cluttering./ kunnampallil gejo

7/27/2019 CLUTTERING./ KUNNAMPALLIL GEJO

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CLUTTERING

KUNNAMPALLIL GEJO JOHN, MASLP


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Introduction

Skills in the timing and integration of speech andlanguage functions are basic to the fluent outputof oral communication

A great deal has been written about the fluencydisorder of stuttering. The fluency disorder ofcluttering however, has received only peripheralfocus.

In America and British literature, relatively littleattention has been paid to it, beyond descriptionof typically hurried and often unintelligiblespeech pattern produced by this group ofspeakers


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Froeschels, Freund, Luchsinger and Weiss have not onlyoutlined the disorder in detail but less fortunately,contrasted the cluttering and the stuttering in termsof personality and behavior in a way which takes noaccount of the wide Varity and complexity of factorsinvolved in stuttering and reduced all clutterers to astereotype

The definition if cluttering adopted by the fluencydisorder 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 orphonological errors and attention deficits


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In the predawn darkness in which scientifically orientedspeech pathologists is now stumble, perhaps theconfusion (between stuttering and cluttering) is to beexpected though not to be tolerated indefinitely {VanRiper 1970}

St.Louis and Hinzman (1986), presented a sampling ofreported symptoms from the literature on the syndromeof cluttering

A syndrome is a constellation of symptoms which co-occur but which may or may not be manifested in agiven individual

It was immediately clear from even a cursory review thatcluttering is not clear identifiable entity


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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 symptomsor descriptions of this disorder.

Rapid sequences rates was reported by 5out of 6 authors and there by reflected thehighest level of agreement.


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4 out of 5 authors reported articulatorysymptoms

St. Louis Hinzman and Hull (1985),reported that lack of research in the areaof cluttering seriously hampered by the

lack of an adequate definition Clinical management of cluttering has

suffered from the same as well


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At west Virginia University, recognized the needfor research designed to defined cluttering inempirical behavioral terms (St. Louis et al 1985)

Their logic in attempting to develop such abehavioral definition was as follows First they assumed, as do most of the authors (e.g.

Weiss 1964; Van Riper 1971, 1982), that clutteringexists, either in isolation or in conjunction withstuttering.

Second, they assumed that cluttering is primarily aspeech and language disorder and such, it mostappropriately dealt with by speech languagepathologist


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The speculative literature available indicates thatclutterers are most likely to be confused with stutterersand other speech and language problems such asmisarticulations, are quite common in the disorder

Again, however, they recognized that otherprofessionals, such as learning disability or remedialspecialists, were likely to have considered researchinterest in clutterers as well, because impairment inareas such as attention, reading, or writing may result in

greater problems for clutterer than speech or languagedifficulties

Third, since they assumed the most appropriatebehavioral dimensions to be used in a definition shouldmainly consist of speech language characteristic


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A working Definition of Cluttering

NSHS (national Speech and HearingSurvey) working definition of cluttering is

as follows Cluttering is a sp & lang disorder and its

chief characteristicsAbnormal fluency which is not stuttering Rapid and irregular speech rate


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Van Riper (1954) descried cluttering ascharacterized by slurred and omitted

syllables, by improper phrasing andpauses, due to excessive speed

Luchsinger (1970) says that repetition ofsyllables and word as the most importantfeature and remarks on an imperfection infinding words amongst these speaker and

a striking monotomy of speech melody.


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Weiss (1964) outline the speechsymptoms in greater detail. Excessive

speed (tachylalia) has always beenconsidered the maintains

Froeschels (1946) that they only speakrelatively too quick for their ability to findwords and formulate sentences

Drawling and interjection are seen asresulting from this difficulty


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The unintelligibility of the speech of manyclutters 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 ofcoarticulation and elision of normal speech


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All these articulatory deviations improvewhen 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-melodypattern (presumably referring tointonation and pitch range)


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Wohl (1970) described the prominentfeature and cluttering as festinating (i.e.

becoming faster and faster as speechproceeds) which leads to elisionarticulation disorder of an erratic and

unstructured type, omission andsubsequent spelling and writing errors.


