Vol. 14 Issue 47
Specialists work to put it on the map of fluency disorders
A rare fluency disorder, cluttering is characterized by an abnormal speech delivery rate and frequent disfluencies unlike those found in stuttering. Identifying the disorder is a challenge because it is difficult to tell which symptoms are unique to the disorder and which are secondary.1
Florence Myers, PhD, CCC-SLP, and Lawrence Raphael, PhD, both of Adelphi University in Garden City, NY; Kenneth O. St. Louis, PhD, at West Virginia University in Morgantown, WV; and Klaas Bakker, PhD, of Southwest Missouri State University, in Springfield, MO, hope to put cluttering on the map of fluency disorders. The senior researchers have studied the disorder for nearly 20 years.
The most common symptom is a problem with speaking rate. Individuals typically exhibit a rate that is either too fast, too irregular (jerky, or speaking in spurts), or both. While people who clutter sound like they're talking 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.
It makes sense to find out that the people who clutter don't go as fast as normal speakers, said Dr. Raphael, an acoustic phonetician at Adelphi University, even though people who clutter are perceived as speaking very rapidly.
"Most theories are speculative at this point, but it might be that people who clutter handle the problem of not being able to say all the sounds they want to say by leaving things out," he said. "To 'fill in' what speakers have omitted is equivalent to reading their minds, which is why we've asked our subjects to perform a number of tasks, such as reciting nursery rhymes, reading tasks, and producing diadokokinetic syllable trains (DDKs), so that we can be sure of what they intended to say."
Another common symptom of cluttering is an excessive amount of normal disfluencies in the form of revisions and hesitations, as opposed to prolongations and blocks found in stuttering.
The third group of symptoms involves articulatory problems, which are usually the direct result of a rapid speaking rate.
"On a surface level the person's speech intelligibility is compromised because of the neutralization of vowels and the deletion of sounds and syllables," said Dr. Myers. "Several people who clutter have said that several thoughts come to them at once, and without sequencing them they continue to talk."
People who clutter also use interjections and revise incomplete words or utterances.
"The speech of the person who clutters is not very efficient; it goes off on momentary tangents and contains an abundance of fillers. It's not right to the point," said Dr. Myers.
While cluttering can co-exist with stuttering, the biggest difference between the two disorders is that even though people who stutter struggle with certain words or sounds, they generally know what they want to say. People who clutter appear to be the complete opposite.
"It's almost as if people who clutter can't decide exactly what it is that they're trying to say. They might have the content in mind, but the actual words are not clearly formed in their minds," said Dr. St. Louis.
Stuttering individuals also exhibit secondary behaviors, such as eye blinking and grimacing, whereas those who clutter usually do not.
People who stutter are more poignantly aware of their condition and seek help, while those who clutter usually are unaware that people can't understand them. This may be attributed to having a poor sense of time, which the team addressed in a presentation titled "Cluttering: It's About Time" at the American Speech-Language-Hearing Association (ASHA) Convention last week.
"Some clients have absolutely no sense that they're going too fast for their own good, and this is after therapy. In this case the perception of time would, analytically, relate to someone who is chronically late with a poor sense of time," said Dr. Myers.
During the evaluation process for cluttering, clinicians and researchers need to obtain a series of good, representative speech samples. However, that's much easier said that done, according to Dr. St. Louis.
"Many cluttering speakers normalize when they have a tape recorder in front of them. When they pay attention and become aware of what they're doing, they'll actually stop making speech errors," he said.
Therefore, 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 of different speaking tasks in therapy, repeating them from time to time. Eventually, individuals will let down their guard, and the cluttering will appear.
People who clutter benefit the most from slowing down their rate of speech, although this proves difficult as well.
"Most of these individuals have been told to slow down almost ad nauseum, and it doesn't help," said Dr. St. Louis. "But if we can get them to slow down by other means, often the articulatory errors drop out, disfluencies reduce, and many symptoms remit. As a result, they become easier to understand."
If these strategies offer little or no success, there are other options.
For example, careful monitoring of speech may lead to a slower rate. Meta-communication skills, a person's ability to reflect on one's own communication and talk about it, may hold some answers. Currently, Dr. Myers is investigating comments and ratings that people who clutter make about their own speech, particularly when they're producing conversational speech.
"We're always monitoring our own speech," she said, "but many people who clutter are unable to do that."
One way to heighten speech monitoring for individuals who clutter is to record and play back samples of their speech on audio and videotape, explained Sandy Ceska, PhD, CCC-SLP, of Corporate Communicology Ltd. in Exton, PA.
"The clinician should point out good speech samples and bad speech samples and specifically explain why they're good or bad. You can make people more aware of the way their speech sounds and identify what needs to be worked on," said Dr. Ceska, adding that it's important for people with cluttering to be their own teachers.
"You need to make sure they're absorbing everything you're teaching them," she said. "With every session you should review what you've taught them during the previous session."
Focusing on clear articulation might prove beneficial, but clinicians also can try teaching individuals to use more acceptable, organized language by outlining what they want to say before saying it.
Other approaches are to teach individuals how to interact with listeners more effectively, such as looking for signals of when the listener doesn't understand and checking in with them from time to time, and to encourage natural speech.
Delayed auditory feedback or a reward system–slowed speech rate gets an award; speeding up too quickly results in having the reward withdrawn–also may be beneficial, depending on the individual.
