When most Speech-Language Pathologists hear the term fluency disorder, they are likely to think of stuttering. While stuttering is the most commonly occurring fluency disorder, there is another that is important for clinicians to be familiar with, and that is cluttering.
What is cluttering, how can SLPs identify cluttering from stuttering or other speech disorders, and what are the top tools and resources for working with clients who have cluttering speech?
Let’s explore the answers to those questions.
Cluttering, defined.
According to The International Cluttering Association (ICA), cluttering is defined as “a fluency disorder characterized by a rate that is perceived to be abnormally rapid, irregular or both for the speaker.”
The ICA states that cluttering speech can be marked by the following symptoms (SLPs must identify at least 1 of these symptoms to make a diagnosis of cluttering):
- An excessive number of disfluencies.
- Frequent use of pauses & prosodic patterns that “do not conform to syntactic and semantic constraints.”
- Atypical (and usually severe) degrees of coarticulation, particularly in multisyllabic words.
Although more research is needed, preliminary studies have estimated that between 1.1% to 1.2% of school-age children demonstrate a speech disorder consistent with cluttering. Individuals are typically diagnosed or start treatment for cluttering around age 8 or later.
Differential Diagnosis
Cluttering can co-occur with other disorders and disabilities, including Autism, ADHD, Tourette’s syndrome, Auditory Processing Disorders, and learning disabilities. Clients with these disorders may show delays in various areas of language, so it is important to understand the specific characteristics of cluttering to make the appropriate diagnosis and guide treatment.
It can be particularly difficult for Speech-Language Pathologists to make a differential diagnosis of cluttering versus stuttering.
In addition to both being types of fluency disorders, it is common for the two to co-occur. The American Speech Language and Hearing Association (ASHA) states that experts believe about one-third of those who stutter also show characteristics of cluttering within their speech.
SLPs should first note that clients who demonstrate cluttering speak at a fast rate. According to the Stuttering Foundation of America, their rate of speech is not always faster than average, but it is “too fast for their system to handle, resulting in communication breakdown”.
Here are a few examples of what that communication breakdown can result in for some clients who have cluttered speech:
- Excessive use of interjections (for example: “um”, “uh”)
- Excessive use of revisions (for example, “do you know – have you seen where my book is?”)
- Extreme coarticulation. (such as saying “imagishn” for the word imagination)
- “Jerky” speech. Pauses in speech are used at unexpected moments in sentences.
- Atypical prosody (due to unusual pausing).
In contrast, stuttering is a fluency disorder that is marked by:
- Repetitions of sounds, syllables, and words
- Prolongations of sounds
- Blocks (a break in a speech where the client is unable to produce sounds).
- Secondary behaviors (for example, facial grimacing or body tensing)
Speech Language Pathologists often see that clients who demonstrate cluttering have decreased awareness. That may contribute to the fact that many people who show characteristics of cluttering in speech go undiagnosed or do not seek treatment until adolescence or early adulthood.
Treatment for Cluttering
Once a Speech Language Pathologist has assessed and diagnosed a client with cluttering, he or she will need to develop a treatment plan. That treatment plan should include goals that address the specific language and fluency difficulties demonstrated by the client. Research-based treatment techniques for improving cluttering should be implemented during speech therapy sessions.
Reduce the rate of speech.
Many of the communication breakdowns in clients who clutter stem from their fast rate of speech. Therefore, working on slowing the client’s rate of speech can help improve many of their symptoms.
Speech Language Pathologists can help teach clients who demonstrate cluttering to slow their rate of speech in the following ways:
- Educate family members and those who are close to the client on how to respond when the client shows disfluencies. For example, do not interrupt or tell the client to “slow down”. Reduce interruptions and limit stress-inducing situations, which can increase cluttered speech.
- Delayed Auditory Feedback: A treatment technique in which the client speaks into a microphone. He or she then hears that spoken message repeated back through headphones after a brief delay.
Research has proven this to be an effective method for reducing a client’s speech rate in spontaneous speech and reducing common disfluencies.
