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Cluttering: Assessment, treatment planning, and case study illustration
ELSEVIER
CLUTTERING: ASSESSMENT, TREATMENT PLANNING, AND CASE STUDY ILLUSTRATION DAVID A. D A L Y University of Michigan, Ann Arbor, Michigan, U.S.A.
M I C H E L L E L. BURNETI" St. Joseph Mercy Hospital, Ann Arbor, Michigan, U.S.A.
Successful treatment of clients who present with a multitude of interrelated impairments is frequently dependent upon thorough and accurate diagnosis of the problems. Individuals who clutter often demonstrate a variety of speech and language deficits that make diagnosis difficult. Two clinical tools believed to be useful for obtaining and organizing diagnostic data and for planning treatment with clients who show symptoms of cluttering are discussed. The case study report illustrates the utility of these tools for collecting and organizing all pertinent data.
INTRODUCTION We view cluttering as a disorder of speech and language processing, resulting in rapid, dysrhythmic, sporadic, unorganized, and frequently unintelligible speech. Accelerated speech is not always present, but an impairment in formulating language almost always is (Daly, 1992). Although a single definition of cluttering has not been agreed upon, we feel this definition encompasses the multitude of variables often associated with cluttering. Because there are many other deficits that may coexist for a given individual, such as attention deficit disorder (ADD), language-learning disorder (LLD), and/or motor-speech impairments, differentiating cluttering from other disorders may prove difficult. In other cases, cluttering may be masked when an individual demonstrates significant strengths, such as superior abilities in math and science. Thus, clinicians must be aware that individuals exhibiting features of cluttering typically do not fit neatly into one diagnostic category. Therefore, the assessment process must be comprehensive, with thorough data collection being essential. Upon obtaining all of the necessary
Address correspondence to David A. Daly, University of Michigan, Ann Arbor, MI 48109. Category: Post hoc Case Study (Clinical Impressions) J. FLUENCY DISORD. 21 (1996), 239-248 © 1996 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0094-730X/96/$15.130 PII S0094-730X(96)00026-0
240
D.A. DALY and M. L. BURNET/"
information, accurate interpretation of the data is critical to diagnosis and treatment planning. In 1992, Daly, Myers, & St. Louis proposed an evaluation protocol that included measures of fluency, rate, language, articulation, hearing, psychoeducational and academic skills, fine motor control (including handwriting), auditory and visual perception, and cognitive function. Whereas such an interdisciplinary evaluation may seem unwieldy for most individual speechlanguage pathologists (SLP) who function rather independently, we feel each piece of information is important and should be considered whenever available. This report describes new assessment and treatment planning strategies to manage all available data and illustrates with a case study the applicability of these clinical tools in helping individuals who clutter.
ASSESSMENT PROCEDURE Typically, youngsters and adults are referred to our office for stuttering or other fluency problems. Our standard evaluation includes measures of the person's automatic speech (such as counting and naming the days of the week), echoic speech (repeating monosyllabic and polysyllabic words, phrases, and sentences), oral reading, and spontaneous speech. Other related areas, including immediate auditory memory, oral diadochokinetic skills, and written expression, are also routinely assessed. There are a number of client responses which may suggest that additional probing or further testing is necessary when cluttering is suspected. Clinical experience has alerted us to seven behaviors or client responses that we believe may warrant further evaluation. They are: low awareness level or denial of any difficulty speaking, rapid or fluctuating speech rate, disorganized language (confused wording or difficulty sequencing events), initially loud voice trailing off to a murmur, misarticulations, frequent word or phrase repetitions, and improved speaking skills when attention to speech and language production is heightened. This last behavior may manifest itself in different ways. For example, the client may produce unusually intelligible and fluent speech throughout the evaluation, which parents report is atypical. On the other hand, variable speech fluency during the examination, marked by definitely improved speech when an audio tape or video recorder is turned on and more rapid, jumbled, or unintelligible speech when the recorder is turned off is noteworthy. When we suspect that the client may be cluttering or possibly exhibiting a combination of both cluttering and stuttering, we collect relevant information on a 33-item checklist. Daly (1992-1993) compiled this list of 33 different behaviors or characteristics believed to be most indicative of cluttering from a larger list of more than 60 items that were suggested by numerous clinical researchers (e.g., Luchsinger & Arnold, 1965; Weiss, 1967; De Hirsch, 1970; Myers & St. Louis, 1992). Each of the items on the checklist is then rated on a