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Wessis heading lack of rhythm and musicalability and yet to admits to knowing cluttererswho, despite dysrhythmic speech have anexcellent sense of rhythm in other respect

Although poor pitch and poor sense of melodyare often found with clutteringsome clutterershave a good sense of musical elements.

Poor concentration and short attention span areclaimed as the basic symptomatic elements ofcluttering, but the evidence cites for this is slight


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Liebmann (1900,1930) proposed 2 groups, one beingmotor in form and having lack of attention to kinestheticand somato-motor performance as its basis, while the

second was said to be receptive in nature, with thedisorders of audition, and attention predominating

Froesches (1946) was one of the earliest to relatecluttering to a disturbance of thinking. He described thesequence of preparatory steps before a phrase or

sentence is uttered. There is a psychic urge or attitudetoward expressive a thought

This is followed by a planning of the sequences andchoice of words to be expressed


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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


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REPETITION

Repetition of one syllable words or thefirst 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 wordor phrase to follow

The speech motor are idling while thebusiness of speaking continues withoutbeing filed by words


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Repetition is common especially in the childrenbetween the ages 2-5yrs

During these yrs substance of what the child

whishes to communicate is too complex forexpression in his limited vocabulary

The rate of speed of clutters repetition is theexact 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 indifferential diagnosis


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The clutters characteristic unawareness of hisspeech deviation accounts for his continuing to

make syllabic noise (repetition of syllables)instead of stopping the speech process while hedecides on the words follow

Children who are unaware of the fact they

repeat will have same but when they are awareand tries to correct it, the rate becomes slower(Froeschels 1975)


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EXCESSIVE SPEED

Excessive speed was considered the mostsignificant symptom of cluttering, and someinvestigators even considered it the basicelement

However normals speech too speed but withperfect order and articulation

And there are some clutters who speak at thenormal rate

Therefore excessive speed must be ruled out asthe one of the primary indicator of cluttering


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In cluttering, on the other hand when there isexcessive speed it is accomplished by poorformulation and delivery, and is therefore anindicator that the speech mechanism cannotcope with its function of communication

A clutterer will sometimes begin polysyllabicwords at an acceptable rate, but his speedincreases as he progress, resulting in a

telescoping of the word

He apparently has an global impression of aword and hence pronounces it in a single spurt.


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He spells as he pronounces, omitting thesame letters.

This is also occurs in some speechdisorders 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


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Gerstmann and Schilder and Seeman attemptedto localize the anatomical site of this speed drive

and concluded that it is in the striopallidarsystem, especially in encephalities, but there areno available histological findings at this time forclutterers.

The hereditary factor in typically cluttering,however it is not anticipated that structuralchanges in the brain will found to causeexcessive speed.


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DRAWING & INTERJENCTION

The clutterers inability to find the words he need insufficient time to maintain a smooth flow of speechcauses him to prolong vowels, most often at the ends ofwords

When they prolong a vowel at beginning of a word, theyare in the process of searching for the next word beforecompleting verbalization of the word they have begun

This is consistent with the clutterers over acceleration ofspeech 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


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The frantic quest for the next word also causesclutters to interject single vowels as ah,consonant such as mm, articulatorycombinations often than ahem, and words suchas well and you know more often than normalspeakers

Clutterers some times prolongs the interjections(ah or mm) and remains unaware of theirpresence in his speech although his listeners findthem utterly tire some


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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 thedifferential diagnosis.

