Studies of cluttering: Perceptions of cluttering by speech-language pathologists and educators

J. FLUENCY DISORD. II (1986). 131-149

STUDIES OF CLUTTERING: PERCEPTIONS OF CLUTTERING BY SPEECH-LANGUAGE PATHOLOGISTS AND EDUCATORS KENNETH 0. ST. LOUIS and AUDREY West Virginia University, Morganrown,

R. HINZMAN

West Virginia

Speech-language pathologists (SLPs) and educators were surveyed by mail regarding their views on the problem of cluttering. The average respondent was aware of a few clutterers, and these individuals were most likely to be placed, educationally, either in a regular classroom or learning disabilities setting. “Clutterer” was the preferred label for these individuals by the majority of respondents. Most respondents did not feel adequately trained to manage clutterers. SLPs’ knowledge of cluttering symptoms and etiology were surprisingly consistent with the literature. Reports of therapy with clutterers were inconsistent and typically pessimistic.

INTRODUCTION Kuhn (1970) argued that science rarely progresses in an orderly, linear direction. Instead, scientific problems are typically investigated heavily, then simply dropped for years while scientists devote their efforts to other, more popular areas of inquiry. Cluttering seems to be such an area. Most early research in cluttering was done in Europe. Weiss (1964, 1968) was primarily responsible for acquainting-or reacquainting-current speechlanguage pathologists (SLPs) in the United States with this unique problem. Although a number of publications on the subject have appeared over the last two decades, the problem of cluttering has been ignored, by and large, in the field of fluency disorders. In the last few years, however, there seems to have been a reawakening of interest in the problem of cluttering (Tiger et al., 1980, Daly, 1986; St. Louis et al., 1985). These recent writings have stressed the virtual absence of careful research into the area of cluttering and have called for empirical data about the disorder. For example, there is, as yet, no definition of cluttering that is derived from systematic investigations of cluttering symptoms. Fur-

Address correspondence to Kenneth 0. St. Louis, Ph.D., Speech Pathology and Audiology, 805 Allen Hall, P.O. Box 6122, West Virginia University, Morgantown, WV 265066122.

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132

K. 0. ST. LOUIS and A. R. HINZMAN

thermore, it is not clear that cluttering, as an entity distinct tering, actually exists in sufficient frequency to be of concern

from stutto clinical

SLPs. Even if clutterers are found to be relatively common, there is reason to suspect that most SLPs have limited exposure, information, and training in the disorder (Daly, 1986). Cluttering is usually described as a syndrome (that is, a constellation of symptoms that may or may not be manifest). Table 1 provides a sampling of symptoms and descriptions of cluttering in terms of essential (obligatory) and other symptoms. Certain symptoms appear to be considered more frequently than others such as disorders of speech rate, speech disfluencies (particularly repetitions), unawareness of the disorder, and concomitant articulation or language problems. Many of the other symptoms, which may or may not be present, lead us to suspect an “organic flavor” (Weiss, 1950, Dalton and Hardcastle, 1977) in the etiology of cluttering. Another interesting hypothesis emerges from a careful inspection of the symptoms in Table 1. The symptoms of cluttering are remarkable similar Table 1. A Sampling

of Symptoms

and Descriptions

of Cluttering

from the

Literature Sources*

Symptom Rapid speech rate (tachylalia) Progressively increasing (festinating) speech rate Irregular speech rate Dysrhythmic speech Stumbling, jerky speech Lack of pauses between words Excessive repetitions Repetitions of one-syllable words and the first sound polysyllabic words Drawling (prolongation of vowels) Interjections Stopping on the first vowel of a word Preliminary to stuttering in some cases Prosodic monotony Stereotyped pitch patterns Faulty phonation Articulation errors Omitting sounds in words Omitting syllables in words Syllabic or verbal transpositions Congenital dyspraxia Congenital language disability Central language imbalance Delayed language Grammatical errors Word-finding problems