In addition, researchers need to investigate if language impairments exist in cluttering since language, discourse and narrative skills appear to be compromised at times.
"Standardized language tests can't tap their potential language impairment because they are usually very short-ended and ask the person to repeat things," said Dr. Myers. In contrast, conversational speech is a much better evaluation tool for people who clutter because it taps into those skills.
Clinically, children who clutter are often unaware of their problem and don't understand why people have difficulty understanding them. Adults who clutter may or may not be aware of their cluttering. Some who are associate anxiety with their speech, said Dr. St. Louis.
"They have failed so many times at approaching speech that after awhile they know they will fall apart. It doesn't focus on specific words or sounds; they just think, 'I don't know what's going to happen, but something will go wrong,'" he explained.
Dr. Ceska observes how adults who clutter interact with a spouse or friend in the waiting room. Additionally, she conducts an initial interview to evaluate speech in a number of different speaking situations.
"I have them call a friend on the phone to get a sample of their conversational speech," she said. "I also have them describe pictures depicting simple and complex scenes and read in order to get different types of language output. Meanwhile, I'll note their sound substitutions, distortions, omissions, disfluencies, and whether stuttering is present."
Currently, researchers are uncertain how successfully people who clutter can be treated, and investigators lack good data on how likely it is to occur.
"We're sure it's less common than stuttering, which in the adult population is slightly less than 1 percent. Therefore, the prevalence of cluttering is substantially less than that," said Dr. St. Louis. "For pure cluttering, although there is no good data available, I would guess that the prevalence is less than three-tenths of 1 percent."
Based on estimates in Europe, cluttering is considered almost as common as stuttering if cluttering co-existing with stuttering is included, Dr. Bakker reports.
Cluttering can co-exist with many other disorders, such as articulation problems, language and learning disabilities, attention deficit hyperactivity disorder (ADHD), Tourette syndrome, and central auditory processing disorders (CAPD).
"You never are quite sure how many of the problems are due to cluttering and how many are due to some of these other problems," said Dr. St. Louis.
Clinicians who have worked with people who clutter have the impression that these are not very easy cases to treat.
"Clinicians must spend a lot of time using directed practice, homework assignments and family monitoring in order to see lasting changes from therapy," he said.
Taking acoustic measurements of the speech that people who clutter produce is an integral part of research. Measurements include syllable rates and syllable and vowel durations. Having only looked at non-speech tasks, the research team is at the beginning of this type of research, said Dr. Raphael.
In DDKs patients utter nonsense syllables like "puh-tuh-kuh" and "kuh-tuh-puh" at four different rates: very slow, comfortable, as fast as possible, and even faster. The team has yet to analyze the sentences, conversational speech and nursery rhymes that are included in the protocol.
"In our preliminary studies we found that people who clutter seem to speak somewhat more slowly than normal speakers at the comfortable and fastest rates," he explained. "Once they've spoken as fast as they can, they don't speak much faster, if at all, when asked to do so. Normal speakers don't increase their speaking rate much either, but the increase is noticeably larger. I can't say at this point that the rate difference is statistically significant. That is something we will be able to determine after we've analyzed the speech samples of a larger number of participants."
The process of acoustic analysis is very slow, he noted.
"At this point, we've probably got close to 20 subjects10 people who clutter and 10 normal control subjectseither fully or partially analyzed. We hope by the end of the year or early next spring to have them finished," Dr. Raphael said.
As of now, there are no plans to do physiological studies, although that may change in the future.
"We can't do anything too invasive [at Adelphi], so electromyography is probably not something we can count on," he stated, "but we certainly could do electropalatography if we receive grant funds for which we have applied."
Electropalatography is a technique that uses an artificial palatal prosthesis that is molded to the shape of a speaker's palatal arch. Electrodes are embedded in the palate; and each time the tongue makes contact with one of them, a signal is sent to a computer so researchers can track the patterns of tongue contact as sounds are articulated.
"That would give us a good idea of the differences that might exist between normal speakers and people who clutter with regard to actual placement of the articulators, particularly the tongue. One theory is that people who clutter are co-articulating more, that they're 'getting further ahead' of themselves than normal speakers do when they're producing speech; but that remains to be seen," said Dr. Raphael, adding that the problem is probably more than a motoric issue.
"Another possible line of physiological research would be to use new techniques for evoked potentials related to linguistic/ attentional processing, for example, using our new brain scan," reported Dr. Bakker, whose university is equipped to carry out electromyography research.
The team hopes their research program will give them the raw material to test the operational definitions by acoustic and perceptual measures and careful research to document what cluttering is and isn't.
"Cluttering has been recognized for more than a century, but many clinicians are only vaguely aware of it," said Dr. St. Louis. "I believe that we are really going to put cluttering on the map."
1. St. Louis, K.O., Raphael, L.J., Myers, F.L., Bakker, K. (2003). Cluttering updated. The Asha Leader, Nov. 18: 4-5, 20-22. Accessed online via www.asha.org.
For More Information
• Sandy Ceska, PhD, (610) 524-1662, e-mail: email@example.com
• Florence Myers, PhD, (631) 286-7533, e-mail: firstname.lastname@example.org
• Lawrence Raphael, PhD, (516) 877-4784, e-mail: email@example.com
• Kenneth St. Louis, PhD, (304) 293-4242, e-mail: firstname.lastname@example.org
Jason Mosheim is an Assistant Editor at ADVANCE. He can be reached at email@example.com.