It is especially common at the beginning of a newphrase or sentence

Blocking on the initial vowel exists among stammers butit is not a common occurrence

The essential difference between the stammerersspasmodic blocking and the clutterers simple vowel stopis the fact that the clutterer is that unaware of hesitationand consequently does not develop a fearful attitudetoward the sound


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ARTICULATION AND MOTORDIASABILITY

Every investigator has noted the clutterers poorarticulation

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


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Liebmann says that these deviationsimproves when speed is reduced, where

as articulation is normal speech does notchange as a function of speed

Seeman & Novak tested the articulatory

ability of 52 clutterers and 52 individualswhose speech was normal. Age genderand intelligence were held consonant


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The test consisted of quick repetition of syllablespah 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 toocomprehension for the simple experimentaldesign


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RESPIRATION

Arnold says that respiratory dysrhythmia is thecause for the clutterers jerky and explosive

speech Froeschels reported that before we speak we

automatically inhale an amount of air sufficientfor the length of sentences or phrase that we

intend to pronounce Clutterers attempt only short phrases and hence

must inhale more frequently


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MONOTONY

Many therapists have recommended on themonotony and uniformity of the clutterersspeech melody pattern

Scripture was the original investigator whoreported on the caquse of this monotony, first inepileptics and then in stammerers

He concluded that monotony of speech melodyis related primarily to lack of musical sense

Arnold, Pearson, roman-Goldziener concurred


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Analysis of the clutterers speech melody andexamination of their speech curves by Arnold and byLuchsinger and Dubois indicated that in fact they doesnot lack variability in pitch.

There is a short melodic pattern confined to a range ofonly 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), butby continual repetition of short melodic pattern

It is stereotype but not monotony in the sense ofunchanging pitch


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Since lack of musicality does not account for lackof melodic variation in all clutterers

D.A.Weiss investigated the possibility ofpsychological basis for this monotony

He found that clutterers thoughts progressivelyproceed by clusters of 2-3 words at a time

where as thought of normals speakersapparently proceed by whole phrases orsentences


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LACK OF RHYTHEM AND MUSICALABILITY

Lack of rhythm in speech is one of themost readily noticable symptoms ofcluttering

The majority of the clutterers havedifficulty both in perciving andreproducing rhythmic

However, there are clutterer with excellentsense of rhythm and dysrhythymic speech


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G.Arnold believes that dysrhythmia is onlya part of what he calls the clutterers

congenital amusia Poor pitch and poor sense of melody are

often found with cluttering


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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 clutteringsuch as reading and writing disordersbecause of this their memory is severely

limited


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Attention span in verbal performance canbe measure by ascertaining how many of

a series of meaningless syllables a patientis able to repeat correctly after examinerhas pronounced them

POORLY INTEGRATED THOUGHT


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POORLY INTEGRATED THOUGHTPROCESS

Thinking too quickly

Thinking too slowly

Unorganized thinking

Inner language


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Thinking too quickly

The supposition that a clutterer thinks faster than heis able to speak

Interpreting clutterer who has reached an articulatorydead end because of what appears to be an attemptto speak as quickly as he is thinking, and ask him tostate 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 hasseveral indefinite and amorphous ideas


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There fore it is not so much an accumulationof 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 theminstantaneously


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Thinking too slowly If thought in preparation for verbal communication is conceived

of as an orderly process of clarifying ideas, then clutterers thinktoo slowly for a normal speed of speech

In addition to the pause in search of concrete thought forexpression there are gaps while the clutterer search for aparticular word.

His limited knowledge of grammar also slow his thinking lack ofaccentuation leaves long words without integration, and thesewords 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, oftenreddening speech grotesque

As a result an intelligent clutterer may appear considerablyunintelligent then he actually is


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Unorganized thinking Poor intergrated and incomplete thought

process, rather than the rate of speed ofthought, is a factor in cluttering.

The clutterers haphazard and tentativethinking 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


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Inner language In normal speech, verbalization does not seem to take place

until the speaker has a clear thought to express, he can inhalethe 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 formulationand as a result delivery is hackneyed haphazard, and studded

with moment when the clutterer seems to lose the thread ofthought completely or forget what he said or the next word tobe spoken

Normal speech reflect inner order and cluttering in the minor ofinner disorder


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In performing a highly skilled movement theindividual generally recalls his previousexecution of the same movement, and this is

dependent upon kinesthetic sense There is also a purely motor type of fluctuating

in which movements are performedautomatically, without recall or imagination of

past performance The clutterers speech process however, is rather

automatic performance


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Clutterers seem to need to exert mental effort even toformulate the idea of the sentence they are about toverbalize, where as normals apparently perform thisinner formulation without conscious effort, as a functionof their predominant type of imagery