- Increase pausing. Working with a client who demonstrates cluttering by integrating pauses in his or her speech at natural, grammatically-appropriate instances can help the client slow their rate of speech. Treatment activities for this may start with identifying appropriate places to pause while reading written sentences. Therapy may progress to working with the client on pausing during spontaneous speech.
According to a study by Scaler, Scott & Ward (2013), increased pausing alone can increase the fluency of speech for clients who clutter.
Reduce excess disfluencies
Along with slowing the client’s speech rate, reducing the excess of disfluencies should be another primary goal in cluttering treatment, according to experts.
- Traditional stuttering modification strategies such as implementing pausing have been shown to improve fluency for some clients who have cluttered speech. Certain fluency shaping techniques (i.e., easy onset) are not always appropriate to teach for decreasing cluttering.
- Teaching over articulation and increasing volume can help increase the client’s intelligibility.
- Work on the client’s ability to overemphasize multisyllabic words. This may reduce his or her excessive coarticulation of multisyllabic words.
Improve speech monitoring
As with other fluency disorders, it is important to work on improving the client’s monitoring of his or her speech. triggers for increasing the severity of cluttering (i.e., emotional stress or certain speaking situations), and teaching strategies for improving communication skills when cluttering does occur.
Therapy for improving the cluttering client’s speech monitoring may include:
- Increasing the client’s awareness of disfluencies.
- Helping the client identify triggers for increasing the severity of cluttering (i.e., emotional stress or certain speaking situations)
- Improving the client’s monitoring of his or her speech (i.e., identify moments of cluttering). For example, treatment may include recording a speech sample during conversation and playing it back for the client to identify disfluent moments.
- Teaching strategies for improving communication skills when cluttering does occur.
Tools and Resources for Treating Cluttering Speech
Tools that provide altered auditory feedback have been proven to have positive effects on speech for those who demonstrate cluttering.
Recommended tools to use during speech sessions or for the client to use in outside environments include:
SpeechEasy. This device fits on the client’s ear like a hearing aid. According to the company, “SpeechEasy devices alter sounds that go through the device so that you hear your voice at a slight time delay and at a different pitch. The purpose of the delay and pitch change is to recreate a natural phenomenon known as the “choral effect.” The choral effect occurs when your stutter is dramatically reduced or even eliminated when you speak or sing in unison with others.”
Digital Speech Aid (DSA). According to Digital-Recordings.com, “DSA picks up the stutterer’s voice via the microphone, processes it digitally in real-time, and puts out the processed sound into the stutterer’s ears via the earphones.”
Small Talk. This small device provides adjustable Delayed Auditory Feedback (DAF) and Frequency-altered auditory feedback (FAF) to increase fluency for those with cluttering speech.
The International Cluttering Association website offers helpful information on assessment and treatment, and other clinical resources available for Speech-Language Pathologists to download. The website also has information for families that is translated into several different languages.
The Stuttering Foundation of America and the American Speech-Language-Hearing Association (ASHA) also have research and downloads available on their websites for Speech Therapists to use in therapy with clients who clutter.
Cluttering Could Be on Your Caseload.
Cluttering is known as a rare fluency disorder. Although stuttering is more prevalent, there is a chance that Speech-Language Pathologists may have a client who demonstrates cluttering speech on their caseload.
It is important to remain knowledgeable about the characteristics of cluttering, research-based techniques for treatment, and what recommended tools and resources exist. That way, if an SLP does assess a client with fluency difficulties, he or she can make an appropriate diagnosis and treat the client.
In a recent study, cluttering was diagnosed in 1,800 patients in one year (2017). Cluttering was found to be more prevalent in males than females, and most prevalent in the age group of 4 to 6 years old.
Research shows that an increasing number of people are being diagnosed with developmental disorders of speech and language, stuttering, and cluttering (as a whole).
If you are a Speech-Language Pathologist working with a client who you suspect is cluttering, it may be beneficial to start by working on reducing his or her speech rate, reducing excess disfluencies, and improving the client’s self-awareness/self-monitoring skills. Using evidence-based research techniques and tools can help your client improve their cluttering and increase the effectiveness of their communication skills.