1. 2, 3. 5. 6

1, 2 2 2

or syllable

of

1, 2 1, 2 1. 6

I, 6 1, 6 1, 6 1, 2, 4, 6 1, 2, 6

2, 6 1, 3, 1, 1. 2 2

2, 3, 6 6 5, 6 2

1, 2, 6 1, 2, 6

133

Table 1. (continued) Sources*

Symptom

Poor listening or turn-taking in conversations Lack of awareness regarding speech difficulties Anxiety regarding speech Lack of anxiety regarding speech Improved performance with concentration Reading disorders Writing disorders Poor handwriting Disturbed visual perception Disturbed auditory perception Enhanced concrete, scientific, mathematical aptitude Enhanced general memory Vague or tentative thinking Disorganized thinking Disorders of imagery and formulation Learning disabilities Poor rhythm Deficit in musical ability Enhanced musical ability Inability to sing on key Deficits in motor coordination Organic etiology Electroencephalographic abnormalities Left-handedness and mixed laterahty Faulty respiration Cluttering relatives Short auditory attention span Poor concentration Hyperactivity; restlessness Distractibility; forgetfulness Impatience Hasty, untidy, erratic temperament Underachieving Lack of consideration of consequences of personal acts for others Superficiality Lack of punctuality Casual acceptance of life Short temper Emotional instability Unfavorable family situations * Sources citing specific symptoms as essential are in italics. 1 = Weiss (1964). 2 = Luchsinger and Arnold (1965). 3 = Wohl (1970). 4 = Van Riper (1971). 5 = Dalton and Hardcastle (1977). 6 = Daly (1986).

1 I, 3, 6

5 1, 2 1 1, 2, 1, 2, 1, 2, 2, 6 6 2, 7 2 1 1 1, 6 6 1, 6 2 1 2 1, 6 1, 2 1, 2 2, 6 2, 6 1, 2, 1, 2, 1, 6 1, 2, 1, 2 1 1, 2 1 1 1 1 1 1 2 2

6 6 3, 6

6 6 5

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K. 0. ST. LOUIS

and A. R. HINZMAN

to symptoms often associated with specific learning disabilities (Tiger et al., 1980; Daly, 1986). The definition of learning disabilities adopted by the National Joint Committee for Learning Disabilities in 1981 and by the American Speech-Language-Hearing Association in 1982 is as follows: “Learning disabilities is a generic term that refers to a heterogeneous group of disorders manifested by significant difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning, or mathematical abilities. These disorders are intrinsic to the individual and presumed to be due to central nervous system of dysfunction. Even though a learning disability may occur concomitantly with other handicapping conditions (e.g., sensory impairment, mental retardation, social and emotional disturbance) or environmental influences (e.g., cultural difference, insufficient/inappropriate instruction, psychogenic factors), it is not the direct result of those conditions or influences” (p. 945).

It appears that many of the symptoms of cluttering are present in learning disabled individuals: uneven levels of academic achievement, language problems, reading or writing disorders, and such “organic” symptoms as sensory or attention deficits. It can be hypothesized, therefore, that many clutterers are learning disabled individuals who also have fluency problems. This study was designed to provide survey data relevant to professional awareness, knowledge, training, academic placement, and remediation of clutterers. In addition, it was intended to investigate the possibility that many clutterers may also have learning disabilities. METHODS Questionnaires Two questionnaires were constructed to generate information relevant to cluttering, one for speech-language pathologists (SLPs) and one for educators. The questionnaires began with the following description of clutterers, which was distilled from published accounts reviewed earlier: Their speech is noticeable because it usually sounds “cluttered” as though they are talking without a clear idea of what they want to say. Their conversation is hard to follow because they seem to talk too fast, or in a jerky fashion, and seem to run words and sentences together. Clutterers may also repeat sounds, syllables, words, or phrases excessively. Despite these characteristics, they are typically unaware of any difficulty and may be talkative and outgoing. Clutterers may also have academic problems in various subjects, yet these may or may not be severe enough to require specialized educational placement. In fact, some clutterers may excel in certain areas, such as mathematics.

PERCEPTIONS

OF CLUTTERING

135

Overall, clutterers seem disorganized, always in a hurry, and unable to concentrate, perhaps due to a poorly developed attention span. In many things the clutterer does-speaking, writing, reading or working at specific activities-there is a curious tendency to function in constant disarray.