Even the most intelligent clutterers are apt to remarkspontaneously that they are often surprised bysomething they say, being unaware of havingentertained the thought before saying it speech

performed without the stabilizing effect rendered byprevious imagery of the act can be called abstractaction, as opposed to concrete action in which imageryis involved


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REDING DISORDERS

One of the characteristic symptoms ofcluttering 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 aresult of having learned to guess at thetext


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Speaking problems in reading and writing may persistthrough and beyond the highest grade of schoolattended

This is closely related to the clutters lack of attentionand result in his ignorance of many words with highfrequency 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 themiddle, or looking back at the beginning because he haslost trend of thought

The quality of the usual dyslectics reading the cluttererusually does not fulfill his reading potential


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WRITING DISORDER

The clutterers had writing is a characteristic ofhis generally reduced motor skill, his ratherformless imagination, and his disregard for the

reader Occasionally repetitions of his speech is seen in

writing as well

Klara Roman-Goldzieher discussrs the generalcharacteristic of the clutterers handwritingrepetitiveness, frequent transposition oromissions of letters and frequent revisions


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The clutterer is capable of much betterperformance when he focuses hisattention upon the task

The most complete and lucid discussion ofthis problem, together with the result ofpsychological tests


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GRAMMATICAL DIFFICULTIES

The clutterers spoken grammar is alsonotoriously poor

Throughout his speech there are minor

deviations such as confusion of he andshe and the use of the singular when theplural is indicated

There is often total confusion in thestructure of long sentences


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The clutterer attention span is so short and hisconcentration so weak than he often gives theimpression that his hearing is impaired, or he is

day dreaming, or even that he has a basicdisorder of perception

Clutterer may forget how he started and so thegrammatical structure of his sentence suffer

The rather fuzzy thinking of the clutterer lead toa less than satisfactory structuring of hissentences


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UNAWARENESS OFSYMPTOMS

The typical clutterer is of his speech disorderand may even react with surprise when hisattention is brought to the problem

The clutterers unawareness of his speech

difficulty is a specific case of his speech difficultyis a specific case of his general lack of selfawareness

Speech as in action, the clutterer proceeds with

sudden impulsive spurts, uncontrolled by thesmoothing influence of modicum of selfawareness or an appreciation of the needs ofother


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Libermann suggested delimiting asubgroup of clutterers based on

perceptual difficulties Froeschels suspected sensory aphasia in

some cluttering children

Arnold considers the poor perception asevere aphasia like symptom which hecallsperceptual dysgnosia


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RESTLESSNESS ANDHYPERACTIVITY

The typical clutterer fidgets by day andrestless even while sleeping according toSeeman

Clutterers seems to be alert and interestedin his surroundings, but a short time only,since his focus of interest changescontinually

During interview they are apt to squirm intheir chair, occasionally assuming addpositions, to play with objects on the desk


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There are many cases of proven lesions ofthe basal ganglia with restlessness of sort

The Seeman school assumes thatsubmicroscopical lesion in this area thecause of the clutterers hyperactivity

The clutterers is not aware of hisrestlessness, but if it is brought to hisattention, he will exert effort to control it


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DELAYED SPEECH DEVELOPMENT In many of the clutterers families it was foundthat 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 leadto 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


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ELECTROENCPHALOGRAPHICFINDINGS

In 1951 Luchsinger and Landolt were first toattempt determination of the speech pathologyof clutterers by electroencepholographicexamination

They found abnormalities in almost 100% oftheir cluttering sample

They found that more irregularities in the EGG

recording in clutterers than in stutterers than innormals

The significance of these recordings are stillquestionable


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HEREDITY

It was found that heredity is a basicfactor in cluttering

Reasons Only small 5 of clutterers

Cluttering has not been included in manystatistical analysis


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PSYCHOLOGY OF THE CLUTTERER

Klencke charecterizes clutterers ascarefree, careless, and lacking inpersistence and sense of responsibility

