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Speech-Language Pathology Department, Misericordia University
Dallas, PA
Department of Speech Pathology and Audiology, West Virginia University
Morgantown, WV
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Introduction |
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Through this special edition our knowledge of cluttering has been considerably upgraded. But we still have a long way to go until cluttering is understood and acknowledged on an equal footing with its relative, stuttering. (1996, p. 353)
Progress has been made since 1996. In recent years, interest in the communication disorder of cluttering has increased significantly, especially in North America, where interest had waned since the 1950s (St. Louis, Myers, Bakker, & Raphael, 2007). The year 2007 marked the First World Congress on cluttering and subsequent formation of the International Cluttering Association (ICA), an organization comprising researchers, clinicians, and consumers devoted to enhancing awareness of and disseminating information about cluttering. In less than 2 years, membership within the ICA has grown from 55 individuals representing 18 countries to 135 members representing 27 countries. A Yahoo-based cluttering online support group (founded and run by consumer Joseph Dewey) makes available and archives daily frequent postings from consumers. A 2009 American Speech-Language-Hearing Association (ASHA) online forum on the topic of cluttering received the second highest number of viewers in a year's time (2009). It seems, then, that the acknowledgment of cluttering Preus called for in 1996 is increasing. Although cluttering continues not to share an equal footing with stuttering, and reports of misdiagnosis of cluttering remain (see Adams, this issue), the aforementioned participation in cluttering discussions suggests that acknowledgment of the disorder among clinicians and researchers shows steady improvement.
Aside from increased interest and recognition, however, we must still question whether understanding of cluttering has increased as well. Increased understanding of cluttering logically requires gains in the availability of solid empirical information about the disorder. It is instructive to consider the critical remarks of Richard Curlee in response to the 1996 special edition on cluttering and the advances that have been made since those remarks:
Much of what is known about cluttering is the product of anecdotal clinical observations rather than findings from systematic empirical research. As a result, the credibility of much of this information is substantially compromised as is its diagnostic value. Current research efforts, unfortunately, continue to reflect many of these same weaknesses. (p. 367)
In 2009, researchers still have not reached consensus on a standard definition of cluttering. Variable definitions play a major contributing role in a lack of evidence about cluttering because it is impossible to draw firm conclusions from studies that examine ostensibly the "same" disorder defined differently. This is not a trivial issue, for it is clear that the available research has focused on different disorders and that clinical diagnoses of cluttering may well identify different core problems (e.g., Curlee, 1996; Daly & Burnett, 1999; Georgieva & Miliev, 1996). For example, diagnostic checklists currently available to measure cluttering (e.g., Daly, 1992-1993; 2003; 2006; Daly & Burnett, 1997) are broad and lack specificity (Georgieva & Miliev, 1996; Scaler Scott, Grossman, & Tetnowski, in press; Van Borsel & Vandermeulen, 2008). Accordingly, a skeptical scholar may very well ask, "What in cluttering has changed?" We need to be cautious not to confuse increased discussions about the topic of cluttering with increased empirical information.
It is important to note that critiques such as these are not meant to discredit pioneers in the area of cluttering. Pioneers such as Froeshels (1955), Luchsinger and Landolt (1951, 1955), and Weiss (1964) identified symptoms of a fluency disorder (i.e., cluttering) that differed from stuttering. The uniformity of their lists of symptoms of cluttering versus stuttering provides validation for symptoms clinicians continue to observe, but experience difficulty describing precisely. Preus' and Curlee's words remind us that we must develop conclusions about cluttering that are empirically based and replicable rather than persisting in approaches for which these characteristics of scientific enquiry are not possible.
We submit that this is an exciting year for advances in the field of cluttering, given that the tide is turning toward gathering sound evidence. Moreover, we would argue that recent shifts in thought about cluttering reflect more than increased acknowledgment. For example, recent references to a shift in thought include acknowledgment of the lack of evidence and recognition of its resultant problems (Ward, 2006). The evidence that the tide is turning also includes moving forward with a more specific definition of cluttering. Increased specificity regarding cluttering is noted in the current working definition of cluttering proposed by St. Louis et al. (2007):
Cluttering is a 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). These rate abnormalities further are manifest in one or more of the following symptoms: a) an excessive number of disfluencies, the majority of which are not typical of people who stutter; b) the frequent placement of pauses and use of prosodic patterns that do not conform to syntactic and semantic constraints; and c) inappropriate (usually excessive) degrees of co articulation among sounds, especially in multisyllabic words. (pp. 299-300)
This definition focuses only upon cluttered speech. While the authors acknowledge that cluttering may, in fact, reflect more than speech characteristics, they also point out that empirical data is currently lacking to determine whether such components are a part of the disorder of cluttering itself or merely symptoms that frequently coexist with its speech characteristics (St. Louis et al.). Until necessary empirical information becomes available to support an alternative, this definition provides a compromise to move forward with a responsible approach to research, assessment, and treatment.
