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Cluttering in the Communicative Disorders Curriculum

Department of Communicative Disorders, University of Louisiana at Lafayette
Lafayette, LA

	Abstract

Top Abstract Introduction Issue #1: What Is... Issue #2: Can Cluttering... Issue # 3: What... Summary #1 Theoretical Questions Conclusions and Recommendations References

 
Cluttering is discussed openly in the fluency literature, but few educational opportunities for learning more about cluttering exist in higher education. The purpose of this manuscript is to explain how a seminar in cluttering was developed for a group of communication disorders doctoral students. The major theoretical issues, educational questions, and conclusions are discussed.

	Introduction

Top Abstract Introduction Issue #1: What Is... Issue #2: Can Cluttering... Issue # 3: What... Summary #1 Theoretical Questions Conclusions and Recommendations References

 
Although I have worked for some 15 years in the field of higher education, a request from one of my students took me by surprise. The request was for an elective seminar on the topic of cluttering. Since I have had both a clinical and theoretical interest in the topic, I agreed and started thinking about the issues that would need to be addressed. Within a few weeks, I realized what a predicament I had gotten myself into. Not only was I sailing on uncharted waters, but, to my knowledge, I was teaching one of the first seminars on cluttering in North America.

I determined that the seminar should address at least three major areas. Each of these areas centered on the philosophical principles/issues that guided the course building process. In turn, as my students and I resolved each of these issues together, we identified important questions for clinicians and researchers interested in cluttering. This article will outline these key these issues and questions. Implications and future directions for dealing with the topic of cluttering in higher education, clinical work, and research will be presented.

	Issue #1: What Is Cluttering?

Top Abstract Introduction Issue #1: What Is... Issue #2: Can Cluttering... Issue # 3: What... Summary #1 Theoretical Questions Conclusions and Recommendations References

 
A quick review and synthesis of cluttering definitions revealed that there are two very distinct views of cluttering. One philosophy views cluttering primarily as a speech disorder. The opposing philosophy views cluttering primarily as a language disorder. Several definitions, including those of Weiss (1968), Luchsinger and Arnold (1965), and Perkins (1978), consider cluttering a complex disorder marked by rapid speech or irregular speech. Their definitions also consider a central language component that drives the resulting speech disorder and the associated learning, processing, and/or reading and writing disorders. In these definitions, cluttering has been called a "central language imbalance" that encompasses oral language, written language, and even musical abilities. The authors state that the underlying cause of cluttering (the central language disorder) can result in hurried or rapid speech and nonfluent formulation.

On the other hand, a more recent definition of cluttering views cluttering as primarily a speech disorder. St. Louis, Myers, Bakker, and Raphael (2007) state that 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 of prosodic patterns that do not conform to syntactic and semantic constraints; and (c) inappropriate (usually excessive) degrees of coarticulation among sounds, especially in multisyllabic words. (pp. 299-300)

This definition does not refer to any language and/or learning disorders.

The initial definitions of cluttering mentioned consider it to be primarily a language-based disorder, while the more recent St. Louis et al. definition considers cluttering to be primarily a speech disorder. This distinction between definitions caused the author to consider the common characteristics related to both groups of definitions and boil them down into what St. Louis (1992) terms the "’lowest common denominator of cluttering" (p. 52; see also St. Louis, Myers, Faragasso, Townsend, & Gallaher, 2004; St. Louis & Schulte, in press). The definitions of cluttering mentioned have only two common factors: rapid and/or irregular speech rate and considerable perceptual nonfluencies. Specific descriptions of the nonfluencies are either inconsistent or poorly defined. The range of these nonfluencies varies considerably. Throughout the rest of this manuscript the following terminology will be used:

• Stuttering-like disfluencies (SLDs; Ambrose & Yairi, 1999; Yairi & Ambrose, 1992) will refer to those speech behaviors that are viewed as stuttering by most experts. These include part-word repetitions, single syllable word repetitions, prolongations, and blocks.
  
• The nonfluencies that are used by many individuals that do not stutter (and also used in nonstuttering situations by PWS) will be referred to as disfluencies. These include interjections, phrase repetitions, incomplete words, and multi-syllable word repetitions.
  
• Whenever the two categories are combined, or when uncertainty exists as to how the classification took place, the term nonfluencies will be used.
  
• Additionally, the irregularities in speech in the definitions are reported as breakdowns in fluent speech, but according to St. Louis et al. (2004), are only "global perceptual judgments"; that is, they are only perceptually noted,.not objectively or systematically defined. Nonetheless, perceptually disfluent speech is a cornerstone of these definitions.
  

The initial conclusion from a literature review and determination of the "lowest common denominator" in definitions would consider cluttering to be primarily a speech disorder that contains irregular or rapid nonfluencies that are marked in nature by perceptual cues.

	Issue #2: Can Cluttering Exist as a Unitary Disorder?

