CLUTTERING

KUNNAMPALLIL GEJO JOHN, MASLP

Introduction

Skills in the timing and integration of speech and language functions are basic to the fluent output of oral communication A great deal has been written about the fluency disorder of stuttering. The fluency disorder of cluttering however, has received only peripheral focus. In America and British literature, relatively little attention has been paid to it, beyond description of typically hurried and often unintelligible speech pattern produced by this group of speakers

Froeschels, Freund, Luchsinger and Weiss have not only outlined the disorder in detail but less fortunately, contrasted the cluttering and the stuttering in terms of personality and behavior in a way which takes no account of the wide Varity and complexity of factors involved in stuttering and reduced all clutterers to a stereotype The definition if cluttering adopted by the fluency disorder division of the American speech language hearing association is:

Cluttering is a fluency disorder characterized by rapid and/or irregular speaking rate, excessive disfluencies, and often other symptoms such as language or phonological errors and attention deficits

In the predawn darkness in which scientifically oriented speech pathologists is now stumble, perhaps the confusion (between stuttering and cluttering) is to be expected though not to be tolerated indefinitely {Van Riper 1970} St.Louis and Hinzman (1986), presented a sampling of reported symptoms from the literature on the syndrome of cluttering A syndrome is a constellation of symptoms which cooccur but which may or may not be manifested in a given individual It was immediately clear from even a cursory review that cluttering is not clear identifiable entity

Weiss 1964, Luchsinger and Arnold 1065, Wow 1970, Van Riper 1971, Dalton and Hardcastle 1977, Daly 1986 did a analysis, they found at least 65 different symptoms or descriptions of this disorder. Rapid sequences rates was reported by 5 out of 6 authors and there by reflected the highest level of agreement.

4 out of 5 authors reported articulatory symptoms St. Louis Hinzman and Hull (1985), reported that lack of research in the area of cluttering seriously hampered by the lack of an adequate definition Clinical management of cluttering has suffered from the same as well

At west Virginia University, recognized the need for research designed to defined cluttering in empirical behavioral terms (St. Louis et al 1985) Their logic in attempting to develop such a behavioral definition was as follows

First they assumed, as do most of the authors (e.g. Weiss 1964; Van Riper 1971, 1982), that cluttering exists, either in isolation or in conjunction with stuttering. Second, they assumed that cluttering is primarily a speech and language disorder and such, it most appropriately dealt with by speech language pathologist

The speculative literature available indicates that clutterers are most likely to be confused with stutterers and other speech and language problems such as misarticulations, are quite common in the disorder Again, however, they recognized that other professionals, such as learning disability or remedial specialists, were likely to have considered research interest in clutterers as well, because impairment in areas such as attention, reading, or writing may result in greater problems for clutterer than speech or language difficulties Third, since they assumed the most appropriate behavioral dimensions to be used in a definition should mainly consist of speech language characteristic

A working Definition of Cluttering

NSHS (national Speech and Hearing Survey) working definition of cluttering is as follows Cluttering is a sp & lang disorder and its chief characteristics
Abnormal fluency which is not stuttering Rapid and irregular speech rate

Van Riper (1954) descried cluttering as characterized by slurred and omitted syllables, by improper phrasing and pauses, due to excessive speed Luchsinger (1970) says that repetition of syllables and word as the most important feature and remarks on an imperfection in finding words amongst these speaker and a striking monotomy of speech melody.