Pleasant temperament Lifes problem very seriously

Alas

Short attention span

Overactive

Change their mind frequently

Child like behavior reactions

Th li f h l


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The personality of the clutterer

Pure stutterers Pure clutterers Stutterer-Clutterer

Timed

Restricted

Regressed

Introspective

Compulsive

Over inhibited

Hesitant

Retarded

Aggressive

Expansive

Extroverted

Impulsive

Uncontrolled

Hasty

Over productive

Mixedpersonalities

containingfeatures of bothprecedingcategories


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Wiss generalized typical differences

between clutterers and stutterersCluttering 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


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Reading unknown text

Hand writing

Attitude toward own speech

Psychological attitude

Goal of therapy

Better

Hasty,

repetitionuninhibited

CarelessOutgoing

Directingattentiontospeech

Worse

Contracted, forced,inhibited

FearfulRatherwithdrawn

Directingattentionfrom

details


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ASSESSMENT OF CLUTTERING

Several principals are held to be particularlyhelpful in the assessment of clutterers

They should be assed for entire communicationsystem including language, rate, articulation and

fluency Need to assess the nature of the reaction

between the various component ofcommunication system

Since some clutterers may also exhibitperceptual motor and learning difficultiesassessment should be broadly based to includeneuro psychological testing


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Strategies for assessment

Language sample and formal testingAnalysis of language sample should seek to

answer a number of question regarding aspectsof 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 toolswhich provided a more structured andstandardized mean of evaluation


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Standardized test serve one or more of thefollowing purposes

To obtain, norm reference measure of the variousaspects of speech and language which appear to be

disorder

To compare and contrast the fluency, articulation,rate and language observed in naturalistic vs. formalsituation

To examine in a more controlled and focused way thebehavior judged to be anomalous based onnaturalistic language sample

S di i i id


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Some diagnostic questions to consider

Selected diagnostic questions will beorganized around the major componentsof speech and language system, eachquery attempts to tap a component from a

slightly different point to extract additionalinsight regarding therapy implication


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Fluency

Rate and rhythm

Articulation

Language

Neuropsychological testing

Self awareness


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Case history and interview

Some important information can beextracted from the case history andinterview with the client and family

Other members of the family have speech andlanguage problem similar to those of theclient

Interaction between client and family

members how is it home, working, schoolAttempt to compensate for the problem


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Dalys checklist for possible cluttering

Rating from 0-3

It consists of 33 questions


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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

Diff ti l di i b t


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Differential diagnosis between

cluttering and stuttering

Cluttering StutteringClient is unaware of dysfluencies Aware

Fluent when concentrate onfluency Less fluent

Spontaneous speech less fluent More fluent

Strangers more fluent Less

Verbalization are less difficult tocontrol

More difficult to control

Hereditary Psychological or functional

Fear of specific sound or situationis not present

Present


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Relaxed situation moreproblem

Less

Prognosis is better never

relaps

Prognosis is better but relaps

Occurs only at childhood At childhood or adult

By taking chloropromazine

drug speech will be better

Becomes worst

EGG deviated pattern EGG normal

M t f l tt i


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Management of cluttering Speech rate modification

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


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Journal articles

An examination of various aspects ofauditory processing in clutterers

LAWRENCE F.MOLTAim of the study

The present study examined various aspects

of auditory processing ability, utilizing a briefCAP test battery and auditory event relatedpotentials


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Subjects 3normals and 3 clutterers

Results CAP:

All the 3 control group performed with in normal limits

All the 3 clutterers performed below normal establishedcriteria

AEP:Abnormal AEP morphology was noted for all 3 clutteringsubjects an absence of N1 and P2components andlengthening of P3 latency


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Neurogenic cluttering

Language Auditory comprehension 57/60

Repetition 92/100

Articulation 60% for single 18%for sentences

Fluency

Self monitoring skills


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cluttering./ kunnampallil gejo

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