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.
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.
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.
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.
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.
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:
- Constraining length of utterance
- Ensuring each sentence had a pre-deterrnined start and ﬁnish point
- Ensuring sentences were concise, and free from ﬁllers
Cluttering response: < 3 secs > Yeah, well I. .. you know... I. . .er. . .by car.
Target response: I came by car.
- Improving sequencing of information at discourse level
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.
Figure 1. Diagrammatic example of TC’ s use of the Pyramid model in response to the question “tell me about your work”.
- Positive outcomes of therapy
- Signiﬁcantly fewer unﬁnished sentences
- Reduction in the use of ﬁllers
- Increase in speech rate (up to 210 SPM in monologue) and reduction in verbal reaction and pause time
- Greater ability to structure more detailed responses, and explain narratives more effectively
- Improved conﬁdence, both within clinic, and elsewhere; particularly at work. (S-24 reduced from 20 to 8)
- Improved ability to monitor and analyze speech performance
- Summary and Implications
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.
The preparation of this paper was supported by a grant from The Stammer Trust
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