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Critical review of the special edition on cluttering
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CRITICAL REVIEW OF THE SPECIAL EDITION ON CLUTTERING LOIS A. NELSON University of Wisconsin-Madison, Madison, Wisconsin. U.S.A.
W H A T DO W E K N O W A B O U T C L U T T E R I N G ? Most authorities agree that although cluttering can occur as a separate disorder, it frequently accompanies stuttering. Further agreement about the nature of cluttering tends to be limited to the characteristics of rapid and irregular rate and rhythm of speaking, and disfluency that differs from stuttering (St. Louis, Hinzman, & Hull, 1985; St. Louis & Myers, 1995). Beyond these obligatory symptoms, the presence of other impairments of speech, language, learning, and behavior in people who clutter are identified primarily on the basis of management experiences of speech-language pathologists and teachers. A definition acceptable to both clinicians and scientists probably will encompass the view that the profession should expect considerable variability rather than homogeneity of symptoms. It often seems that each person who clutters is a subgroup of one. Concerns of scientists and clinicians continue to be those of thorough evaluation of the speech, language, and learning disorders that contribute to the communication problem, and selection and sequencing of appropriate treatment strategies. The particular combination of strengths and weaknesses for each one who clutters--intellectual, neurological, environmental, educational, coping strategies--contributes to the difficulty professionals find in designing and implementing programs. Individual variability interferes with attempts to classify those who clutter into groups. Many speech-language pathologists have identified children's and adult's difficulty in detecting and monitoring target behavior, maintaining interest in therapy for a time period sufficient to achieve changes, and transfer and maintenance of skill level. Effectiveness of
Address correspondence to Lois A. Nelson, Department of Communicative Disorders. University of Wisconsin-Madison. Madison. WI 53706.
Category: Critical Summary J. FLUENCY DISORD. 21 (1996), 345-348 © 1996 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0094-730X/96/S 15.00 PII S0094-730X(96)00037-6
346
L.A. NELSON
therapy has been questioned by all at one time or another. Developmental cluttering is not expected to be outgrown.
WHAT HAVE WE LEARNED ABOUT CLUTTERING IN T H I S I S S U E ? Clinical contributors to this special joumal edition on the nature and treatment of cluttering clearly expect only a few symptoms to be similar from client to client. Myers & St. Louis articulated the similarities as: rate anomalies, disfluencies, linguistic maze behaviors, and poor speech intelligibility. They caution that beyond these four areas, the hallmark of cluttering will be heterogeneity of symptoms. Likewise, Daly & Burnett reiterate that cluttering does not fit nearly into one diagnostic category. There is recognition by the contributors of the need for extensive evaluation that is multidimensional, requiring knowledge and participation of other professionals for purposes of differentiation of cluttering and treatment planning. Whether researchers administered Daly's 33-item checklist of behaviors or relied on other in-depth evaluation protocols as did Georgieva and Miliev, among others, they appear to have reasonable confidence in their ability to differentiate clients into disfluency categories of stuttering, cluttering, and mixed. Of interest to clinicians is the identification of behaviors that Daly states should alert clinicians to the need for additional testing. The behaviors range from low levels of awareness of difficulty speaking to the observation that speaking skills improve when attention to production is heightened. Details are presented in the Daly and Burnett article. Contributors to treatment procedures included Teigland's findings that the teen subjects who cluttered violated pragmatic conventions in a manner similar to young people who exhibit language-learning disorders. The teens did not provide relevant information to a conversational partner during a verbal instruction task. Any attempts to reformulate unclear directions resulted in wordy indirect explanations, often as mazes, spoken rapidly. Teigland noted that the partner did not ask for clarification and speculated that having listened ineffectively, lack of motivation to request clarification, or politeness also contributed to the client's failures to reformulate successfully. This finding suggests that listeners as well as speakers need to be programmed for their partner roles. Strategies for persons who stutter and clutter were detailed in two studies. Finding are pertinent to program planning. Craig and Langevin & Boberg reported that intensive therapy utilizing rate control procedures and focus on cognitive changes/counseling were effective for both disorders. In addition, Craig's treatment program stressed airflow techniques. Langevin & Boberg pointed out that their typical 90:hour program for persons who stutter was
CRITICAL REVIEW OF SPECIAL EDITION ON CLUTTERING
