Cluttering Revisited

I received three calls in October and November from parents looking for help with cluttering. I had to tell them I have not treated cluttering per se, however, given my experience with stuttering and other speech/language issues I felt qualified to provide such treatment. Two of the callers moved on. One visited with me this week, which prompted me to review all the possible scenarios that might evolve when this new student walked through my door. For cluttering, there are many.

The ASHALeader article by St. Loius et. al. (11) describes assessment and treatment in a practical way for the clinician seeking to make the best use of the brief amount of time normally available for an evaluation. Cluttering can present with a constellation of symptoms to be teased apart in differential diagnosis. “One especially frustrating problem is that people with the disorder frequently do not clutter, for example, when they speak in a short screening evaluation.” (11, p.1) The SLP must select speech/language tasks that will reveal fluency, articulation, linguistic, and pragmatic problems that identify cluttering in particular. Conducting an evaluation in more than one session is recommended.

Knowing that “…rate problems are somehow central to cluttering” (11, p.2), it becomes important to video tape, transcribe, and calculate speech rates for a variety of speaking tasks. I happen to have the APAT (9) and therefore I chose a few tasks from this test. St. Loius et. al. recommend several tasks and provide data:

“Average conversational rates for normal preschoolers are reported to range from 110-180 SPM; for elementary aged children from 140-200 SPM; and for adults from 180 – 220 SPM.” (11, p.3) [see Sturm & Seery (10)] However, rate data alone must be supplemented by a description of pausing and phrasing. “While people who clutter sound like they are speaking too fast, the fact is they actually end up speaking slower than normal due to their rapid runs of speech being interrupted by long pauses.” (7, p.7) There is “…the frequent placement of pauses and use of prosodic patterns that do not conform to syntactic and semantic constraints…”(8) “Cluttering is fluency disorder characterized by a rate that is perceived to be abnormally rapid, irregular, or both for the speaker (although measured syllable rates may not exceed normal limits). (8)

Those of us well versed in stuttering issues will easily recognize the clutterer’s use of “an excessive number of disfluencies, the majority of which are not typical of people who stutter.” (8) Dewey lists these disfluencies in his personal story (5). I highly recommend Dewey’s well-organized, intimate essay as a take-home for parents as well as teen age students and adults. It can serve as an introduction to cluttering during an assessment and it could provide a point of reference throughout a treatment program.

Rapid rate (bursts of speech) and disfluency combine with articulation errors to result in speech which is difficult to understand. These errors will be familiar to the SLP. We have listened to a variety of articulation patterns that have been analyzed and re-analyzed according to the philosophies of the most popular university professors of the day. We’ve read debates over whether apraxia is a language or speech/language disorder, whether articulation disorders are functional, phonologically based or motoric in nature. SLPs are familiar with sound errors found in reading and spelling disorders. Analysis of the speech sample will not be unfamiliar. St. Louis, et. al. recommend using Systematic Disfluency Analaysis (11) which would result in a very detailed description. I imagine there are other methods of close transcription. Speech and writing samples generously shared by Peter Kissagizlis are found in his 2009 ISAD paper (8). We can listen to Dewey’s speech as well. (5)

Of course, as I read the latest news about cluttering, I question how many of my previous students presented with cluttering in addition to their stuttering. I have observed stuttering resolve by way of normal disfluencies and St. Louis makes note of this stuttering-cluttering relationship. “Moreover, cluttering is often noticed before the stuttering takes over during development of the disorders and after stuttering is treated successfully, but not while a person manifests significant stuttering.” (11, p.1) I have not recommended stuttering therapy in some cases of preschoolers who were very dysfluent but not stuttering and I’ve done a lot of language work with school children as part of their stuttering treatment. Maybe this is why.

I’m left wondering if treating cluttering may be easier than assessing it. My new client performed well for a variety of video taped speech samples. He completed the PCI with a score too low for a cluttering diagnosis. This leads us to a crucial aspect of cluttering and of cluttering assessment: “…the evaluation process must be long enough so the person doesn’t get that chance to consistently normalize. The clinician should carry out a number different speaking tasks in therapy, repeating them from time to time. Eventually, individuals will let down their guard, and the cluttering will appear. In addition, clutterers “are usually unaware of their disfluencies and misarticulations…” (3, p.1)

Given what we know about cluttering AND as a specialist who has been asked for a second opinion consult AND presented with somewhat good quality speech and language in a 60 minute initial visit AND a self report PCI score below 80 I DO NOT report that cluttering is not present in this case.

What next? Hopefully this student will be more spontaneous at the next visit as I challenge him with more complex linguistic material and ask for more in depth, extemporaneous opinions about familiar and unfamiliar topics in monologue and conversation. When I complete the PCI, it may score above 80. Assuming this student is coming to me for a diagnosis of cluttering and recommendations for speech therapy, it will be up to him to choose whether or not to reveal the communication problems that brought him to my door. Then we will discover it together by watching the video we make at his next session.

(1) Daly, D. (1993) “Cluttering: The Orphan of Speech-Language Pathology” American Journal of Speech Language Pathology, Vol. 2, pp 6-8

(2) Daly, D. (1996) The Source for Stuttering and Cluttering, East Moline, IL: LinguiSystems, Inc.

(3) Daly, D. (2007) “Cluttering: Characteristics Identified as Diagnostically Significant by 60 Fluency Experts” http://www.mnsu.edu/comdis/isad10/papers/daly10/daly10.html

(4) Daly, D. (2006) Predictive Cluttering Inventory (PCI) http://www.mnsu.edu/comdis/isad10/papers/daly10/dalycluttering2006R.pdf

(5) Dewey, J. (2005) “My Experiences with Cluttering” http://www.mnsu.edu/comdis/isad8/papers/dewey8.html

(6) Kleiman, L. (2003) Functional Communication Profile Revised: Assessing Commuicative Effectiveness with Clients with Developmental Delays, East Moline, IL: LinguiSystems

(7) Mosheim, J. (2004) “Cluttering: Specialists work to put it on the map of fluency disorders” advance for Speech-Language Pathologists & Audiologists, November 22, pp. 6-9

(8) Myers, F. & Kissagizlis, P. (2009) “Putting Cluttering on the World Map: Formation of the International Cluttering Association (ICA)” http://www.mnsu.edu/comdis/isad10/papers/myers10.html

(9) Ross-Swain, D. & Long, N. (2004) Auditory Processing Abilities Test (APAT), Novato, CA: Academic Therapy Publications

(10) Sturm, J & Seery, C. (2007) “Speech and Articulatory Rates of School-Age Children in Conversation and Narrative Contexts, Language, Speech, and Hearing Services in Schools, Vol 38, pp. 47-59.

(11) St. Louis, K. et al (2003) “Cluttering Updated” the ASHALeader, pp. 4-5, 20-22

(12) St. Louis, K. & Meyers, F. ( ) Cluttering www.stutteringhelp.org

(13) International Cluttering Association, http://associations.missouristate.edu/ICA/

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