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Research |
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Assessment |
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Treatment |
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The least straightforward symptom of cluttered speech is that of excessive disfluencies that resemble nonstuttering-like disfluencies (NSLDs; Ambrose & Yairi, 1999; Yairi & Ambrose, 1992). Before choosing a treatment to reduce excessive disfluencies, clinicians should attempt to understand the reasons for each client's use of such NSLDs. For example, if a client uses them to "buy time" to think of a word, word finding problems should be further assessed and treated accordingly. If the client uses NSLDs to avoid moments of stuttering (which may occur concomitantly with cluttering), targeting the fear of stuttering is warranted. If NSLDs are related to rate problems, e.g., attempting to speak faster than the speaker is able (either motorically and/or formulation-wise), teaching rate modification would be indicated.
Discovering what underlies a client' use of excessive disfluency involves more than documenting below-average performance on a standardized test of word retrieval. Instead, the clinician should carry out detailed analyses of speech patterns to test the aforementioned hypotheses. For example, if a clinician hypothesizes that a client typically uses excessive NSLDs to buy time to organize thoughts or retrieve words, other corroborating evidence is necessary. That is, when the client produces excessive NSLDs, the clinician searches for evidence that the client also circumlocutes or makes such comments as, "How do you say it again?" or "What's the word?" Additionally, the clinician may make note of language suggesting that the client's thoughts are out of sequence. To rule out stuttering avoidance, the clinician searches for patterns of stuttering that precede or follow NSLDs, indicating that perhaps these are used to escape or avoid stuttering. In addition to these objective analyses of patterns, if a client has the meta-cognitive skills to do so, asking a client to explain the reasons for restarting, revising, hesitating, or using fillers may provide explanatory information. Most cluttering clients likely will not have such insights at first, because they typically have not thought much about their speech (although there are exceptions). However, given training to listen for patterns, clients may become introspective enough to explain the suspected root cause of their disfluency, which can then be further tested and treated accordingly.
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Cautions |
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In the realm of assessment, a skeptical scholar may be concerned that using the aforementioned criteria (i.e., rate, intelligibility, prosody/pausing, and disfluency) would result in ignoring other areas in addition to cluttered speech (e.g., language disorders). We re-emphasize that the clinician should not ignore such potential areas of difficulty. If a potential client were to present with any suspected communication disorder and the expected communication symptoms were observed or reported, the clinician would assess those areas of complaint. For example, if a client were referred with a w/r substitution, and the clinician suspected receptive language and/or pragmatic language issues as well, it would not conform to accepted best practice in speech-language pathology to ignore these latter symptoms and only evaluate the w/r substitution. Exceptions exist, of course, such as a client who is already receiving treatment for other areas and does not wish further evaluation. Likewise, it would be irresponsible to label a client who presents with a w/r substitution, receptive language problems, and pragmatic difficulties as someone with autism spectrum disorder or a language-based learning disability simply because these symptoms frequently coexist in such diagnoses. Instead of making a broad diagnosis based upon a few symptoms, the clinician would compare the symptoms observed to agreed-upon diagnostic criteria before making any diagnoses in communication disorders.
Finally, the skeptical scholar may wonder about the effectiveness of treating individual symptoms based upon a narrow definition of cluttered speech. Myers and Bradley (1992) suggested that the symptoms of cluttering interact in a synergistic manner and that, therefore, synergistic therapy approaches for one area can be expected to affect and even benefit another. To the extent that synergism accurately characterizes cluttering treatment, focusing upon individual symptoms, as we have thus far suggested, may have a positive impact upon other areas that are not being targeted, therefore improving overall communication effectiveness.
Clinicians have a wide variety of options in recognizing and managing cluttering. Some choose to question its existence (e.g., Ryan, 2001). Others may label it as some other disorder about which they have more evidence and/or clinical training (Ward, 2006). Would we take such an approach with the common situation wherein a child presents with a concomitant articulation/phonological and language disorder? Assuming articulation or phonology were not our area of expertise and we were uncomfortable treating in this area, would we (a) deny the existence of an articulation/phonological disorder; (b) label the client as having only a language disorder (i.e., the focus of our background and training); or (c) similarly, treat the language disorder only and ignore the sound errors? We submit that it is clear that to select any of these options would not conform to best practice and even perhaps approach violation of professional ethics. Yet, parents report such things happening when seeking help for their child's cluttering (see Adams, this issue). The rationale for cluttering to be ignored, not to be taken seriously, and not to be diagnosed can be attributed to a lack of empirical data and a specific definition of cluttered speech. That rationale will soon be no longer tenable. Given the advent of a strong consumer movement in fluency disorders in general (Reeves, 2006) and the current efforts of the International Cluttering Association to educate others (Scaler Scott et al., 2008), cluttering should no longer be ignored. Nevertheless, to maintain the credibility of a cluttering diagnosis and for such diagnoses to reflect more than token recognition of a currently popular, well-marketed communication disorder, we must be careful to focus on the speech aspects of the disorder that we know and for which we have evidence. It may not be an overstatement to suggest that jumping on a bandwagon of a particular view of cluttering without sound evidence does not help our clients, while using the evidence we do have to think critically about research design, assessment, and treatment in the area of cluttering does.
In summary, we encourage those engaged in research to design studies based on a consistent and specific definition of cluttered speech. Simultaneously, we encourage clinicians to check their journals regularly for new data regarding cluttering as it becomes available. Solid evidence is the best basis for sound treatment decisions.
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References |
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