347
lengthened if the client had both disorders in order to work on self-monitoring of rate and disfluencies. They recommended that therapy for any existing language problems be included in the complete program. William & Wener stated it was more difficult to make improvements in the first place and more difficult for the client to sustain gains if he both cluttered and stuttered. St. Louis et al. commented that sustained periodic intervention may be necessary for the client who is willing to continue in therapy if transfer is to be achieved. Molt researched auditory processing difficulties of three school-aged children diagnosed with both cluttering and attention deficit disorder (ADD). He reported below normal performance on two of four central auditory processing measures (two linguistic and two nonlinguistic). All three children failed one of the linguistic measures (SSW-Staggered Spondaic Word test). Details are stated in his article. In view of these findings, Molt's call for research to identify the linkage among cluttering, ADD, and CAPD is timely. He raised the possibility that the three disorders may reflect different manifestations of a single underlying component or differing degrees of severity of that component. Researchers report potential linkages among other dimensions of cluttering--motoric skills including speaking rate, articulatory movement, diadochokinetic rate, and phonation time. Lees, Boyle, & Woolfson presented motoric differences in the speech of a 15 year old who cluttered. Their findings included slower DDK rates, limited tongue movement, and short phonation time. Speech rate was judged faster if only perceptually fluent utterances were measured. Included in this issue are reports of three patients who exhibited speech, language, and cognitive behavior similar to cluttering after brain damage. For all three, rate was identified as a key aspect of the production problem. R. Thacker and DeNil described increased rate as a central feature of their subject's speech problems. Likewise, LeBrun expressed concern for the difficulty two persons with Parkinson disease had regulating their rate of speaking. At this level of our knowledge, it may be wise to heed Rosenbek's caution for the issue of identifying neurogenic stuttering: to continue to observe and report rather than to label. It may be equally relevant to apply that caution to the issue of identifying "neurogenic" cluttering (Rosenbek, 1984).
W H A T DO W E H A V E YET T O L E A R N ABOUT CLUTTERING? Much. There is reason to expect that researchers and clinicians will be able to identify clusters of components that accompany or contribute to cluttering. It should be possible to delineate subgroups of cluttering, depending on the components or combinations of characteristics found in different individuals. As the researchers and clinicians in this special issue have noted, determina-
348
L.A. NELSON
tion of subgroups would have direct bearing on designing appropriate treatment programs. It seems logical that there is need to separate those components that are basic to speech delivery physically for persons who clutter, such as rate and articulatory precision, from those components which are basic to difficulties of processing and formulating language. To what extent might mechanics be linked with content for cluttering? Will the profile of components or the number of different components be crucial in estimating severity of cluttering for an individual and for estimating prognosis? A fruitful area of investigation may be the client's perspectives of some of the problems experienced. This writer has been educated by the insights of young people in their teens: "No, I don't talk too fast. You listen too slow" or the response given by a young adult to his overall fast rate and speed spurts, "I know my mouth won't go as fast as my brain wants it to" coupled with an explanation for the fast rate, "I think if I don't get them out [the words] they're not going to be there and then I get completely lost on the topic." Those insights have resulted in altered programming. Further investigation of client's perspectives may lead clinicians to revise their interpretations regarding the level of awareness that is attributed to individuals who clutter. For some, the issue may be choosing to alter some aspect of the behavior without having learned strategies to cope effectively and thus accomplish a desired change. For others, the improvement does not appear to be worth the effort. It is a challenge, and an exciting challenge, as a professional, to participate in the discovery of evaluation and treatment strategies for cluttering.
REFERENCES Rosenbek, John C. (1984). Stuttering secondary to nervous system damage. In R.F. Curlee & W.H. Perkins (Eds.), Nature and Treatment of Stuttering: New Directions. College-Hill Press, pp. 31-48. St. Louis, K.O., Hinzman, A.R., & Hull, F.M. (1985). Studies of cluttering: Disfluency and language measures in young possible clutterers and stutterers. Journal of Fluency Disorders 10, 151-172. St. Louis, K.O., & Myers, F.L. (1995). Clinical management of cluttering. Language, Speech, and Hearing Services in Schools 26, 187-195.
