" and "right" speech samples several times a day. Other clutterers may need repeated "coaching sessions," during which the clutterer and clinician evaluate which behaviors most compromise the effectiveness of their communication, which behaviors are relatively easier to monitor, and which behaviors are relatively easier to change. From these criteria, a hierarchy of goals can be established which would be most meaningful and helpful to the clutterer.
Effectiveness Of Therapy
It is hard to predict whether or not a clutterer will benefit from speech therapy. Most who benefit have become convinced from friends, family, or employers (or on their own) that they do have a significant speech problem. Also, motivation is a key element; they have good reason for working hard to change, such as the likelihood of a job promotion.
On the other hand, clutterers who are not sure that they have a problem, or are relatively unconcerned about it, tend not to improve as much or as easily from therapy. These clients need continual affirmation and encouragement from a trusted clinician. A good working relationship and considerable time is needed to try to convince such a clutterer of the importance of speech change. The impact of reduced speech intelligibility and linguistic coherence must be discussed and illustrated repeatedly. When there is improvement, however seemingly modest, the clutterer will benefit from an abundance of praise and perhaps playing back a taped segment of improved speech so that he or she can be convinced that all the effort was indeed worthwhile. =20
Sources Of Help
Since cluttering is neither common nor well understood, some speech-language pathologists (SLPs) may express doubt about whether or not they can effectively evaluate and treat the problem. If so, they can be referred to a number of sources of information about the disorder. (See the references below.) With such information, many of these SLPs may well be willing to provide therapy for cluttering.
Fortunately, most SLPs who are specialists in stuttering are also willing to evaluate and treat cluttering as well. The Stuttering Foundation of America lists and can supply names of individuals in specific geographic area that regard themselves as specialists in fluency disorders. In addition, the Special Interest Division of the American Speech-Language-Hearing Association is in the process of identifying and formally recognizing specialists in these areas as well.
References And Annotations
Daly, D. A. (1996). The Source for Stuttering and Cluttering. East Moline, IL: LinguiSystems. (A commercially available therapy program for cluttering.)
Daly, D. A. (1992-1993). Cluttering: A language-based syndrome. The Clinical Connection, 6, 4-7. (An article about cluttering with a checklist to help diagnose cluttering.)
Daly, D. A., & Burnett-Stolnack, M. (1994). Identification of and treatment planning for cluttering clients: Two practical tools. The Clinical Connection, 8,1-5. (A followup to the previous article with a form designed to plan and evaluate treatment.)
Myers, F. L. & St. Louis, K. O. (1992). Cluttering: A clinical perspective. Kibworth, Great Britain: Far Communications. (Reissued in 1996 by Singular Press, San Diego, California). (An edited book by several other well-known authorities on the nature, diagnosis, and treatment of cluttering.)
St. Louis, K. O. (Ed.) (1996). Research and opinion on cluttering: State of the art and science, Special issue of the Journal of Fluency Disorders, 21. (A special journal edition devoted entirely to cluttering containing an annotated bibliography, case studies, research investigations, and commentaries by several well-known authorities.)
St. Louis, K. O. (1998). Cluttering: Some Guidelines. Memphis, TN: Stuttering Foundation of America. (A brochure written for lay readers [from which the framework and much of the content of this paper were taken].)
St. Louis, K. O., & Myers, F. L. (1995). Clinical management of cluttering. Language, Speech, and Hearing Services in Schools, 25, 187-195. (A clinically oriented article on cluttering designed for clinicians.)
St. Louis, K. O., & Myers, F. L. (1997). Management of cluttering and related fluency disorders. In R. Curlee and G. Siegel (Eds.), Nature and treatment of stuttering: New directions (pp. 313-332). NY: Allyn and Bacon. (A summary of the nature of cluttering with information on coexisting problems, diagnostic procedures, and therapeutic intervention.)
Weiss, D. (1964). Cluttering. Englewood Cliffs NJ: Prentice-Hall. (A well-known source on cluttering with extensive coverage of early European contributions.)
September 2, 1998