Weiss (1964) outline the speech symptoms in greater detail. Excessive speed (tachylalia) has always been considered the maintains Froeschels (1946) that they only speak relatively too quick for their ability to find words and formulate sentences Drawling and interjection are seen as resulting from this difficulty

The unintelligibility of the speech of many clutters is caused by

Ommissions of sounds, syllables and whole words Displacement of sounds Inversions of the order of sounds Anticipation of sounds Post position of sounds Repetition of initial sounds Telescoping of several syllable of a word many Many of features seem to be an exaggeration of coarticulation and elision of normal speech

All these articulatory deviations improve when speed is reduced and, indeed, many disappear altogether Weiss also noted the clutterers jerky respiration and short respiratory span and the monotony of the speech-melody pattern (presumably referring to intonation and pitch range)

Wohl (1970) described the prominent feature and cluttering as festinating (i.e. becoming faster and faster as speech proceeds) which leads to elision articulation disorder of an erratic and unstructured type, omission and subsequent spelling and writing errors.

Wessis heading lack of rhythm and musical ability and yet to admits to knowing clutterers who, despite dysrhythmic speech have an excellent sense of rhythm in other respect Although poor pitch and poor sense of melody are often found with clutteringsome clutterers have a good sense of musical elements. Poor concentration and short attention span are claimed as the basic symptomatic elements of cluttering, but the evidence cites for this is slight

Liebmann (1900,1930) proposed 2 groups, one being motor in form and having lack of attention to kinesthetic and somato-motor performance as its basis, while the second was said to be receptive in nature, with the disorders of audition, and attention predominating Froesches (1946) was one of the earliest to relate cluttering to a disturbance of thinking. He described the sequence of preparatory steps before a phrase or sentence is uttered. There is a psychic urge or attitude toward expressive a thought This is followed by a planning of the sequences and choice of words to be expressed

SYMPTOMS

REPETITION EXCESSIVE SPEED DRAWING & INTERJENCTION VOWEL STOP ARTICULATION AND MOTOR DIASABILITY RESPIRATION MONOTONY LACK OF RHYTHEM AND MUSICAL ABILITY CONCENTRATION AND ATTENTION POORLY INTEGRATED THOUGHT PROCESS

INNER LANGUAGE READING DISORDER WRITING DISORDER GRAMMATICAL DIFFICULTIES UNAWARENESS OF SYMPTOMS RESTLESSNESS AND HYPERACTIVITY DELAYED SPEECHAND LANGUAGE DEVELOPMENT ELECTROENCEPHLOGRAPHIC FINDINGS HEREDITY PSYCHOLOGY OF CLUTTERER

REPETITION

Repetition of one syllable words or the first syllable of polysyllabic words is an important symptoms of cluttering In normal or clutterers speech is a sign that the speaker is uncertain of the word or phrase to follow The speech motor are idling while the business of speaking continues without being filed by words

Repetition is common especially in the children between the ages 2-5yrs During these yrs substance of what the child whishes to communicate is too complex for expression in his limited vocabulary The rate of speed of clutters repetition is the exact syllabic speed of his non repetitive (or free-following) speech This is also true of the repetition of normals under stress and is an important factor in differential diagnosis

The clutters characteristic unawareness of his speech deviation accounts for his continuing to make syllabic noise (repetition of syllables) instead of stopping the speech process while he decides on the words follow Children who are unaware of the fact they repeat will have same but when they are aware and tries to correct it, the rate becomes slower (Froeschels 1975)

EXCESSIVE SPEED

Excessive speed was considered the most significant symptom of cluttering, and some investigators even considered it the basic element However normals speech too speed but with perfect order and articulation And there are some clutters who speak at the normal rate Therefore excessive speed must be ruled out as the one of the primary indicator of cluttering

In cluttering, on the other hand when there is excessive speed it is accomplished by poor formulation and delivery, and is therefore an indicator that the speech mechanism cannot cope with its function of communication A clutterer will sometimes begin polysyllabic words at an acceptable rate, but his speed increases as he progress, resulting in a telescoping of the word He apparently has an global impression of a word and hence pronounces it in a single spurt.