Both questionnaires asked respondents to indicate what label they would prefer to give to the individual described and provide information on persons in their classes, caseloads, or acquaintance who might match the description. Speech-language pathologists were asked to identify obligatory and optional symptoms, as well as the most likely etiology of cluttering. When applicable, they were asked to comment on therapy they had provided for clutterers. Also, they were requested to evaluate their professional training in the area of cluttering and indicate sources of information or reasons for the lack of perceived competence in cluttering remediation. Educators were queried about school placement of clutterers, their own competence in teaching such children, and their need for continuing education. Finally, both groups were asked to provide any other information relevant to clutterers or cluttering. Survey Sample Five hundred questionnaires were sent to SLPs, and 500 were sent to educators in the spring of 1984. The majority of those going to SLPs were sent to public school personnel (n = 345), with approximately five-sixths of this group in West Virginia and one-sixth in Pennsylvania. The remainder (n = 155) were mailed to SLPs in clinics or hospitals in the two states (n = 67) and to individuals who had presented papers on fluency topics at the American Speech-Language-Hearing Association convention (n = 88). Most of the latter group were affiliated with colleges or universities in the roles of teaching, research, or clinical supervision. All of the 500 questionnaires for educators were mailed to teachers in West Virginia. Because it was judged to be especially important to sample teachers of special classes, 160 forms were sent to teachers listed as learning disabilities specialists and 160 forms were sent to others listed as special education teachers (usually of the educable or trainable mentally impaired) or remedial reading specialists. The remaining 180 forms went, at random, to regular classroom teachers (60 in elementary schools, 60 in junior high schools, and 60 in high schools). RESULTS Respondents Of the 345 questionnaires mailed to public school SLPs, 126 (36.5%) were filled out and returned. Thirty (19.4%) of the 155 mailed to other SLPs were mailed back. The total return rate for SLPs was 156 of 500 or 3 1.2%.

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K. 0. ST. LOUIS and A. R. HINZMAN

It was impossible to assign respondents to the exact special education groups to which questionnaires were mailed because the directory used in mailing had sometimes listed individuals inappropriately. Also, in many cases, names were not reported on the returned questionnaires. Thus, a learning disabilities (LD) group comprised of educators specializing on/y in specific learning disabilities was separated from a special education (SE) group who listed as their area of specialty any combination of the special education areas (including learning disabilities in combination with other areas). Combined, the 133 respondents in these groups (60 LD and 73 SE) accounted for 42.6% of the 320 questionnaires mailed out. Thirtysix (20%) of the 180 forms were returned by regular teachers (REG). The overall return rate for educators was 33.8% (169 of 500). The combined return rate of 32.5% was between similar single-mailing return rates reported in two recent studies (24% by Hurst and Cooper, 1983; 40% by Silverman, 1982).

Awareness of Cluttering Number of “clutterers” known. Asked to indicate the number of children with whom the respondent was acquainted and who meet the description of cluttering, SLPs reported a mean of 2.6 clutterers per respondent, and educators reported a mean of 3.8. The sex ratio of clutterers known was practically identical for the two respondent groups (75.1% male versus 24.9% female for SLPs [n = 3711, and 75.4% male versus 24.6% female for educators [n = 6271). Figure 1 shows graphically the percentage of clutterers reported by both

Figure 1. Percentage

0

SLPS

l

EDUCATORS

of individuals matching the description whom SLPs and educators were acquainted by grade (age).

of cluttering

with

PERCEPTIONS

OF CLUTTERING

137

groups as a function of grade (age). Speech-language pathologists were acquainted with many more preschool and other (adult) clutterers than were educators. Also, there was an uneven decline from grades 1 to 12 in the number of clutterers known by SLPs. In contrast, educators reported few acquaintances prior to or beyond the regular school grades. The number of clutterers known generally increased to a peak at the seventh grade, then decreased through the junior high and high school years. Educational placement. Both groups of respondents were asked to indicate, generally, the type of educational placement that clutterers received at their place of work, and then to answer whether or not they agreed with that placement. The results for these questions are displayed in Table 2. From 40 to 50% of the clutterers reported by SLPs were typically from regular classrooms, and 25% were involved in learning disabilities programs. The remainder were variously placed in mentally impaired classes, behavior-disordered classes, or in other settings. Uniformly, slightly more than 60% of the SLPs agreed with this placement, about 5% disagreed, but slightly more than 30% had no opinion regarding the appropriateness of clutterers’ educational placement. Educators were less uniform in their responses. The greatest frequency of SE and LD teachers reported clutterers typically to be in learning disabled programs (34.0% and 68.9%, respectively). Regular teachers, Table 2. Typical Educational

Placement of Children Meeting the Description of Clutterers and Agreement with that Placement Reported by SLPs and Educators (percent of total reported)

13X

K. 0. ST. LOUIS and A. R. HINZMAN

perhaps not surprisingly, reported only 19.5% in the learning disabilities settings, but 58.5% in regular classrooms. Special education teachers were the only group reporting a substantial number (25.5%) of clutterers in educable mentally impaired classes. Regular teachers generally agreed with the educational placement of these individuals (65.6%), but were less sure than SE teachers (74.3%) or LD specialists (82.1%). More educators than SLPs disagreed with the typical education placement of clutterers where they worked (11.1% versus 5.0%. respectively), but substantially fewer were undecided (13.6% versus 31.8%, respectively).

