2003 IFA Congress: Montreal, Canada

Cluttering, Speech Rate and Linguistic Deficit: A Case Report

David Ward
School of Linguistics, The University of Reading, Whiteknights, Reading, RG6 6AA, UK, and The Apple House Stammering Unit, The Wameford Hospital, Oxford, OX3 7JX, U.K.

SUMMARY

This paper describes the case of a 29 year-old man who was referred to the Apple House fluency clinic for a second opinion as to his speech fluency. Assessment revealed linguistic difficulties in the absence of motor speech abnormalities together with slow speech rate. A firm diagnosis was not possible from assessment, but in the apparent absence of neurological damage, cluttering was suspected. An MRI brain scan revealed no abnormality, and he was subsequently seen for therapy. As therapy progressed, the cluttering behaviours both changed, and responded to treatment. Implications for the diagnosis and treatment of cluttering are briefly discussed.

  1. Introduction
T.C., a healthy 29 year-old man with no previous history of developmental speech or language disorder, or developmental or acquired neurological problems was referred to the Apple House Centre for Stammering for a second opinion of his speech and language. This followed an initial referral by his general practitioner for a speech and language assessment which took place at a local hospital. The clinician who assessed T.C. felt his obvious communication difficulties did not easily fit into any single diagnosis, although some language deficits were somewhat consistent to those seen in aphasia associated with head injury. At the assessment, summarized below, both T.C. and his father who accompanied him, indicated that the communication difficulty dated back around eight years. At that time the mild speech hesitancies noted had been considered to be signs of lack of confidence and social withdrawal, at a time when T.C. was struggling with a difficult course, and being away from home for the first time. T.C.’s difficulties with clear verbal expression increased slowly, over the next few years, although there was not sufficient concern to see a speech—language therapist/pathologist. However, there had been a more significant deterioration over the last two years, and both T.C. and his father felt that T.C.’s confidence was seriously being affected by it. It was, apparently, this latter concern more than any thing else that precipitated T.C.’s referral for an assessment. There was no history of any developmental problems or significant medical issues, and there was a negative history for head injury or neurological problems. T.C. had achieved a solid set of exam results at school. A history of stuttering on T.C.’s mother’s side of the family was reported. A summary of assessment findings were as follows:

  1. Assessment
Speech and Language

TC presented with very slow verbal response times (up to 7 seconds to respond to a simple question) and multiple aborted attempts at answering simple questions. This meant that he was unable to give understandable, coherent or complete responses to even simple closed questions. Speech was also typified by short and often unfinished sentences, and in addition, there was also excessive use of fillers, with utterances commonly starting with ‘yeah” or ‘well’, together with instances of apparent anomia. For example, in response to the request ‘tell me about your journey here today’ he replied ‘(pause). . .. yeah, well...I came, I came, by  Um. ...’. After a final pause, a shrug gesture indicated that this was the end of his comment. T.C. also showed a reduced ability to name within a given semantic category (for example, he was only able to list four different makes of car in one minute). Language comprehension was found to be within normal limits.

Speech rate and Fluency

Speech rate was measured at 143 syllables per minute (SPM) in monologue. This rate did not include time taken during extended pauses, but revised and reiterated phrases were included in the count Speech was clearly produced, but the meaning was often lost due to the high proportion of unfinished sentences. No bursts of faster rates of speech were observed at assessment, and speech rhythm was apparently normal, although this was hard to assess due to limited output There was no evidence of primary or secondary stuttering° nor was there any sign of speech—related struggle behaviour.

Motor ability and Articulation

Examination for gross and fine oromotor ability revealed no abnormality. Diadochokinetic (DDK) rates for alternating phoneme /p/ -/t/, /t/ —/k/ and /p/—/t/—/k/ were all produced at appropriate speed, with good accuracy and with normal rhythm. There was no evidence of difficulty in motor coordination outside the speech domain. Writing was well formed and legible.

Other

T.C. was fit and well and a keen and very able sportsman who excelled at golf and soccer.’ A behavioural psychologist’s assessment revealed an IQ of 93. T.C. showed both awareness of his speech difficulties, and indicated concern about them. There was no evidence of the cluttering personality that can help with a positive identification of the disorder. T .C.’s manner appeared calm and reflective, and his father indicated that T.C. had always aimed for perfection in anything he undertook. T.C. agreed that he tended to have an anxious personality, and that, generally, he lacked confidence. An S—24 evaluation (Andrews & Cutler, 1974) confirmed that he held a very negative perception of himself as a speaker (20/24).

Summary and Diagnosis

T.C. presented with a marked linguistic deficit — aspects of which were consistent with a diagnosis of cluttering, although the possibility of language disorder was also considered. In addition, the report of worsening symptoms, without apparent cause, together with very slow verbal response times gave some cause for concern over a possible neurological explanation for T.C.’s difficulties, and therefore the possibility of aphasia was not excluded.

In sum; cluttering was considered alongside a number of potential disorders, but no firm diagnosis was recorded at assessment.