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4-point scale. A rating of zero indicates that the item was not true for the individual, and a rating of three indicates that the statement is very much true of the individual. Thus, a total score of 99 on the checklist is possible. It is suggested that the clinician complete the checklist by scoring each of the 33 items only ~/fter obtaining and reviewing all available information from the client's file, including medical, school, and psychological reports. Pertinent information regarding the developmental history and behavioral observations is important, as well as other data gathered during the clinical interview. Recordings of oral reading and several (more than two) short monologues should be carefully analyzed to accurately rate the items related to speech and language output. In addition, examination of writing samples is often revealing. Clinical data collected over the last few years (Daly & Burnett-Stolnack, 1995) suggest that a score of 55 and above on the checklist is strongly indicative of a cluttering diagnosis. Of course, the pattern of items checked as "pretty much true" and "very much true" is also important for accurate diagnosis. Readers are reminded that the checklist is not a scientific instrument, but a tool that allows us to succinctly organize pertinent information on one page. Total scores between 35 and 55 on the checklist would more accurately identify a person with a combination of both cluttering and stuttering. Clients exhibiting a combination of cluttering and stuttering symptoms may be more common than previously thought. Preus (1992) suggested that cluttering and stuttering may coexist in approximately 35% of stuttering cases. Conservatively, this may represent about one-third of all cases seen. In an effort to organize the information from the checklist, a profile analysis form was developed (Daly & Burnett-Stolnack, 1994). The profile analysis form highlights each individual's pattern of deficits and displays the extent of deviancy from normal for each item. Profiles may then be analyzed to design the overall treatment plan. Thus, the checklist identifies key features of cluttering, and the profile analysis form assists the clinician in structuring relevant data into a framework for identifying the person's strengths and weaknesses. This is illustrated in the f,~llowing case study.
CASE STUDY S 8, who was referred to us from a neighboring state, was initially evaluated at our center in May of 1993 and re-evaluated in July 1995. At the time of this first evaluation, S 8 was in third grade and was receiving special education services from the learning disability teacher for a reading disorder as well as treatment from the school SLP. Earlier speech treatment had focused on rate, clearness, and intelligibility of speech articulation. After our initial evaluation, we remained in contact with the family and the school speech clinician who saw him during the 1993-1994 and 1994-1995 school years. Reports were
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also received from another SLP who saw S 8 for 16 treatment sessions in a hospital speech program during the spring and summer of 1994.
Initial Evaluation Findings At the time of the initial evaluation, S 8 was 9 years, 7 months of age. Developmental history obtained from the parents showed that S 8 was just within normal limits for motor developmental milestones, but his speech and language development was substantially delayed. Specifically, his mother recalled that baby-talk persisted and that the family experienced increasingly more difficulty understanding S 8. She attributed the problem in comprehending him to speech misarticulations, an unusually fast rate, and repetitions that began between 2.5 and 3 years. His mother also reported a familial history of fast talking and stuttering. His parents also mentioned that S 8 had received school speech therapy for speech articulation for several years with only minimal improvement. The school psychologist's report indicated that S 8's IQ was within the high-average range. Reading ability was below average, whereas arithmetic scores were above average. In fact, S 8 was placed in the gifted program for math and science. Although verbal skills fell in the high-average range, the psychologist stated that S 8's conversational speech was characterized by "excessive speed, slurred or omitted syllables and sounds, and a low volume, especially at the ends of his sentences." Analysis of the information gathered during the evaluation revealed that S 8 had difficulty with organization and formulation of language, topic maintenance, rate and tempo of speech, intelligibility, and prosody. S 8 seemed unaware of his deficits and unconcerned with the listener's difficulty understanding him; however, he clearly improved when he noted activation of a recorder. Oral-coordination skills on diadochokinetic speech tasks were below those of his peers, as were his auditory memory abilities. These findings prompted us to utilize the checklist for possible cluttering. His score of 59 substantiated a diagnosis of "cluttering." S 8's scores on each of the 33 items on the rating form are shown on Figure 1.
Recommendations To analyze the checklist scores further, S 8's scores were charted on the Profile Analysis for Treatment Planning form (see Figure 2). S 8's pattern allowed us to determine which deficit areas might be focused upon first in therapy. We recommended targeting the following areas: oral-motor coordination; rate; language abilities (including formulation of stories, topic maintenance, sequencing of events); awareness of deficits; and reading difficulties.
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DALY’SCHECKLIST FOR POSSIBLE CLUTTERLWG
E%permenral Edhla”
Figure 1. S 8’s completed checklist for possible cluttering.