Knowledge of Cluttering Preferred label. The same description of cluttering was provided for all persons surveyed (see above). Respondents were asked to indicate their preferred term for the type of individual described. Most SLPs (89.7%) checked only one label (mean 1.16; range 1 to 4). As seen in Table 3, the most common label checked was “clutterer” (by 79.3% of all SLPs). The next highest category was “stutterer” (10.4%) followed by “all others” (7.6%) and “learning disabled” (6.2%). Each of the other labels was preferred by less than 5% of the SLPs. There were few differences between public school and other SLPs’ preferences. Table 3 demonstrates a substantial difference between SLPs and educators. The combined group of teachers typically scored more than one label (X = 1.71). “Clutterer” was preferred by a majority of teachers (51.8%), but this was 27.5% less than the comparable percentage of SLPs. “Learning disabled” was preferred by 44.6% of all educators and “hyperactive” by 21.7%. “Stutterer” was chosen by 14.5%, “minimal brain Table 3. Preferred

Labels for Individuals Meeting the Description of Cluttering Reported by SLPs and Educators (percent of respondents in each group) SLPS

Preferred

Label(s)

Clutterer Stutterer Learning disabled Minimal brain dysfunction Developmental apraxia Behavior disordered Hyperactive Mentally handicapped (impaired) All others

Educators

Public Schools

Other

Total

SE

LD

REG

Total

82.1 12.0 6.8 4.3

78.6 3.6 7.1 3.6

79.3 10.4 6.2 4.1

58.3 22.2 38.9 12.5

70.0 5.0 55.0 15.0

5.9 14.7 38.2 11.8

51.8 14.5 44.6 13.3

4.3 1.7 0.0 0.0

0.0 0.0 3.6 0.0

3.5 1.4 0.7 0.0

5.6 1.4 25.0 19.4

5.0 5.0 18.3 3.3

2.9 8.8 20.6 5.9

4.8 4.2 21.7 10.8

6.0

14.3

7.6

5.6

5.0

5.9

5.4

PERCEPTIONS

OF CLUTTERING

139

dysfunction” by 13.3%, and “mentally handicapped (impaired)” by 10.8%. The other categories were checked by less than 6% of the teachers. Responses by the three subgroups of educators reflected several interesting differences. Both SE and LD teachers were 10 to 12 times more likely than REG teachers to prefer the term “clutterer.” Learning disabled specialists preferred “stutterer” only one-third or one-fifth as frequently as REG and SE teachers, respectively. Regular teachers scored “behavior disorded” more frequently than either of the other groups. Predictably, SE teachers preferred “mentally handicapped (impaired)” more, and “learning disabled” less, than did LD specialists. Speech-language pathologists were provided Symptoms of cluttering. a list of 29 symptoms reported to be characteristic of clutterers or stutterers. They were asked to indicate which symptoms they believed to be essential symptoms of cluttering and which they thought may be present, but not necessarily essential. The number of essential symptoms checked ranged from 1 to 23, with a mean of 8.8 (median = 8). The reported number of optional or associated characteristics had the same range, but a mean of 6.71 (median = 6). All symptoms scored are shown in Table 4 for both essential and optional categories and are rank-ordered from highest to lowest. Each symptom is followed by the percentage of respondents scoring that item. Dotted lines are placed below the median number of essential and optional symptoms. In this way, it can be seen that “fast speech rate,” “run-on sentences, ” “disorganized thinking,” “irregular speech rate,” “unawareness of the problem,” “word repetitions,” “sound/syllable repetitions,” and “phrase repetitions” were the “average” perceived essential characteristics. “Misarticulations,” “neurological impairment,” “family history of cluttering,” “language delay,” “motor coordination problems,” and “academic achievement difficulties” were the “average” perceived optional symptoms. Symptoms commonly listed as essential or optional easily could have been the same; however, it was apparent that they were not. The Spearman rank-order correlation coefficient (Siegel, 1956) between the two groups of symptoms is 0.02, which indicates that those considered essential were not at all likely to be considered optional, and conversely. Etiology of cluttering. Table 5 presents the average results for SLPs who were requested to indicate their views of the “most likely cause” of cluttering. Nearly half of all SLPs suspected the cause of cluttering to be either definitely physiologic (41.5%) or an organic predisposition to cluttering affected by experience (46.3%). Speech-language pathologists in the “other” category (including hospital, clinic, and university settings) were more sure than “public school” SLPs that the cause of cluttering

