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  1. 1. Cluttering
  2. 2. What is cluttering? <ul><li>Cluttering is a relatively rare (and controversial) disorder characterized by dysfluency similar to that seen in stuttering, but accompanied by other behaviors not typically seen in people who stutter. Among its additional symptoms are: </li></ul><ul><ul><li>Excessive and irregular speech rate ( tachylalia ). This may be a real phenomenon or may reflect a rate of speech that appears fast because it is in excess of the patient’s motor and linguistic planning abilities. The resulting articulatory imprecision may have the perceptual effect of too-rapid rate. </li></ul></ul><ul><ul><li>A high number of interjections and prolonged interjections (drawling) </li></ul></ul>
  3. 3. Symptoms (continued) <ul><li>Impaired speech intelligibility, due to: </li></ul><ul><ul><li>Omissions of sounds, syllables, and occasionally, whole words; </li></ul></ul><ul><ul><li>Metathesis of speech segments </li></ul></ul><ul><ul><li>Anticipatory and progressive assimilation of sound segments </li></ul></ul><ul><ul><li>Repetitions of initial segments </li></ul></ul><ul><ul><li>Telescoping of multi-syllabic targets (usually via weak syllable deletion) </li></ul></ul><ul><li>These symptoms appear ameliorated by slowed rate of speech, pacing and monitoring. </li></ul>
  4. 4. Symptoms (continued) <ul><li>Impaired (monotonic) prosody </li></ul><ul><li>Impaired respiratory patterns for speech </li></ul><ul><li>Co-morbid learning disability, usually in reading/writing </li></ul><ul><li>Relative lack of awareness of communicative impairment, including dysfluencies and articulation errors. </li></ul>
  5. 5. Symptoms of Cluttering (Daly, 1994) <ul><li>Obligatory Symptoms </li></ul><ul><li>Excessive repetitions </li></ul><ul><li>Poorly organized thinking </li></ul><ul><li>Short attention span and poor concentration </li></ul><ul><li>Lack of awareness of cluttering problem </li></ul><ul><li>Facultative Symptoms </li></ul><ul><li>Excessive speech rate </li></ul><ul><li>Grammatical difficulties </li></ul><ul><li>Delayed speech and language development </li></ul><ul><li>Auditory imperceptiveness </li></ul><ul><li>Oral reading and reading comprehension problems </li></ul><ul><li>Writing problems </li></ul><ul><li>Other Facultative Symptoms </li></ul><ul><li>Abnormal respiration </li></ul><ul><li>Monotony </li></ul><ul><li>Motor problems </li></ul><ul><li>Family history of disfluency </li></ul><ul><li>Academically weak in reading/language arts </li></ul><ul><li>Volume problems (explosive speech) </li></ul><ul><li>Personality factors (aggressive, untidy, impulsive) </li></ul><ul><li>Articulation problems </li></ul><ul><li>Lack of rhythm </li></ul><ul><li>Small for age </li></ul><ul><li>Academically strong in math </li></ul><ul><li>Dysphonia </li></ul><ul><li>Language/grammar difficulties (word retrieval; word order; sentence simplification; verb conjugation; sequencing of prepositions; pronoun reference. </li></ul>
  6. 6. Symptoms of cluttering (Weiss, 1968) <ul><li>Obligatory Symptoms </li></ul><ul><li>Excessive repetitions (8-10) </li></ul><ul><li>Short attention span and poor concentration </li></ul><ul><li>Lack of awareness of the problem </li></ul><ul><li>Perceptual weakness </li></ul><ul><li>Poorly organized thinking </li></ul><ul><li>Facultative Symptoms </li></ul><ul><li>Excessive speech rate </li></ul><ul><li>Interjections </li></ul><ul><li>Vowel stops </li></ul><ul><li>Articulatory and motor disabilities </li></ul><ul><li>Grammatical difficulties </li></ul><ul><li>Vocal monotony </li></ul><ul><li>Respiratory dysrhythmia </li></ul><ul><li>Delayed speech development </li></ul><ul><li>Associated Symptoms </li></ul><ul><li>Reading disorder </li></ul><ul><li>Writing disorder </li></ul><ul><li>Lack of rhythmical and musical ability </li></ul><ul><li>Restlessness and hyperactivity </li></ul><ul><li>EEG findings </li></ul><ul><li>Lag in maturation </li></ul><ul><li>Heredity </li></ul>