Treatment. Reports from the school and hospital speech-language pathologists indicated that our recommended goal areas were addressed. The school SLP treated S 8 twice a week and reported good results following the Riley’s (1985) Oral Syllable Assessment and Treatment program to address his oral-motor discoordination difficulty. In her treatment summary report for the 1993-l 994 school year, the school SLP noted that although three-syllable sets initially had been very frustrating for S 8, by the end of the semester S 8 could produce all sets with accuracy and an even flow. Rate tapes, as de-
D. A. DALY and M. L. BURNETT
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PROFILE ANALYSIS FOR PLANNING TREATMENT WITH CLUITERING CLIENTS NAME:
j_JtchadtacI i
Experimental DATE:
E ‘tion - Daly and Burnett-Stolnack
(1995)
5 73
AGE:
87
NDMOTOR (1) Repeats syllables, words, phrases (5) Silent gaps, hesitations, many “tiller” words (6) Stops before initial vowels (9) Jerky breathing pattern; respiratory dysrhythmia (101 Slurred articulation (omits sounds/unstressed syllables) (11) Misprommciatlon of/r/, N, and/or sibilanu (191 Clumsy & uncoordinated; hasty motor activities iZl) Poor &or control; disintegrated witing (17) Poor rhythm. timing, or musical ability SU&.&EGME~AL FEA?LIRES (7) Rapid rate (tachylalla); speaks in spurts (24) Initial loud voice, trail on to murmur; mumbles (28) Improper stress pattern B. LANG-ND COGNIT’Q, Y AUDITORY COMPREHENSION (13) Ditliculty following directions; impatient listener VERBAL EXPRESSION (16) Word.tinding dificulty; resembles anemia (17) Inappropriate pronoun reference (18) Poor grammar &syrIta.x; improper language structure WRITTEN
(32) Impatient,
PRAGreless, hasty, impulsive, or forgetful superfltial, short-tempered
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(2) SMed talking late; o”set sentenced delayed (3) Early fluency disruptions with no remissions; never very fluent (23) Left-rtgb, conIusion, delayed hrmd preference (29) Immahue; nppePn younger (30) Famitinl; same or sbnllar problem
Figure 2. Completed profile analysis for planning S 8’s treatment.
scribed in Daly (1988, 1993), were produced to facilitate reduction of speech rate, which in turn improved awareness and intelligibility. The hospital SLP’s diagnosis was “cluttering with central auditory processing disorder.” Her reports documented specific attention to: improving concentration and memory; increasing specificity of language; focusing on various linguistic skills (thought organization, narrative formation, and topic
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maintenance); and improving self-monitoring. She reported substantial improvement in all areas. During the 1994-1995 school year, the school SLP focused on conversational speech with reduced rate and increased self-monitoring. She reported significant improvement in these areas. At our request, the school speech-language pathologist completed the Checklist for Possible Cluttering in June of 1995. Her ratings yielded a total score of 37, which is in the lower range of the mild cluttering or the combined cluttering-stuttering category.
Re-evaluation In July of 1995, more than 2 years after the initial evaluation, we had the opportunity to re-evaluate S 8, who was then 11 years, 8 months of age. We completed the same evaluative measures. The checklist was readministered, using both our observations and input from his parents. He achieved a score of 39, which closely approximates his school SLP's score of 37. Ratings notably improved with respect to rate, articulation, rhythm, and awareness which were specifically targeted in treatment. As shown in Table 1, S 8 actually improved in nine of 10 variables measured, except for rate of oral reading, which was within normal limits initially. Interesting clinical observations made during the re-evaluation included more reserved behavior and generally low volume. Although volume did not diminish at the end of sentences as noted initially, its lower intensity did reduce intelligibility somewhat. Additionally, S 8 frequently kept his hands in front of his mouth, used very brief responses, and improved eye contact only after cuing. There were some instances in which S 8 blinked his eyes in a very rapid repetitive fashion in association with linguistic revisions or other speech production difficulties. These observations could be interpreted as being reflective of maturation or of an increased awareness of his speech and language difficulties. On the other hand, they could also be interpreted as anticipatory or struggle behaviors associated with stuttering. At this point, the authors believe that these behaviors should continue to be monitored.