He spells as he pronounces, omitting the same letters. This is also occurs in some speech disorders that are a result of brain lesions (e.g. postencephalitic speech). Seeman called it interverbal acceleration Luchsinger added the concept of intraverbal acceleration in cluttering

Gerstmann and Schilder and Seeman attempted to localize the anatomical site of this speed drive and concluded that it is in the striopallidar system, especially in encephalities, but there are no available histological findings at this time for clutterers. The hereditary factor in typically cluttering, however it is not anticipated that structural changes in the brain will found to cause excessive speed.

DRAWING & INTERJENCTION

The clutterers inability to find the words he need in sufficient time to maintain a smooth flow of speech causes him to prolong vowels, most often at the ends of words When they prolong a vowel at beginning of a word, they are in the process of searching for the next word before completing verbalization of the word they have begun This is consistent with the clutterers over acceleration of speech and disharmony of reading and verbalization rates when reading aloud He reads much faster than he verbalizes The clutterers complains that they often seemed to be a head of themselves

The frantic quest for the next word also causes clutters to interject single vowels as ah, consonant such as mm, articulatory combinations often than ahem, and words such as well and you know more often than normal speakers Clutterers some times prolongs the interjections (ah or mm) and remains unaware of their presence in his speech although his listeners find them utterly tire some

VOWEL STOP

Vowel stop consist of a stop before pronunciation of the initial vowel with the mouth open as if frightened. Liebmann considers it a decisive symptom in the differential diagnosis. It is especially common at the beginning of a new phrase or sentence Blocking on the initial vowel exists among stammers but it is not a common occurrence The essential difference between the stammerers spasmodic blocking and the clutterers simple vowel stop is the fact that the clutterer is that unaware of hesitation and consequently does not develop a fearful attitude toward the sound

ARTICULATION AND MOTOR DIASABILITY

Every investigator has noted the clutterers poor articulation Alber Liebmann specifies these deviations as: Omission of sounds, syllables and whole words (ellipsis) Displacement of sounds (heterotopy) Inversion of the order of sounds (metathesis) Anticipation of sounds Post position of sounds Repetition of initial sounds and Telescoping of several syllables of a word

Liebmann says that these deviations improves when speed is reduced, where as articulation is normal speech does not change as a function of speed Seeman & Novak tested the articulatory ability of 52 clutterers and 52 individuals whose speech was normal. Age gender and intelligence were held consonant

The test consisted of quick repetition of syllables pah and tah. The performance of the youngest subjects (ages 7-11) in each group did not differ Clutterers overage 11 performed better than normals over age 11 The investigator concluded that poor motor skill is not the cause of poor articulation in cluttering, a conclusion which seems a but too comprehension for the simple experimental design

RESPIRATION

Arnold says that respiratory dysrhythmia is the cause for the clutterers jerky and explosive speech Froeschels reported that before we speak we automatically inhale an amount of air sufficient for the length of sentences or phrase that we intend to pronounce Clutterers attempt only short phrases and hence must inhale more frequently

MONOTONY

Many therapists have recommended on the monotony and uniformity of the clutterers speech melody pattern Scripture was the original investigator who reported on the caquse of this monotony, first in epileptics and then in stammerers He concluded that monotony of speech melody is related primarily to lack of musical sense Arnold, Pearson, roman-Goldziener concurred

Analysis of the clutterers speech melody and examination of their speech curves by Arnold and by Luchsinger and Dubois indicated that in fact they does not lack variability in pitch. There is a short melodic pattern confined to a range of only several notes of the scale This pattern repeated continually The clutterers speech, therefore, is not characterized by monotony in the strict sense of the word (one tone), but by continual repetition of short melodic pattern It is stereotype but not monotony in the sense of unchanging pitch

Since lack of musicality does not account for lack of melodic variation in all clutterers D.A.Weiss investigated the possibility of psychological basis for this monotony He found that clutterers thoughts progressively proceed by clusters of 2-3 words at a time where as thought of normals speakers apparently proceed by whole phrases or sentences