Action

The first action was to have T.C. referred for a magnetic resonance imaging (MRI) brain scan to limit the possibility of acquired neurological damage. This was completed some months later and failed to uncover any abnormality. T.C. was then seen by this author for an initial period of 12 one- hourly weekly sessions with the general goals of securing a firm diagnosis and improving functional communication.

  1. Therapy
Despite the lack of a firm diagnosis, T .C. was seen for a trial period of 12 weekly sessions at The Apple House with a View to treating the symptoms, and to continue to search for an explanation for his difficulties. During the first two sessions, it became more obvious that a diagnosis of “pure” cluttering was appropriate. As he grew more confident within the clinical setting, T.C.’s speech output increased, and with it more significant difficulties with structuring dialogue appeared. This pattern of an increase in cluttering behaviour when the client is more relaxed is regarded by many as typical of the condition (e.g. St Louis & Myers, 1997) An example below taken from the first therapy session describes T.C.’s response to the question: “How would you go about changing a tyre on a bicycle?” Note: three dots (“. . .”) indicate shorter unfilled pauses ( up to 2 seconds). Longer pauses are identified by numbers between arrowheads in the text (e.g. < 3 secs >),. The passage was free of any articulation errors. Speech rhythm was interrupted by fillers, revisions and reiterations, as recorded below, but was otherwise normal. Speech rate was consistent throughout at 146 SPM. Pauses were not included in the rate calculations.
< 6 secs > To get the inner tube, you have to < 3 secs> have to get the inner tube from the tyre < 3 secs> have to get...use...er some...er...anything really...have to get the tyre 013‘ the wheel. < 5 secs > Then you. . . you ’ve got the inner tube... you have to get the puncture — that’s the hole- < 4 secs > got to make sure it’s where the puncture is. < 3 secs >Then to repair it you have to put...er...like...er..have to put something on the ...on the < 3 secs >like usually...there. ..usually the hole is not usually. . .sort of. ..er. .. rubber material thing goes on the hole, u/usually...er...have to make sure... put some glue on, then the...the...let it dry, then put the inner tube back in the tyre.

Therapy focused on increasing functional communication. Specifically: Increasing coherence at single sentence level
This was achieved by ensuring T.C. firstly had a clear mental plan of the sentence, which was then translated into a complete pre-rehearsed verbal plan. (This approach was based on Weiss’s [1964, 1967] concept that cluttering is related to difficulties with thought organization prior to speech.) When developing the mental and verbal sentence plan T.C. practiced:
  1. Constraining length of utterance
  2. Ensuring each sentence had a pre-deterrnined start and finish point
  3. Ensuring sentences were concise, and free from fillers
e.g.,
Question: How did you get here today?
Cluttering response: < 3 secs > Yeah, well I. .. you know... I. . .er. . .by car.
Target response: I came by car.

  1. Improving sequencing of information at discourse level
We used a “pyramid model” to help with this. The pyramid simply provides a mnemonic for sequencing information with shorter essential information at the top, and subordinate information increasing through lower levels, see Figure 1.

As T.C. became practiced at structuring language more effectively, so speech rate steadily increased in the absence of any direct work on rate modification. At the end of the 12 week block of therapy, when T.C. was speaking at normal speech rates of around 200 SPM, a small number ofcluttering errors more commonly associated with elevated rates occasionally began to appear, which further supported the diagnosis of cluttering, over, say an adult with a language disorder, which had also been considered a possibility, at assessment. These included telescoping of words, consonant cluster reduction, occasionally, weak syllable deletion, and with the increase in speech rate, a tendency towards a less consistent speech rhythm. Although easily identifiable, these aspects did not significantly interfere with intelligibility. They could, however, potentially, require a therapeutic focus if the incidence of these were to increase.

CSR_F1.png

Figure 1. Diagrammatic example of TC’ s use of the Pyramid model in response to the question “tell me about your work”.

  1. Positive outcomes of therapy
By the end of the 12-week period, T.C. had become better able to control his speech and language output. This resulted in:
  1. Significantly fewer unfinished sentences
  2. Reduction in the use of fillers
  3. Increase in speech rate (up to 210 SPM in monologue) and reduction in verbal reaction and pause time
  4. Greater ability to structure more detailed responses, and explain narratives more effectively
  5. Improved confidence, both within clinic, and elsewhere; particularly at work. (S-24 reduced from 20 to 8)
  6. Improved ability to monitor and analyze speech performance
  1. Summary and Implications
Cluttering is a disorder that is not easy to define. While authorities mostly agree on a range of features that characterize the disorder, opinions differ as to which of these features are actually core attributes — that is, which need to be present in order to make a diagnosis of cluttering (e.g. Daly, 1996; St Louis, 1992; St Louis & Myers, 1997; Ward in preparation; Weiss, 1964).