SUMMARY The improvements noted in this 2-year study documents the benefits of professional collaboration in designing and following a structured yet individualized treatment program. We found the checklist and profile analysis to be helpful in synthesizing all the pertinent data and organizing the evaluation results to assist in treatment planning. Reports from the school speech-language pathologist indicated that the suggested goal areas were appropriate. S 8's parents shared reports and letters from teachers and team-members which indicated that they too witnessed substantial progress. He is still eligible for spe-
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Table 1. Comparison of 1993 and 1995 Evaluation Findings Measures Automatic speech
Multisyilablic word/phrase repetition Oral motor a
Expected outcome Intelligible; consistent rate and tempo Clinical judgment --~ 18/20 (90%)
10 yr. norms: 3.7-4.2 sec. 5.5-6.4 sec. ,'~ 7.1 sec. 12 yr. norms: Single syllable 4.0-4.5 sec. Double syllable 5.9-6.6 sec. Tri-syllable ,,~ 7.7 sec. Auditory memoryb 9 yr. mean = 24 (in syllables) 12 yr. mean = 26 Oral reading rate Age appropriate performance Speaking rate Age appropriate performance Awareness Aware of own errors and listener difficulty Language Sequencing Sequential output events Topic Maintain topic maintenance Checklist score <35 Single syllable Double syllable Tri-syltable
1993 Evaluation Intelligible; variable rate and tempo 14/20 (70%) accurate
1995 Evaluation Intelligible; consistent rate and tempo 17/20 (85%) accurate
3.8-4.6 seconds 5.7-7.1 seconds -,~ 8.1 seconds 3.3-3.9 seconds 5.8-7.1 seconds ~ 7.3 seconds 20 syllables 129 wpm
23 syllables 129 wpm
Mean = 126 wpm (range = 115-145) No self-corrections, maximal cueing to elicit change
Mean = 116 wpm (range = 118-126) Self-correction of own errors and positive response to minimal cuing
Disorganized, 8 revisions Off topic 3 times in 60-second sample 59
Sequential, 2 revisions Off topic 0 times in 60-second sample 39
a Norms according to Fletcher (1992). b Norms according to Daly et al. (1981).
cial education services for his reading disability. Although this assistance with receptive language skills will likely enhance his overall linguistic abilities, further expressive language training may be beneficial. Given the behaviors described above and the fact that S 8 is moving into adolescence, continued contact with the SLP may serve to enhance consistency of performance and contribute to building self-esteem and self-confidence in communication. The authors wish to express their gratitude to S 8, his parents, and all of the professionals who contributed to and cooperated in this endeavor.
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REFERENCES Daly, D.A. (1988). The Freedom of Fluency: A Therapy Program for the Chronic Stutterer. Moline, IL: LinguiSystems, Inc. Daly, D.A. (1992). Helping the clutterer: Therapy considerations. In F.L. Myers and K.O. St. Louis (Eds.), Cluttering: A Clinical Perspective. Kibworth, England: Far Communications, pp. 107-121 (reissued in 1996 by Singular, San Diego, CA). Daly, D.A. (1992-1993). Cluttering: A language-based syndrome. The Clinical Connection 6, 47. Daly, D.A. (1993). Cluttering: Another fluency syndrome. In R.F. Curlee (Ed.), Stuttering and Related Disorders of Fluency. New York: ThiemeStratton Medical Publishers, Inc. Daly, D.A., & Burnett-Stolnack, M.L. (1994). Differential diagnosis of cluttering and stuttering for individualized treatment planning. Presented at the annual convention of the American Speech-Language-Hearing Association, New Orleans, LA. Daly, D.A., & Burnett-Stolnack, M.L. (1995). Identification of and treatment planning for cluttering clients: Two practical tools. The Clinical Connection 8,15. Daly, D.A., Myers, F.L., & St. Louis, K.O. (1992). Cluttering: A pathology lost but found. Presented at the annual convention of the American SpeechLanguage-Hearing Association, San Antonio, TX. Daly, D.A., Ostreicher, H.J., Jonassen, S.A., & Darnton, S.W. (1981). Memory for unrelated sentences: A normative study of 480 children. Presented at the annual convention of the International Neurological Society, Atlanta, GA. De Hirsch, K. (1970). Stuttering and cluttering: Developmental aspects of dysrhythmic speech. Folia Phoniatrica 22, 311-324. Fletcher, S.G. (1972). Time-by-count measurement of diadochokinetic syllable rate. Journal of Speech Hearing Research 15, 763-770. Kowal, S., O'Conneil, D.C., & Sabin, E.J. (1975). Development of temporalpatterning and vocal hesitations in spontaneous narratives. Journal of Psycholinguistic Research 4, 195-207. Luchsinger, R., & Arnold, G.E. (1965). Voice-Speech-Language: Clinical Communicology: Its Physiology and Pathology. Belmont, CA: Wadsworth. Myers, F.L., & St. Louis, K.O. (Eds). (1992). Cluttering: A Clinical Perspec-
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five. Kibworth, England: Far Communications (reissued in 1996 by Singular, San Diego, CA). Preus, A. (1992). Cluttering and stuttering: Related, different, or antagonistic disorders? In F.L. Myers and K.O. St. Louis (Eds.), Cluttering: A Clinical Perspective. Kibworth, England: Far Communications, pp. 55-70 (reissued in 1996 by Singular, San Diego, CA). Riley, G., & Riley, J. (1985). Oral Motor Assessment and Treatment: Improving Syllable Production. Austin, TX: PRO-ED. Inc. Weiss, D.A. (1967). Similarities and differences between stuttering and cluttering. Folia Phoniatrica 19, 98-104.