LACK OF RHYTHEM AND MUSICAL ABILITY

Lack of rhythm in speech is one of the most readily noticable symptoms of cluttering The majority of the clutterers have difficulty both in perciving and reproducing rhythmic However, there are clutterer with excellent sense of rhythm and dysrhythymic speech

G.Arnold believes that dysrhythmia is only a part of what he calls the clutterers congenital amusia Poor pitch and poor sense of melody are often found with cluttering

CONCENTRATIONM AND ATTENTION SPAN

Poor attention and concentration are the basic symptomatic elements of cluttering (Hermann, Gutzmann) Attention span appears to be a function of concentration and together they constitute the basis of other symptoms of cluttering such as reading and writing disorders because of this their memory is severely limited

Attention span in verbal performance can be measure by ascertaining how many of a series of meaningless syllables a patient is able to repeat correctly after examiner has pronounced them

POORLY INTEGRATED THOUGHT PROCESS

Thinking too quickly Thinking too slowly Unorganized thinking Inner language

Thinking too quickly

The supposition that a clutterer thinks faster than he is able to speak Interpreting clutterer who has reached an articulatory dead end because of what appears to be an attempt to speak as quickly as he is thinking, and ask him to state his thought slowly and clearly find that he is still unable to proceed with facility Either he has no clear thought to express, or he has several indefinite and amorphous ideas

There fore it is not so much an accumulation of thoughts that speeds him on, but vague and tentative ideas Froschels calls them thought that are unripe for speech These germs of thought occur to the clutterer and he is driven to express them instantaneously

Thinking too slowly

If thought in preparation for verbal communication is conceived of as an orderly process of clarifying ideas, then clutterers think too slowly for a normal speed of speech In addition to the pause in search of concrete thought for expression there are gaps while the clutterer search for a particular word. His limited knowledge of grammar also slow his thinking lack of accentuation leaves long words without integration, and these words are then misaccented, mispronounced, misspelled, and often even misunderstood by the clutterer himself The tachylalia rapidity of verbal utterance manifested by many clutterers worsen the effect of slow preparatory thought, often reddening speech grotesque As a result an intelligent clutterer may appear considerably unintelligent then he actually is

Unorganized thinking

Poor intergrated and incomplete thought process, rather than the rate of speed of thought, is a factor in cluttering. The clutterers haphazard and tentative thinking in perception for speech reflects his general approach to all understanding This is the basic characteristic of cluttering and hence one of the prime target of therapy

Inner language

In normal speech, verbalization does not seem to take place until the speaker has a clear thought to express, he can inhale the necessary amount of breath to pronounce the length of the sentence he intends to speak Thus the normal speaker does not run out of breath, nor is he left notes with an excess of breath The clutterer speech lacks this inner harmony one of the basic characteristic of cluttering is a lack of clarity of inner formulation and as a result delivery is hackneyed haphazard, and studded with moment when the clutterer seems to lose the thread of thought completely or forget what he said or the next word to be spoken Normal speech reflect inner order and cluttering in the minor of inner disorder

In performing a highly skilled movement the individual generally recalls his previous execution of the same movement, and this is dependent upon kinesthetic sense There is also a purely motor type of fluctuating in which movements are performed automatically, without recall or imagination of past performance The clutterers speech process however, is rather automatic performance

Clutterers seem to need to exert mental effort even to formulate the idea of the sentence they are about to verbalize, where as normals apparently perform this inner formulation without conscious effort, as a function of their predominant type of imagery Even the most intelligent clutterers are apt to remark spontaneously that they are often surprised by something they say, being unaware of having entertained the thought before saying it speech performed without the stabilizing effect rendered by previous imagery of the act can be called abstract action, as opposed to concrete action in which imagery is involved

REDING DISORDERS

One of the characteristic symptoms of cluttering is reading disability Virtually all clutterers manifest a reading problem The dyslexia of the clutterer may apper at all age levels In young clutterers, poor reading is a result of having learned to guess at the text