Top Abstract Introduction Issue #1: What Is... Issue #2: Can Cluttering... Issue # 3: What... Summary #1 Theoretical Questions Conclusions and Recommendations References

 
The distinction between cluttering as a speech disorder or cluttering as a language disorder is complicated by the fact that cluttering may occur concomitantly with other diagnosable conditions. A review of the literature reveals that the rapid and/or irregular nonfluencies associated with cluttering exist with many other conditions including Fragile X Syndrome (Shprintzen, 1997) and Down syndrome's (Otto & Yairi, 1975). A review of speech and language data bases in the United States found that a "significant" number of children with fluency disorders who may be clutterers were also likely to have phonological, language, or language-based learning disorders (St. Louis & Hinzman, 1988; St. Louis, Hinzman, & Hull, 1985).

The question for many clinicians, however, may simply be whether the language, learning, or other disorders exist concomitant to cluttering or are part of cluttering. This was a serious dilemma for me, because in my clinical experiences, I had never seen a "clutterer" who only exhibited the speech characteristics of cluttering without any language, processing, writing, or other learning disorder. I had never seen a "pure clutterer" in my clinical career. This led to a discussion with one of the experts in cluttering research who assured me that I was not alone in my observations and clinical experiences. Even the most experienced researchers in cluttering have seen just a few "pure-clutterers" in their clinical careers (K. O. St. Louis, personal communication, July 25, 2006). Since that time, I have met at least one "pure-clutterer" while attending the First World Congress on Cluttering.

In my opinion, cluttering can exist as a unitary disorder, but in very, very rare situations. Based upon these conclusions, I prefer to not use the term "clutterer" in clinical evaluations or research. The term "person who clutters" or "person who exhibits cluttered speech" is preferable, not only to show respect for the patient/client, but also to be exact in defining the condition. That is, in my opinion, the "lowest common denominator" of cluttered speech seems to be rapid and/or irregular speech with marked nonfluencies. These symptoms may be more than likely to appear concomitant to other speech, language, learning, or other conditions. Therefore, our class decided that referring to the symptoms of an individual's speech (as in, "a person who exhibits cluttered speech") is far more descriptive for clinical evaluations and far more accurate for research purposes.

	Issue # 3: What Are Concomitant Disorders?

Top Abstract Introduction Issue #1: What Is... Issue #2: Can Cluttering... Issue # 3: What... Summary #1 Theoretical Questions Conclusions and Recommendations References

 
A review of the literature reveals that the rapid and/or irregular nonfluencies associated with cluttering exist with many other conditions, including language and learning disorders (Daly & Burnett, 1999; Tiger, Irvine, & Reis, 1981), motor disorders or weaknesses (Freund, 1970), suspected central auditory processing disorders (CAPD; Molt, 1996), social differences such as autism spectrum disorders (Scott, Grossman, Abendroth, Tetnowski, & Damico, 2007), neurological conditions (Thacker & De Nil, 1996), and congenital disorders including Down's syndrome, Fragile-X Syndrome, Prader-Willi syndrome, neurofibromatosis, and others (Van Borsel & Tetnowski, 2007). It is apparent that cluttering likely to occur not only in a cluster of symptoms, but it is likely to exist in a cluster of symptoms. The terminology "clutterer" does not sufficiently provide the control needed in experimental research nor is it descriptive enough in clinical settings. The terminology "a person who clutters" or "a person who exhibits cluttered speech" is far more descriptive and precise in both settings. Thus, a clutterer who also has a learning disability would be appropriately described as an individual with a learning disability who also "exhibits cluttered speech."

	Summary #1

Top Abstract Introduction Issue #1: What Is... Issue #2: Can Cluttering... Issue # 3: What... Summary #1 Theoretical Questions Conclusions and Recommendations References

 
These three major issues lead to at least three secondary issues, which are outlined in the next sections and are more philosophical or theoretical in nature. The answers are yet to be determined, but the questions should serve as informational guidelines.

	Theoretical Questions

Top Abstract Introduction Issue #1: What Is... Issue #2: Can Cluttering... Issue # 3: What... Summary #1 Theoretical Questions Conclusions and Recommendations References

 
What Are the Pitfalls To Be Avoided?
The review of the literature above indicates that there are various views of cluttering. Simply taking the first definition that you come across will not be sufficient. For example, a quick search of textbooks may reveal scales to quantify a diagnosis of cluttering. If a clinician came across Daly and Burnett's chapter on cluttering in the 1999 text on Stuttering and Related Disorders of Fluency (Curlee, 1999), he/she would find a checklist that outlines 36 features of cluttering (Daly & Burnett, 1999). This model is based upon cluttering being under the umbrella of cognitive, language, pragmatic, speech and motor disorders. Thus, items that stress potential concomitant symptoms (e.g., Item #17: Inappropriate pronoun referents; overuse of pronouns; Item # 20: Reading disorder or difficulty reported or noted; or Item # 22: Writing shows omission or transposition of letters, syllables, or words) are not differentiated from pure cluttered speech itself (e.g., Item #8: Rapid rate (tachylalia) or irregular rate; speaks in spurts; Item #1: Repeats words or phrases). These items are all equally weighted in this checklist. Although the authors do stress that the client should respond descriptively, a client who uses pronouns inappropriately and does not have rapid and/or irregular speech may be just as likely to fit the profile as a person who uses rapid and/or irregular speech. It is my opinion that one of the major pitfalls is choosing a single view without understanding all of the major views in cluttering. Since there are at least two major views of cluttering, both models must be studied and understood before a personal decision is made. Therefore, my solution in teaching a course on cluttering was to expose students to both viewpoints while they are in the process of deciding what constitutes a diagnosis of cluttering. Upon completion of the seminar, we unanimously agreed that describing "cluttered speech" as a symptom was superior to describing "cluttering" as a self-standing diagnosis.