CLUTTERING: ASSESSMENT, TREATMENT PLANNING, AND CASE STUDY ILLUSTRATION DAVID A. D A L Y University of Michigan, Ann Arbor, Michigan, U.S.A.
M I C H E L L E L. BURNETI" St. Joseph Mercy Hospital, Ann Arbor, Michigan, U.S.A.
Successful treatment of clients who present with a multitude of interrelated impairments is frequently dependent upon thorough and accurate diagnosis of the problems. Individuals who clutter often demonstrate a variety of speech and language deficits that make diagnosis difficult. Two clinical tools believed to be useful for obtaining and organizing diagnostic data and for planning treatment with clients who show symptoms of cluttering are discussed. The case study report illustrates the utility of these tools for collecting and organizing all pertinent data.
INTRODUCTION We view cluttering as a disorder of speech and language processing, resulting in rapid, dysrhythmic, sporadic, unorganized, and frequently unintelligible speech. Accelerated speech is not always present, but an impairment in formulating language almost always is (Daly, 1992). Although a single definition of cluttering has not been agreed upon, we feel this definition encompasses the multitude of variables often associated with cluttering. Because there are many other deficits that may coexist for a given individual, such as attention deficit disorder (ADD), language-learning disorder (LLD), and/or motor-speech impairments, differentiating cluttering from other disorders may prove difficult. In other cases, cluttering may be masked when an individual demonstrates significant strengths, such as superior abilities in math and science. Thus, clinicians must be aware that individuals exhibiting features of cluttering typically do not fit neatly into one diagnostic category. Therefore, the assessment process must be comprehensive, with thorough data collection being essential. Upon obtaining all of the necessary
Address correspondence to David A. Daly, University of Michigan, Ann Arbor, MI 48109. Category: Post hoc Case Study (Clinical Impressions) J. FLUENCY DISORD. 21 (1996), 239-248 © 1996 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0094-730X/96/$15.130 PII S0094-730X(96)00026-0
240
D.A. DALY and M. L. BURNET/"
information, accurate interpretation of the data is critical to diagnosis and treatment planning. In 1992, Daly, Myers, & St. Louis proposed an evaluation protocol that included measures of fluency, rate, language, articulation, hearing, psychoeducational and academic skills, fine motor control (including handwriting), auditory and visual perception, and cognitive function. Whereas such an interdisciplinary evaluation may seem unwieldy for most individual speechlanguage pathologists (SLP) who function rather independently, we feel each piece of information is important and should be considered whenever available. This report describes new assessment and treatment planning strategies to manage all available data and illustrates with a case study the applicability of these clinical tools in helping individuals who clutter.
ASSESSMENT PROCEDURE Typically, youngsters and adults are referred to our office for stuttering or other fluency problems. Our standard evaluation includes measures of the person's automatic speech (such as counting and naming the days of the week), echoic speech (repeating monosyllabic and polysyllabic words, phrases, and sentences), oral reading, and spontaneous speech. Other related areas, including immediate auditory memory, oral diadochokinetic skills, and written expression, are also routinely assessed. There are a number of client responses which may suggest that additional probing or further testing is necessary when cluttering is suspected. Clinical experience has alerted us to seven behaviors or client responses that we believe may warrant further evaluation. They are: low awareness level or denial of any difficulty speaking, rapid or fluctuating speech rate, disorganized language (confused wording or difficulty sequencing events), initially loud voice trailing off to a murmur, misarticulations, frequent word or phrase repetitions, and improved speaking skills when attention to speech and language production is heightened. This last behavior may manifest itself in different ways. For example, the client may produce unusually intelligible and fluent speech throughout the evaluation, which parents report is atypical. On the other hand, variable speech fluency during the examination, marked by definitely improved speech when an audio tape or video recorder is turned on and more rapid, jumbled, or unintelligible speech when the recorder is turned off is noteworthy. When we suspect that the client may be cluttering or possibly exhibiting a combination of both cluttering and stuttering, we collect relevant information on a 33-item checklist. Daly (1992-1993) compiled this list of 33 different behaviors or characteristics believed to be most indicative of cluttering from a larger list of more than 60 items that were suggested by numerous clinical researchers (e.g., Luchsinger & Arnold, 1965; Weiss, 1967; De Hirsch, 1970; Myers & St. Louis, 1992). Each of the items on the checklist is then rated on a