Speaking problems in reading and writing may persist through and beyond the highest grade of school attended This is closely related to the clutters lack of attention and result in his ignorance of many words with high frequency usage scores The clutterer, as a rule, does not actually read he skips When he reads we may observe him trying to glimpse the end of the sentence before he has reached the middle, or looking back at the beginning because he has lost trend of thought The quality of the usual dyslectics reading the clutterer usually does not fulfill his reading potential

WRITING DISORDER

The clutterers had writing is a characteristic of his generally reduced motor skill, his rather formless imagination, and his disregard for the reader Occasionally repetitions of his speech is seen in writing as well Klara Roman-Goldzieher discussrs the general characteristic of the clutterers handwriting repetitiveness, frequent transposition or omissions of letters and frequent revisions

The clutterer is capable of much better performance when he focuses his attention upon the task The most complete and lucid discussion of this problem, together with the result of psychological tests

GRAMMATICAL DIFFICULTIES

The clutterers spoken grammar is also notoriously poor Throughout his speech there are minor deviations such as confusion of he and she and the use of the singular when the plural is indicated There is often total confusion in the structure of long sentences

The clutterer attention span is so short and his concentration so weak than he often gives the impression that his hearing is impaired, or he is day dreaming, or even that he has a basic disorder of perception Clutterer may forget how he started and so the grammatical structure of his sentence suffer The rather fuzzy thinking of the clutterer lead to a less than satisfactory structuring of his sentences

The typical clutterer is of his speech disorder and may even react with surprise when his attention is brought to the problem The clutterers unawareness of his speech difficulty is a specific case of his speech difficulty is a specific case of his general lack of self awareness Speech as in action, the clutterer proceeds with sudden impulsive spurts, uncontrolled by the smoothing influence of modicum of self awareness or an appreciation of the needs of other

UNAWARENESS OF SYMPTOMS

Libermann suggested delimiting a subgroup of clutterers based on perceptual difficulties Froeschels suspected sensory aphasia in some cluttering children Arnold considers the poor perception a severe aphasia like symptom which he calls perceptual dysgnosia

The typical clutterer fidgets by day and restless even while sleeping according to Seeman Clutterers seems to be alert and interested in his surroundings, but a short time only, since his focus of interest changes continually During interview they are apt to squirm in their chair, occasionally assuming add positions, to play with objects on the desk

RESTLESSNESS AND HYPERACTIVITY

There are many cases of proven lesions of the basal ganglia with restlessness of sort The Seeman school assumes that submicroscopical lesion in this area the cause of the clutterers hyperactivity The clutterers is not aware of his restlessness, but if it is brought to his attention, he will exert effort to control it

DELAYED SPEECH DEVELOPMENT

In many of the clutterers families it was found that they begun to speak rather late This has consider to be the constitutional weakness of there speech disposition A late start in speaking does not necessarily lead to cluttering There are factors of maturation involve in the development of cluttering

Most of the clutterers start speaking late but they ultimately develop satisfactory speech There are no indications that minimal and discrete lesions are involved in cluttering

ELECTROENCPHALOGRAPHIC FINDINGS

In 1951 Luchsinger and Landolt were first to attempt determination of the speech pathology of clutterers by electroencepholographic examination They found abnormalities in almost 100% of their cluttering sample They found that more irregularities in the EGG recording in clutterers than in stutterers than in normals The significance of these recordings are still questionable

HEREDITY

It was found that heredity is a basic factor in cluttering Reasons

Only small 5 of clutterers Cluttering has not been included in many statistical analysis

PSYCHOLOGY OF THE CLUTTERER

Klencke charecterizes clutterers as carefree, careless, and lacking in persistence and sense of responsibility

Pleasant temperament Lifes problem very seriously Alas Short attention span Overactive Change their mind frequently Child like behavior reactions