  7. 8. Etiology of cluttering <ul><li>Currently unknown. </li></ul><ul><ul><li>Difficulty of isolating group; there is clear overlap between cluttering and stuttering, and some individuals may have both conditions. </li></ul></ul><ul><ul><li>As with stuttering, there is a clear familial component. </li></ul></ul><ul><li>Almost certainly a neurological condition; </li></ul><ul><ul><li>In early studies, over 90% of clutterers showed abnormal EEG function (Luchsinger & Landholt, 1951). </li></ul></ul><ul><li>In other early studies, PWS and PWC showed inverse reactions to DAF, and drugs such as chlorpromazine (tranquilizer) and dexfenmatrazine (amphetamine). </li></ul><ul><li>May be frequently seen in Fragile X and certain other conditions </li></ul><ul><ul><li>See: http://www.fragilex.org/html/articulation.htm </li></ul></ul>
  8. 9. Diagnostic considerations <ul><li>Case history, including family history, academic history, etc. </li></ul><ul><li>Observation of speech and reactions to speech </li></ul><ul><li>Spontaneous speech sample </li></ul><ul><li>Oral reading of extended (3-5 minutes) passage 1 year below presumed reading level </li></ul><ul><li>Rhythmic ability </li></ul><ul><li>Writing sample </li></ul><ul><li>Speech tasks used in stuttering assessments </li></ul><ul><ul><li>Also observe when taping is discontinued </li></ul></ul><ul><li>Auditory memory via sentence repetition </li></ul>
  9. 10. Dx (continued) <ul><li>Checklist for Possible Cluttering (Daly, 1991) </li></ul><ul><ul><li>33 items rated on a 4 point scale; 99 possible points. </li></ul></ul><ul><ul><li>55+ strongly suggestive of cluttering </li></ul></ul><ul><ul><li>35-55 = stutterer-clutterer </li></ul></ul><ul><ul><li>Items most sensitive to cluttering: 2,3,7,9,10,12,14,20,25,33. </li></ul></ul><ul><li>Perceptions of Speech Communication (Daly, 1978) </li></ul><ul><ul><li>Adapted from Woolf (1967) Perceptions of Stuttering Inventory. Low score indicates lack of awareness; the average PWS scores ~ 30. </li></ul></ul><ul><li>Articulation and language assessments as appropriate. </li></ul><ul><li>More guidelines for identifying cluttering at: </li></ul><ul><ul><li>http://www.stuttersfa.org/br_clutt.htm </li></ul></ul>
  10. 12. Therapy approaches <ul><li>Recommendations from St. Louis & Myers: </li></ul><ul><ul><li>Reduce speaking rate (DAF sometimes helpful) </li></ul></ul><ul><ul><li>Speaking softly to “calm down” speech system. </li></ul></ul><ul><ul><li>Learning to pause at appropriate places </li></ul></ul><ul><ul><ul><li>Via tape review, tapping </li></ul></ul></ul><ul><ul><li>Direct work on articulation </li></ul></ul><ul><ul><ul><li>Beginning with short phrases and moving to lengthier units </li></ul></ul></ul><ul><ul><ul><li>Emphasis on unstressed syllables </li></ul></ul></ul><ul><ul><li>Increased self-monitoring skills and self-awareness </li></ul></ul><ul><ul><li>Teach fluency enhancing skills as necessary to treat stuttering symptoms </li></ul></ul>
  11. 13. Treatment recommendations (continued) <ul><li>Recommendations from Daly & Burnett: </li></ul><ul><ul><li>Modify speech rate and regularity via: </li></ul></ul><ul><ul><ul><li>DAF </li></ul></ul></ul><ul><ul><ul><li>Self-monitoring </li></ul></ul></ul><ul><ul><ul><li>Window reading </li></ul></ul></ul><ul><ul><ul><li>Breathing modification </li></ul></ul></ul><ul><ul><ul><li>Oral motor syllable training program </li></ul></ul></ul><ul><ul><ul><li>Over articulation of segments </li></ul></ul></ul><ul><ul><li>Relaxation and mental imagery, including positive self-talk and affirmation </li></ul></ul><ul><ul><li>Increased self-awareness: </li></ul></ul><ul><ul><ul><li>Via video- and audio- tape </li></ul></ul></ul><ul><ul><ul><li>Vibrotactile feedback </li></ul></ul></ul><ul><ul><ul><li>Counseling and attitude change </li></ul></ul></ul><ul><ul><ul><li>Interpersonal and listening skills </li></ul></ul></ul><ul><ul><li>Improving attention span: </li></ul></ul><ul><ul><ul><li>Memory games </li></ul></ul></ul><ul><ul><ul><li>Sequencing story events </li></ul></ul></ul><ul><ul><ul><li>Problem-solving tasks </li></ul></ul></ul>
  12. 14. <ul><li>Other information about cluttering and its diagnosis and treatment at: </li></ul><ul><ul><li>http://www.mankato.msus.edu/dept/comdis/kuster/related.html </li></ul></ul><ul><li>If you have a client who you think clutters, you may wish to refer him/her to the ongoing NIH study (PI: Christy Ludlow) on this topic: </li></ul><ul><ul><li>http://clinicalstudies.info.nih.gov/detail/A_1996-N-0088.html </li></ul></ul>