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4-point scale. A rating of zero indicates that the item was not true for the individual, and a rating of three indicates that the statement is very much true of the individual. Thus, a total score of 99 on the checklist is possible. It is suggested that the clinician complete the checklist by scoring each of the 33 items only ~/fter obtaining and reviewing all available information from the client's file, including medical, school, and psychological reports. Pertinent information regarding the developmental history and behavioral observations is important, as well as other data gathered during the clinical interview. Recordings of oral reading and several (more than two) short monologues should be carefully analyzed to accurately rate the items related to speech and language output. In addition, examination of writing samples is often revealing. Clinical data collected over the last few years (Daly & Burnett-Stolnack, 1995) suggest that a score of 55 and above on the checklist is strongly indicative of a cluttering diagnosis. Of course, the pattern of items checked as "pretty much true" and "very much true" is also important for accurate diagnosis. Readers are reminded that the checklist is not a scientific instrument, but a tool that allows us to succinctly organize pertinent information on one page. Total scores between 35 and 55 on the checklist would more accurately identify a person with a combination of both cluttering and stuttering. Clients exhibiting a combination of cluttering and stuttering symptoms may be more common than previously thought. Preus (1992) suggested that cluttering and stuttering may coexist in approximately 35% of stuttering cases. Conservatively, this may represent about one-third of all cases seen. In an effort to organize the information from the checklist, a profile analysis form was developed (Daly & Burnett-Stolnack, 1994). The profile analysis form highlights each individual's pattern of deficits and displays the extent of deviancy from normal for each item. Profiles may then be analyzed to design the overall treatment plan. Thus, the checklist identifies key features of cluttering, and the profile analysis form assists the clinician in structuring relevant data into a framework for identifying the person's strengths and weaknesses. This is illustrated in the f,~llowing case study.
CASE STUDY S 8, who was referred to us from a neighboring state, was initially evaluated at our center in May of 1993 and re-evaluated in July 1995. At the time of this first evaluation, S 8 was in third grade and was receiving special education services from the learning disability teacher for a reading disorder as well as treatment from the school SLP. Earlier speech treatment had focused on rate, clearness, and intelligibility of speech articulation. After our initial evaluation, we remained in contact with the family and the school speech clinician who saw him during the 1993-1994 and 1994-1995 school years. Reports were
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D.A. DALY and M. L. BURNETI"
also received from another SLP who saw S 8 for 16 treatment sessions in a hospital speech program during the spring and summer of 1994.
Initial Evaluation Findings At the time of the initial evaluation, S 8 was 9 years, 7 months of age. Developmental history obtained from the parents showed that S 8 was just within normal limits for motor developmental milestones, but his speech and language development was substantially delayed. Specifically, his mother recalled that baby-talk persisted and that the family experienced increasingly more difficulty understanding S 8. She attributed the problem in comprehending him to speech misarticulations, an unusually fast rate, and repetitions that began between 2.5 and 3 years. His mother also reported a familial history of fast talking and stuttering. His parents also mentioned that S 8 had received school speech therapy for speech articulation for several years with only minimal improvement. The school psychologist's report indicated that S 8's IQ was within the high-average range. Reading ability was below average, whereas arithmetic scores were above average. In fact, S 8 was placed in the gifted program for math and science. Although verbal skills fell in the high-average range, the psychologist stated that S 8's conversational speech was characterized by "excessive speed, slurred or omitted syllables and sounds, and a low volume, especially at the ends of his sentences." Analysis of the information gathered during the evaluation revealed that S 8 had difficulty with organization and formulation of language, topic maintenance, rate and tempo of speech, intelligibility, and prosody. S 8 seemed unaware of his deficits and unconcerned with the listener's difficulty understanding him; however, he clearly improved when he noted activation of a recorder. Oral-coordination skills on diadochokinetic speech tasks were below those of his peers, as were his auditory memory abilities. These findings prompted us to utilize the checklist for possible cluttering. His score of 59 substantiated a diagnosis of "cluttering." S 8's scores on each of the 33 items on the rating form are shown on Figure 1.
Recommendations To analyze the checklist scores further, S 8's scores were charted on the Profile Analysis for Treatment Planning form (see Figure 2). S 8's pattern allowed us to determine which deficit areas might be focused upon first in therapy. We recommended targeting the following areas: oral-motor coordination; rate; language abilities (including formulation of stories, topic maintenance, sequencing of events); awareness of deficits; and reading difficulties.
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DALY’SCHECKLIST FOR POSSIBLE CLUTTERLWG
E%permenral Edhla”
Figure 1. S 8’s completed checklist for possible cluttering.