CRITICAL REVIEW OF THE SPECIAL EDITION ON CLUTTERING LOIS A. NELSON University of Wisconsin-Madison, Madison, Wisconsin. U.S.A.
W H A T DO W E K N O W A B O U T C L U T T E R I N G ? Most authorities agree that although cluttering can occur as a separate disorder, it frequently accompanies stuttering. Further agreement about the nature of cluttering tends to be limited to the characteristics of rapid and irregular rate and rhythm of speaking, and disfluency that differs from stuttering (St. Louis, Hinzman, & Hull, 1985; St. Louis & Myers, 1995). Beyond these obligatory symptoms, the presence of other impairments of speech, language, learning, and behavior in people who clutter are identified primarily on the basis of management experiences of speech-language pathologists and teachers. A definition acceptable to both clinicians and scientists probably will encompass the view that the profession should expect considerable variability rather than homogeneity of symptoms. It often seems that each person who clutters is a subgroup of one. Concerns of scientists and clinicians continue to be those of thorough evaluation of the speech, language, and learning disorders that contribute to the communication problem, and selection and sequencing of appropriate treatment strategies. The particular combination of strengths and weaknesses for each one who clutters--intellectual, neurological, environmental, educational, coping strategies--contributes to the difficulty professionals find in designing and implementing programs. Individual variability interferes with attempts to classify those who clutter into groups. Many speech-language pathologists have identified children's and adult's difficulty in detecting and monitoring target behavior, maintaining interest in therapy for a time period sufficient to achieve changes, and transfer and maintenance of skill level. Effectiveness of
Address correspondence to Lois A. Nelson, Department of Communicative Disorders. University of Wisconsin-Madison. Madison. WI 53706.
Category: Critical Summary J. FLUENCY DISORD. 21 (1996), 345-348 © 1996 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0094-730X/96/S 15.00 PII S0094-730X(96)00037-6
346
L.A. NELSON
therapy has been questioned by all at one time or another. Developmental cluttering is not expected to be outgrown.
WHAT HAVE WE LEARNED ABOUT CLUTTERING IN T H I S I S S U E ? Clinical contributors to this special joumal edition on the nature and treatment of cluttering clearly expect only a few symptoms to be similar from client to client. Myers & St. Louis articulated the similarities as: rate anomalies, disfluencies, linguistic maze behaviors, and poor speech intelligibility. They caution that beyond these four areas, the hallmark of cluttering will be heterogeneity of symptoms. Likewise, Daly & Burnett reiterate that cluttering does not fit nearly into one diagnostic category. There is recognition by the contributors of the need for extensive evaluation that is multidimensional, requiring knowledge and participation of other professionals for purposes of differentiation of cluttering and treatment planning. Whether researchers administered Daly's 33-item checklist of behaviors or relied on other in-depth evaluation protocols as did Georgieva and Miliev, among others, they appear to have reasonable confidence in their ability to differentiate clients into disfluency categories of stuttering, cluttering, and mixed. Of interest to clinicians is the identification of behaviors that Daly states should alert clinicians to the need for additional testing. The behaviors range from low levels of awareness of difficulty speaking to the observation that speaking skills improve when attention to production is heightened. Details are presented in the Daly and Burnett article. Contributors to treatment procedures included Teigland's findings that the teen subjects who cluttered violated pragmatic conventions in a manner similar to young people who exhibit language-learning disorders. The teens did not provide relevant information to a conversational partner during a verbal instruction task. Any attempts to reformulate unclear directions resulted in wordy indirect explanations, often as mazes, spoken rapidly. Teigland noted that the partner did not ask for clarification and speculated that having listened ineffectively, lack of motivation to request clarification, or politeness also contributed to the client's failures to reformulate successfully. This finding suggests that listeners as well as speakers need to be programmed for their partner roles. Strategies for persons who stutter and clutter were detailed in two studies. Finding are pertinent to program planning. Craig and Langevin & Boberg reported that intensive therapy utilizing rate control procedures and focus on cognitive changes/counseling were effective for both disorders. In addition, Craig's treatment program stressed airflow techniques. Langevin & Boberg pointed out that their typical 90:hour program for persons who stutter was
CRITICAL REVIEW OF SPECIAL EDITION ON CLUTTERING
347
