Presented by: Renee Koskey & Kelly Vant Cluttering Presented by: Renee Koskey & Kelly Vant

History Documented in Europe since 1717 First textbook written in 1964 by Dr. Deso Weiss Pure stutterers – 55%, Stutterer-Clutterers – 40%, Pure clutterers – 5% (Daly, 1996) There is a great deal of discrepancy amongst professionals regarding the cause/s of cluttering, how to define cluttering, and therapy approaches to reduce cluttering

Cluttering Defined “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)” (St. Louis, et al., 2007) “Cluttering is a disorder of speech and language processing resulting in rapid, dysrhythmic, sporadic, unorganized an frequently unintelligible speech. Accelerated speech is not always present, but an impairment in formulating language almost always is” (Daly, 1992)

Rate Abnormality Symptoms An excessive number of disfluencies, the majority of which are not typical of people who stutter The frequent placement of pauses and use of prosodic patterns that do not conform to syntactic and semantic constraints Inappropriate (usually excessive) degrees of coarticulation among sounds, especially in multisyllabic words (St. Louis, et al., 2007)

Possible Models of Etiology Central Nervous System Function Models Cognitive Processing Capabilities Models Genetic Models Cluttering-Stuttering Models Central Nervous System Function Models Microscopic lesions in basal ganglia region Studies using new brain imaging technologies suggest a link between cluttering and certain forms of learning disability and attention-related disturbances Cognitive Processing Capabilities Models 1) linguistic processing, 2) attention, 3) central auditory processing, 4) motor-speech related functions, 5) multiple cognitive systems-related explanations Suggests that cluttering is a linguistic syndrome Genetic Models Possible genetic predisposition for disfluent speech Tends to be hereditary – occurring in males 4x more than females – suggests family history Cluttering-Stuttering Models Possible links (St. Louis, et al., 2007)

What Is It? – The Characteristics 4 essential characteristics for a Dx excessive number of whole word or phrase repetitions poorly organized thinking (speaks before clarifying thoughts) short attention span and poor concentration lack of complete awareness of the problem Repetitions – documented through observation Organization – often lacking clarity of inner formulation of speech, word finding problems Concentration/attention – inability to focus on details, poor auditory attention Awareness – don’t understand why people have a hard time understanding them (Daly, 1996)

(Daly, 1996)

Co-Existing Disorders Generally Agreed Upon Possible Theoretical Relevance Fluency disorder Language disorder Central Auditory Processing Disorder Rate deviations ADD / ADHD Basal Ganglia Syndrome Stuttering Specific learning disability Apraxia of Speech Articulation disorder Subgroups of Cluttering Rate – too rapid, too irregular (jerky) Stuttering – co-exits in 40% PWS exhibit part-word repetitions, prolongations, blocks; PWC excessive but normal disfluencies, interjections, revisions, word repetitions, phrase repetitions, and unfinished words Articulation – Deletion of sounds in multisyllabic words, deletion or neutralize syllables (explation for explanation), consistent substitutions or distortions Language – Pragmatic and narrative problems Difficulty maintaining cohesive and coherent conversations Attention – Exhibit many ADD/ADHD symptoms SLD – Difficulties in expression, reading, and writing CAPD – Exhibit similar speech characteristics such as rapid speech, omit weak syllables, excessive disfluencies, excessive verbal revisions Basal Ganglia – difficulties with executive functioning Apraxia – 9 of 12 symptoms overlap, differential diagnosis Subgroups – comfortable diagnosing pure cluttering from co-existing with stuttering (St. Louis, et al., 2007)

International Cluttering Association First International Cluttering Conference held in May 2007 in Bulgaria 60 individuals representing 18 countries Voted to form the ICA Goal of ICA is to increase public and professional awareness about this communication disorder, so that ultimately more effective treatments can be established Yahoo-based online support group (International Cluttering Association, 2007)

Assessment Speech and Language Performance Tasks Speech samples Articulation tests Language tests – comprehension and production Computer-Based Cluttering Assessment Tool Uses a speech naturalness scale of 1-9 Self-Awareness Measures Self appraisal questionnaires Other Potential Tasks and Measures Oral exam, audiological evaluation, samples of motor skills Speech samples - rote tasks, imitation, oral reading, monologue, conversation Spontaneous language sample to get MLU Some normalize when in front of a camera or microphone Questionnaires – Self-Awareness of Speech Index (SASI), Less aware of speech difficulties than PWS (St. Louis, et al., 2007)

Supplementary Assessment Tools Cluttering Symptoms Summary Checklist 4 mandatory symptoms 6 most common facultative symptoms Other facultative symptoms Checklist for Possible Cluttering Total score Cluttering Treatment Planning Profile Speech and Motor Coordination Language and Cognition Behavioral – Pragmatic Developmental (Daly, 1996)

Therapy Increase awareness and self-monitoring skills Improve rate (as well as articulation and speech intelligibility) Improve linguistic and narrative skills Improve fluency skills Improve meta-cluttering skills Improve phonatory and respiratory behaviors Improve family, friend, and employer support Improve collaboration with other team members Foster transfer and maintenance Increase awareness and self-monitoring skills: Use audio and video-taped speech to monitor and self-correct. Use feedback from listeners Use computer-generated visual feedback of speech rate, such as Visi-Pitch Heighten client’s sensory awareness of movements during nonspeech motor acts then during speech motor acts Improve Rate Use delayed auditory feedback Use syllable-timed speech (i.e. metronome) Pause for breath groups Improve Linguistic and Narrative Skills Teach elements of story grammar Help clients sequence thoughts Increase speed and accuracy of word retrieval Improve Fluency Skills Review audio- and videotapes for use of fillers, revisions, incomplete phrases, and other disfluencies Improve Meta-Cluttering Skills Point out specific attributes of client’s cluttering behaviors Improve Phonatory and Respiratory Behaviors Mark passages with pauses for breath intake Improve Family, Friend, and Employer Support Obtain feedback, during moments of clear speech and poor communication, from family and friends Improve Collaboration with Other Team Members Consult with or refer to psychologist, mental health specialist, pediatric or general neurologist Need training in anticipating, perceiving, and responding to standard cues provided by listeners during conversations Lack of research regarding effectiveness of therapy (St. Louis, et al., 2007)

Therapy Modifying speech rate and regularity Delayed Auditory Feedback (DAF) Self-monitoring with DAF Window reading Breathing modifications Drone-type speaking style Oral motor syllable training program Exaggerated mouth movements Breathing Modifications pause and take a new breath at each comma and period, between breath groups Drone-Type similar to continuous voicing (Daly, 1996)

Therapy Promoting relaxation and mental imagery Positive self-talk and affirmation Increasing awareness of cluttering Video / audio tape The language of fluency Vibro-tactile feedback Counseling and attitude change Group sessions Interpersonal / listening skills Improving attention span (Daly, 1996)

References Daly, D.A., (1996). The Source for Stuttering and Cluttering. East Moline, IL: LinguiSystems St. Louis, K.O., Myers, F.L., Bakker, K., & Raphael, L.J. (2007). Understanding and treating cluttering. In E.G. Conture & R.F. Curlee (Eds.), Stuttering and related disorders of fluency (pp. 297-325). New York: Thieme Medical Publishers, Inc. St. Louis, K.O., Raphael, L.J., Myers, F.L., & Bakker, K., (2003, Nov. 18). Cluttering updated. The ASHA Leader, p. 4-5, 20-22 International Cluttering Association (2007). Retrieved December 12, 2007, from http://associations.missouristate.edu/ICA/