How Can Cluttering Be Diagnosed?
Clearly, the answer to this question follows the decision made on the previous question. The perspective I gained from the first question is that cluttered speech is primarily a speech disorder marked by rapid and/or irregular speech with perceptually nonfluent speech. Using this as a basis for evaluation, I determined that cluttered speech can only be diagnosed by careful transcription and analysis. Studies on cluttering have revealed that, when a client "exhibits cluttered speech," the speech must be carefully analyzed for rate and form (Scaler Scott & Tetnowski, 2006; Scott et al., 2007). These studies reveal that the perceived rapid and irregular rate was not necessarily outside of normative standards, but that the nonfluencies associated with the cluttering can be either SLDs or disfluencies. In my opinion, cluttered speech can only be defined by a group of symptoms that relate to the use of nonfluencies accompanied by rapid and irregular rate. Making a diagnosis of "cluttered speech" requires careful descriptive analysis of spoken samples. At this time, there is no standardized test to diagnose cluttering.

How Can Outcome Studies Be Viewed in a Logical Manner?
Once again, the definition of cluttering will dominate this discussion. There are several studies that have explored the success of treatment for cluttering (Craig, 1996; Dewar, Dewar, & Barnes, 1976; Langevin & Boberg, 1996). Unfortunately, these studies are based upon co-occurring conditions (e.g., stuttering and cluttering) or an unclear definition and description of the cluttering. At this time, a label of "cluttering" is insufficient for treatment efficacy studies. However, outcome studies can be helpful, if the participants' symptoms are meticulously described in the methodology section. With this descriptive information, symptoms can be carefully measured and reported, giving clinicians ideas on how to successfully treat a person who "exhibits cluttered speech." Unfortunately, participant inclusion in the previously mentioned studies was based on a diagnosis of "cluttering" by a certified clinician and, thus, is not sufficient to gain insights into all presenting speech characteristics. A description of the cluttering behavior and any concomitant disorder is a key component in understanding treatment outcomes.

	Conclusions and Recommendations

Top Abstract Introduction Issue #1: What Is... Issue #2: Can Cluttering... Issue # 3: What... Summary #1 Theoretical Questions Conclusions and Recommendations References

 
This process of preparing for and leading a seminar in cluttering has led me to several conclusions. First, cluttering is a complex disorder that is not understood by all who diagnose and treat it. As a matter of fact, it is not even clearly understood by the researchers who write about it. The result is likely to be poor clinical diagnosis and treatment outcomes. After a semester of planning and another semester of leading a seminar devoted only to cluttering, I realize how much there is to learn about this fluency disorder. My students and I wondered how much information on cluttering the typical starting clinician had accrued. In order to help answer this question, we conducted a preliminary survey of some of the world's training programs in speech-language pathology, using the list of individuals that appear on the mailing list of the International Fluency Association and the American Speech-Language-Hearing Association's Special Interest Division on Fluency Disorders and Fluency Disorders (Scaler Scott, Grossman, & Tetnowski, in press). The modal amount of time devoted to cluttering in a graduate fluency course was merely 60 minutes and the mean was 100 minutes. More recent surveys suggest similar findings in Canada (Di Domenicantonio & Duldulao, 2009). This is hardly enough time to tackle such a complex and misunderstood disorder.

In conclusion, a set of working recommendations for clinicians (and instructors) interested in cluttering includes

1. It is essential to read significantly and complete a self-study in cluttering prior to diagnosing and treating an individual with cluttering.
   
2. It should be required to understand the basics of cluttering before one is considered to be a fluency specialist.
   
3. There is much confusion in the clinical and research world about what cluttering actually is. The common factor in all of the definitions is the perception of fluency breakdowns that are not necessarily stuttering and speech marked by a rapid and/or irregular rate that is not always outside of reported norms but is too rapid or irregular.
   
4. A standard definition of cluttering should be agreed on by international and national organizations dealing with fluency disorders.
   
5. As a prerequisite for publication, outcome studies must carefully outline their definition of cluttering.
   

	Acknowledgments

 
I would like to thank my three doctoral students who participated in the seminar: Kathy Scaler Scott, Mitch Trichon, and Heather Grossman. This seminar and manuscript would not have been possible without you. Thank you for helping me learn!

	References

Top Abstract Introduction Issue #1: What Is... Issue #2: Can Cluttering... Issue # 3: What... Summary #1 Theoretical Questions Conclusions and Recommendations References

 

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Curlee, R. F. (1999). Stuttering and related disorders of fluency (2nd ed.). New York: Thieme.

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