lengthened if the client had both disorders in order to work on self-monitoring of rate and disfluencies. They recommended that therapy for any existing language problems be included in the complete program. William & Wener stated it was more difficult to make improvements in the first place and more difficult for the client to sustain gains if he both cluttered and stuttered. St. Louis et al. commented that sustained periodic intervention may be necessary for the client who is willing to continue in therapy if transfer is to be achieved. Molt researched auditory processing difficulties of three school-aged children diagnosed with both cluttering and attention deficit disorder (ADD). He reported below normal performance on two of four central auditory processing measures (two linguistic and two nonlinguistic). All three children failed one of the linguistic measures (SSW-Staggered Spondaic Word test). Details are stated in his article. In view of these findings, Molt's call for research to identify the linkage among cluttering, ADD, and CAPD is timely. He raised the possibility that the three disorders may reflect different manifestations of a single underlying component or differing degrees of severity of that component. Researchers report potential linkages among other dimensions of cluttering--motoric skills including speaking rate, articulatory movement, diadochokinetic rate, and phonation time. Lees, Boyle, & Woolfson presented motoric differences in the speech of a 15 year old who cluttered. Their findings included slower DDK rates, limited tongue movement, and short phonation time. Speech rate was judged faster if only perceptually fluent utterances were measured. Included in this issue are reports of three patients who exhibited speech, language, and cognitive behavior similar to cluttering after brain damage. For all three, rate was identified as a key aspect of the production problem. R. Thacker and DeNil described increased rate as a central feature of their subject's speech problems. Likewise, LeBrun expressed concern for the difficulty two persons with Parkinson disease had regulating their rate of speaking. At this level of our knowledge, it may be wise to heed Rosenbek's caution for the issue of identifying neurogenic stuttering: to continue to observe and report rather than to label. It may be equally relevant to apply that caution to the issue of identifying "neurogenic" cluttering (Rosenbek, 1984).
W H A T DO W E H A V E YET T O L E A R N ABOUT CLUTTERING? Much. There is reason to expect that researchers and clinicians will be able to identify clusters of components that accompany or contribute to cluttering. It should be possible to delineate subgroups of cluttering, depending on the components or combinations of characteristics found in different individuals. As the researchers and clinicians in this special issue have noted, determina-
348
L.A. NELSON
tion of subgroups would have direct bearing on designing appropriate treatment programs. It seems logical that there is need to separate those components that are basic to speech delivery physically for persons who clutter, such as rate and articulatory precision, from those components which are basic to difficulties of processing and formulating language. To what extent might mechanics be linked with content for cluttering? Will the profile of components or the number of different components be crucial in estimating severity of cluttering for an individual and for estimating prognosis? A fruitful area of investigation may be the client's perspectives of some of the problems experienced. This writer has been educated by the insights of young people in their teens: "No, I don't talk too fast. You listen too slow" or the response given by a young adult to his overall fast rate and speed spurts, "I know my mouth won't go as fast as my brain wants it to" coupled with an explanation for the fast rate, "I think if I don't get them out [the words] they're not going to be there and then I get completely lost on the topic." Those insights have resulted in altered programming. Further investigation of client's perspectives may lead clinicians to revise their interpretations regarding the level of awareness that is attributed to individuals who clutter. For some, the issue may be choosing to alter some aspect of the behavior without having learned strategies to cope effectively and thus accomplish a desired change. For others, the improvement does not appear to be worth the effort. It is a challenge, and an exciting challenge, as a professional, to participate in the discovery of evaluation and treatment strategies for cluttering.
REFERENCES Rosenbek, John C. (1984). Stuttering secondary to nervous system damage. In R.F. Curlee & W.H. Perkins (Eds.), Nature and Treatment of Stuttering: New Directions. College-Hill Press, pp. 31-48. St. Louis, K.O., Hinzman, A.R., & Hull, F.M. (1985). Studies of cluttering: Disfluency and language measures in young possible clutterers and stutterers. Journal of Fluency Disorders 10, 151-172. St. Louis, K.O., & Myers, F.L. (1995). Clinical management of cluttering. Language, Speech, and Hearing Services in Schools 26, 187-195.