Many commentators emphasise the significance of articulatory and rate disturbances, and it is common to find people who clutter (PWC) who experience difficulties in both language and motor speech domains. Some also believe that a certain degree of language disturbance is almost invariably associated with the disorder (Cooperman, 2003; St Louis, Raphael, Myers, & Bakker, 2003, Ward, in preparation). However, it is less common to see PWC presenting with language impairments only, and there are, to my knowledge, no studies which describe cluttering with extreme language difficulties associated with slow speech rate, and in the absence of other motor speech or speech rate or non—speech anomalies. Although a diagnosis of cluttering was not clear from the assessment, as T.C.’s confidence increased with therapy, features that are regarded as characteristic of the disorder became more prominent, including: poor lexical access, reiterations, inappropriate pausing, overcoarticulation, and weak syllable deletion.

One explanation of T.C.’s initially atypical slow speech rate type of cluttering is that it reflects an extreme difficulty in organizing thought processes for speech and language. As therapy helped with language organization, and led to increased confidence in speaking, speech rate subsequently increased toward a normal pace. Associated with this, some mild difficulties with speech errors consistent with cluttering were seen. The fact that these problems appeared at a normal speech rate supports the notion that articulatory problems in cluttering are not only related to excessive speed, but may also reflect a more generalized motor speech difficulty. A second possibility is that the initially depressed speech rate could represent a conscious attempt to control speech when T.C. felt unsure of himself, however he denied consciously using any controlling strategies.

It is certainly unusual to see increases in speech rate associated with successful cluttering therapy. It is more often the case that clinicians work on reducing speech rate in the belief that, in some cases, at least, it allows more time for speech and language processing, and also the implementation of speech controlling techniques. (Of course, a similar rationale underpins some stuttering programs.) T.C.’s case highlights the fact that regardless of whether cluttering is either (a) indirectly related to speech and language function, due to disorganized thought processing prior to speech, or, (b) directly related, through difficulties with speech and language processing itself, or, (C) a combination of both of these; when cluttering is associated with a slower speech rate, increasing that speech rate to one within normal limits can lead to a more natural sounding output. It also appears that more effective cognitive/language processing can take place at these increased rates.

Finally, T.C.’s case is also unusual in that, although we can be sure of the time period in which the difficulties with language were first clearly observed, we are still uncertain as to whether this represents the true beginning of his language problems. It seems that T.C. was a reluctant talker throughout his school years, although there were no concerns about his communicative abilities during those years, either from home or from school, and as mentioned earlier, the problem seems to have become more noticeable following a period of stress in his early twenties. But it is perhaps surprising that although T.C.’s stress resolved after this episode, and he was apparently leading a happy life, the difficulties with language continued and indeed worsened over the subsequent seven years.

If there really was no developmental speech/language problem, then, in the absence of a neurogenic cause, a psychogenic onset, dating to his early twenties must be considered. Equally, though, it is difficult to rule out the possibility that there had always been an undetected mild clutter, or some susceptibility to weaker language abilities, but that the problems had only became manifest when the extra demands of the challenging course T.C. undertook resulted in increased stress levels. We know that acquired cluttering can exist (e. g., Thacker & De Nil, 1996), and it is possible, then, that in addition to the neurogenic cluttering that Thacker and De Nil describe, T.C.’s case might be seen to comprise a psychogenic version. Perhaps a further possibility is that the present case might fit as a cluttering version of Van Riper’s (controversial) notion of an “occult stutter” (Van Riper, 1982), which some interpret as comprising some kind of “reactivation” of a dormant difficulty. It will be interesting to see if clinicians identify cases of sustained psychogenic cluttering in the future.

Acknowledgements
The preparation of this paper was supported by a grant from The Stammer Trust

References
Andrews, G. & Cutler, J. (1974). Stuttering therapy: the relation between changes in symptom level and attitudes. Journal of Speech and Hearing Research, 39, 312-319.

Cooperman, D. (2003). Personal communication -

Daly, D. (1996). The source for stuttering and cluttering. Linguisystems, lnc. East Moline: IL.

St Louis, K.O. (1992). On defining cluttering. In F.L. Myers and K.O. St Louis (Eds.) Cluttering: a clinical perspective. Kibworth, Great Britain: Far Communications.

St Louis, K.O., & Myers, F.L. (1997). Management of cluttering and related fluency disorders. In R.F. Curlee and G.M. Seigel (Eds.) Nature and treatment of stuttering: New directions. 2”‘ edition. Allyn and Bacon.

St. Louis, K., Raphael, L., Myers, F., & Bakker, K. (2003). Cluttering updated. The ASHA leader; November, 4, 5, 20,21, 22.

Thacker, R.C., & De Nil, L. (1996). Neurogenic cluttering. Journal of Fluency Disorders, 21, 227- 238.

Van Riper, C. (1982). The nature of stuttering. Prentice—Hall.

Ward, D. (In preparation). Stuttering and cluttering: A clinical handbook. Taylor and Francis: Psychological Press

Weiss, D. (1964). Cluttering. Englewood Cliffs, N.J.: Prentice Hall.

Weiss, D. (1967). Similarities and differences between cluttering and stuttering. Folia Phoniatrica, 19, 98-104.

Translation

The IFA implemented Japanese translations of some pages on the site for the 2018 Joint World Congress. Choosing Japanese below to see these translations.

Not all pages are translated, but you can use Google translate to see a machine translation using the switch below

Google Translate