Treatment. Reports from the school and hospital speech-language pathologists indicated that our recommended goal areas were addressed. The school SLP treated S 8 twice a week and reported good results following the Riley’s (1985) Oral Syllable Assessment and Treatment program to address his oral-motor discoordination difficulty. In her treatment summary report for the 1993-l 994 school year, the school SLP noted that although three-syllable sets initially had been very frustrating for S 8, by the end of the semester S 8 could produce all sets with accuracy and an even flow. Rate tapes, as de-
D. A. DALY and M. L. BURNETT
244
PROFILE ANALYSIS FOR PLANNING TREATMENT WITH CLUITERING CLIENTS NAME:
j_JtchadtacI i
Experimental DATE:
E ‘tion - Daly and Burnett-Stolnack
(1995)
5 73
AGE:
87
NDMOTOR (1) Repeats syllables, words, phrases (5) Silent gaps, hesitations, many “tiller” words (6) Stops before initial vowels (9) Jerky breathing pattern; respiratory dysrhythmia (101 Slurred articulation (omits sounds/unstressed syllables) (11) Misprommciatlon of/r/, N, and/or sibilanu (191 Clumsy & uncoordinated; hasty motor activities iZl) Poor &or control; disintegrated witing (17) Poor rhythm. timing, or musical ability SU&.&EGME~AL FEA?LIRES (7) Rapid rate (tachylalla); speaks in spurts (24) Initial loud voice, trail on to murmur; mumbles (28) Improper stress pattern B. LANG-ND COGNIT’Q, Y AUDITORY COMPREHENSION (13) Ditliculty following directions; impatient listener VERBAL EXPRESSION (16) Word.tinding dificulty; resembles anemia (17) Inappropriate pronoun reference (18) Poor grammar &syrIta.x; improper language structure WRITTEN
(32) Impatient,
PRAGreless, hasty, impulsive, or forgetful superfltial, short-tempered
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(2) SMed talking late; o”set sentenced delayed (3) Early fluency disruptions with no remissions; never very fluent (23) Left-rtgb, conIusion, delayed hrmd preference (29) Immahue; nppePn younger (30) Famitinl; same or sbnllar problem
Figure 2. Completed profile analysis for planning S 8’s treatment.
scribed in Daly (1988, 1993), were produced to facilitate reduction of speech rate, which in turn improved awareness and intelligibility. The hospital SLP’s diagnosis was “cluttering with central auditory processing disorder.” Her reports documented specific attention to: improving concentration and memory; increasing specificity of language; focusing on various linguistic skills (thought organization, narrative formation, and topic
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maintenance); and improving self-monitoring. She reported substantial improvement in all areas. During the 1994-1995 school year, the school SLP focused on conversational speech with reduced rate and increased self-monitoring. She reported significant improvement in these areas. At our request, the school speech-language pathologist completed the Checklist for Possible Cluttering in June of 1995. Her ratings yielded a total score of 37, which is in the lower range of the mild cluttering or the combined cluttering-stuttering category.
Re-evaluation In July of 1995, more than 2 years after the initial evaluation, we had the opportunity to re-evaluate S 8, who was then 11 years, 8 months of age. We completed the same evaluative measures. The checklist was readministered, using both our observations and input from his parents. He achieved a score of 39, which closely approximates his school SLP's score of 37. Ratings notably improved with respect to rate, articulation, rhythm, and awareness which were specifically targeted in treatment. As shown in Table 1, S 8 actually improved in nine of 10 variables measured, except for rate of oral reading, which was within normal limits initially. Interesting clinical observations made during the re-evaluation included more reserved behavior and generally low volume. Although volume did not diminish at the end of sentences as noted initially, its lower intensity did reduce intelligibility somewhat. Additionally, S 8 frequently kept his hands in front of his mouth, used very brief responses, and improved eye contact only after cuing. There were some instances in which S 8 blinked his eyes in a very rapid repetitive fashion in association with linguistic revisions or other speech production difficulties. These observations could be interpreted as being reflective of maturation or of an increased awareness of his speech and language difficulties. On the other hand, they could also be interpreted as anticipatory or struggle behaviors associated with stuttering. At this point, the authors believe that these behaviors should continue to be monitored.