The personality of the clutterer

Pure stutterers Timed Restricted Regressed Introspective Compulsive Over inhibited Hesitant Retarded Pure clutterers Aggressive Expansive Extroverted Impulsive Uncontrolled Hasty Over productive StuttererClutterer Mixed personalities containing features of both preceding categories

Wiss generalized typical differences

between clutterers and stutterers
Cluttering Stuttering Awareness of disorder Speaking under stress In relaxed position Calling attention to speech Speaking after interruption Short answer Foreign language Reading well known text Absent Better Worse Better Better Better Better Worse Present Worse Better Worse Worse Worse Worse Better

Reading unknown text Hand writing

Attitude toward own speech Psychological attitude Goal of therapy

Better Hasty, repetition uninhibit ed Careless Outgoing Directing attention to speech

Worse Contracte d, forced, inhibited Fearful

Rather withdrawn Directing attention from details

ASSESSMENT OF CLUTTERING

Several principals are held to be particularly helpful in the assessment of clutterers They should be assed for entire communication system including language, rate, articulation and fluency Need to assess the nature of the reaction between the various component of communication system Since some clutterers may also exhibit perceptual motor and learning difficulties assessment should be broadly based to include neuro psychological testing

Strategies for assessment

Language sample and formal testing

Analysis of language sample should seek to answer a number of question regarding aspects of the clients fluency, language, rate and articulation There should be notations regarding non verbal speech behavior Based on the information from the language sample, the clinician select assessment tools which provided a more structured and standardized mean of evaluation

Standardized test serve one or more of the following purposes

To obtain, norm reference measure of the various aspects of speech and language which appear to be disorder To compare and contrast the fluency, articulation, rate and language observed in naturalistic vs. formal situation To examine in a more controlled and focused way the behavior judged to be anomalous based on naturalistic language sample

Some diagnostic questions to consider

Selected diagnostic questions will be organized around the major components of speech and language system, each query attempts to tap a component from a slightly different point to extract additional insight regarding therapy implication

Fluency Rate and rhythm Articulation Language Neuropsychological testing Self awareness

Case history and interview

Some important information can be extracted from the case history and interview with the client and family

Other members of the family have speech and language problem similar to those of the client Interaction between client and family members how is it home, working, school Attempt to compensate for the problem

Dalys checklist for possible cluttering

Rating from 0-3 It consists of 33 questions

Analysis

Speaking rate in terms of syllables per min They speak 10-15% above the normal This analysis should be among the articulation, fluency, rate and melody

Differential diagnosis between cluttering and stuttering

Cluttering
Client is unaware of dysfluencies Fluent when concentrate on fluency Spontaneous speech less fluent Strangers more fluent Aware Less fluent More fluent Less

Stuttering

Verbalization are less difficult to control

Hereditary Fear of specific sound or situation is not present

More difficult to control

Psychological or functional Present

Relaxed situation more problem Prognosis is better never relaps

Occurs only at childhood By taking chloropromazine drug speech will be better EGG deviated pattern

Less
Prognosis is better but relaps

At childhood or adult
Becomes worst EGG normal

Management of cluttering

Speech rate modification

Increasing client awareness Video tape play back Audio tape Vibro Tactile feed back Cognitive training Letter reading Accent ration Rhythmic tapping Story creativity

DAF

Journal articles

An examination of various aspects of auditory processing in clutterers

LAWRENCE F.MOLT

Aim of the study

The present study examined various aspects of auditory processing ability, utilizing a brief CAP test battery and auditory event related potentials

Subjects

3normals and 3 clutterers

Results

CAP:

All the 3 control group performed with in normal limits All the 3 clutterers performed below normal established criteria

AEP:

Abnormal AEP morphology was noted for all 3 cluttering subjects an absence of N1 and P2components and lengthening of P3 latency

Neurogenic cluttering

Language

Auditory comprehension 57/60 Repetition 92/100

Articulation

60% for single 18%for sentences

Fluency Self monitoring skills