SUMMARY The improvements noted in this 2-year study documents the benefits of professional collaboration in designing and following a structured yet individualized treatment program. We found the checklist and profile analysis to be helpful in synthesizing all the pertinent data and organizing the evaluation results to assist in treatment planning. Reports from the school speech-language pathologist indicated that the suggested goal areas were appropriate. S 8's parents shared reports and letters from teachers and team-members which indicated that they too witnessed substantial progress. He is still eligible for spe-
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Table 1. Comparison of 1993 and 1995 Evaluation Findings Measures Automatic speech
Multisyilablic word/phrase repetition Oral motor a
Expected outcome Intelligible; consistent rate and tempo Clinical judgment --~ 18/20 (90%)
10 yr. norms: 3.7-4.2 sec. 5.5-6.4 sec. ,'~ 7.1 sec. 12 yr. norms: Single syllable 4.0-4.5 sec. Double syllable 5.9-6.6 sec. Tri-syllable ,,~ 7.7 sec. Auditory memoryb 9 yr. mean = 24 (in syllables) 12 yr. mean = 26 Oral reading rate Age appropriate performance Speaking rate Age appropriate performance Awareness Aware of own errors and listener difficulty Language Sequencing Sequential output events Topic Maintain topic maintenance Checklist score <35 Single syllable Double syllable Tri-syltable
1993 Evaluation Intelligible; variable rate and tempo 14/20 (70%) accurate
1995 Evaluation Intelligible; consistent rate and tempo 17/20 (85%) accurate
3.8-4.6 seconds 5.7-7.1 seconds -,~ 8.1 seconds 3.3-3.9 seconds 5.8-7.1 seconds ~ 7.3 seconds 20 syllables 129 wpm
23 syllables 129 wpm
Mean = 126 wpm (range = 115-145) No self-corrections, maximal cueing to elicit change
Mean = 116 wpm (range = 118-126) Self-correction of own errors and positive response to minimal cuing
Disorganized, 8 revisions Off topic 3 times in 60-second sample 59
Sequential, 2 revisions Off topic 0 times in 60-second sample 39
a Norms according to Fletcher (1992). b Norms according to Daly et al. (1981).
cial education services for his reading disability. Although this assistance with receptive language skills will likely enhance his overall linguistic abilities, further expressive language training may be beneficial. Given the behaviors described above and the fact that S 8 is moving into adolescence, continued contact with the SLP may serve to enhance consistency of performance and contribute to building self-esteem and self-confidence in communication. The authors wish to express their gratitude to S 8, his parents, and all of the professionals who contributed to and cooperated in this endeavor.
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REFERENCES Daly, D.A. (1988). The Freedom of Fluency: A Therapy Program for the Chronic Stutterer. Moline, IL: LinguiSystems, Inc. Daly, D.A. (1992). Helping the clutterer: Therapy considerations. In F.L. Myers and K.O. St. Louis (Eds.), Cluttering: A Clinical Perspective. Kibworth, England: Far Communications, pp. 107-121 (reissued in 1996 by Singular, San Diego, CA). Daly, D.A. (1992-1993). Cluttering: A language-based syndrome. The Clinical Connection 6, 47. Daly, D.A. (1993). Cluttering: Another fluency syndrome. In R.F. Curlee (Ed.), Stuttering and Related Disorders of Fluency. New York: ThiemeStratton Medical Publishers, Inc. Daly, D.A., & Burnett-Stolnack, M.L. (1994). Differential diagnosis of cluttering and stuttering for individualized treatment planning. Presented at the annual convention of the American Speech-Language-Hearing Association, New Orleans, LA. Daly, D.A., & Burnett-Stolnack, M.L. (1995). Identification of and treatment planning for cluttering clients: Two practical tools. The Clinical Connection 8,15. Daly, D.A., Myers, F.L., & St. Louis, K.O. (1992). Cluttering: A pathology lost but found. Presented at the annual convention of the American SpeechLanguage-Hearing Association, San Antonio, TX. Daly, D.A., Ostreicher, H.J., Jonassen, S.A., & Darnton, S.W. (1981). Memory for unrelated sentences: A normative study of 480 children. Presented at the annual convention of the International Neurological Society, Atlanta, GA. De Hirsch, K. (1970). Stuttering and cluttering: Developmental aspects of dysrhythmic speech. Folia Phoniatrica 22, 311-324. Fletcher, S.G. (1972). Time-by-count measurement of diadochokinetic syllable rate. Journal of Speech Hearing Research 15, 763-770. Kowal, S., O'Conneil, D.C., & Sabin, E.J. (1975). Development of temporalpatterning and vocal hesitations in spontaneous narratives. Journal of Psycholinguistic Research 4, 195-207. Luchsinger, R., & Arnold, G.E. (1965). Voice-Speech-Language: Clinical Communicology: Its Physiology and Pathology. Belmont, CA: Wadsworth. Myers, F.L., & St. Louis, K.O. (Eds). (1992). Cluttering: A Clinical Perspec-
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five. Kibworth, England: Far Communications (reissued in 1996 by Singular, San Diego, CA). Preus, A. (1992). Cluttering and stuttering: Related, different, or antagonistic disorders? In F.L. Myers and K.O. St. Louis (Eds.), Cluttering: A Clinical Perspective. Kibworth, England: Far Communications, pp. 55-70 (reissued in 1996 by Singular, San Diego, CA). Riley, G., & Riley, J. (1985). Oral Motor Assessment and Treatment: Improving Syllable Production. Austin, TX: PRO-ED. Inc. Weiss, D.A. (1967). Similarities and differences between stuttering and cluttering. Folia Phoniatrica 19, 98-104.