140

K. 0.

Table 4. Symptoms Optional

of Cluttering

Identified

Essential

LOUIS

by SLPs

and A. R. HINZMAN

as Either

Essential

or

Optional

Symptom* Fast speech rate Run-on sentences Disorganized thinking Irregular speech rate Unawareness of the problem Word repetitions Sound/syllable repetitions Phrase repetitions Inability to get to the point Reduced attention span Revisions Academic achievement difficulties Misarticulations Poor syntax Circumlocutions Interjection overuse Motor coordination problems Language delay Learning disabilities Struggle during speech Neuro!ogical impairment Tension during speech Prolongations Handwriting difficulties Family history of cluttering Monotone speech All others Social maladjustment Secondary behaviors Poor music abilities

ST.

%

----.

88.96 62.99 59.74 59.74 57.80 47.40 44.81 41.56 _--_40.91 38.96 33.77 26.62 25.97 25.32 25.32 24.68 21.43 20.13 20.13 19.50 16.89 12.99 11.69 11.04 9.10 7.80 7.80 7.14 3.25 1.30

Symptom*

%

Misarticulations Neurological impairment Family history of cluttering Language delay Motor coordination problems Academic achievement

40.00 35.71 33.57 30.71 29.29 29 29 __I__

-di&!lties______ Social maladjustment Phrase repetitions Struggle during speech Learning disabilities Inability to get to the point Poor syntax Word repetitions Reduced attention span Sound/syllable repetitions Prolongations Run-on sentences Handwriting difficulties Disorganized thinking Tension during speech Irregular speech rate Unawareness of the problem Circumlocutions Revisions Monotone speech Poor music abilities Secondary behaviors Interjection overuse Fast speech rate All others

27.14 27.14 27.14 27.14 27.14 27.14 26.43 23.57 21.43 20.71 20.71 20.00 20.00 18.57 17.86 17.14 16.43 16.43 15.71 15.00 15.00 13.57 6.43 3.57

* Symptoms are rank-ordered from most to least frequent, and are followed by the percentage subjects scoring each symptom. Dotted lines are placed below the median number of essential and optional symptoms.

of

was definitely organic (63.3% versus 35.9%, respectively). For the remainder of the etiologies, SLPs suspected “psychologically based” (19.1%), no opinion (17.0%), learned (14.3%), and “all others” (7.5%) in decreasing frequency. Training Respondents were asked to indicate whether or not they were adequately trained to work with or teach clutterers. For SPLs, the question was posed separately for child and adult clutterers. Table 6 summarizes the results

PERCEPTIONS OF CLUTTERING

141

Likely Cause(s) of Cluttering Reported by SLPs (percent of respondents in each group)

Table 5. Most

SLPS

Definite physiological (organic) differences Organic predisposition affected by experience Learned Psychologically based No opinion All others

Table 6. Adequacy

of Training

in Cluttering

Public Schools

Other

Total

35.9

63.3

41.5

50.4

33.3

46.3

17.1 23.1 18.8 6.8

3.3 3.3 10.0 10.0

14.3 19.1 17.0 7.5

Reported

SLPS

Child clutterers Yes No Adult clutterers Yes No All clutterers Yes No

for responses

by SLPs and Educators Educators

Public Schools

Other

Total

SE

LD

34.1 65.9

72.4 27.6

41.3 58.7

-

25.7 74.3

83.3 16.7

37.8 62.2

-

30.1 69.9

78.0 22.0

39.6 60.4

to these questions.

45.7 54.3

REG

Total

-

-

-

-

-

-

62.3 37.7

35.2 64.7

49.7 50.3

Overall, most of the SLPs (60.4%) felt

142

K. 0. ST. LOUIS and A. R. HINZMAN Table 7. Sources of Training in Cluttering by SLPs Who Felt Trained in Cluttering (percent of total listed)

Adequately

SLPS

Source Articles (publications) College coursework Clinical practice Other professionals in speech pathology Own research Other * The Table

number

of respondents

6 as those

on the SLP

adequately

do

trained

not

Public School (n = 41)*

Other (n = 23)*

Total (n = 64)*

24.6 25.4 22.8 17.5

25.3 12.0 29.3 16.0

24.9 20.1 25.4 16.3

6.1 3.5

13.3 4.0

9.0 3.7

convert

to the

due to inconsistencies

exact

percentages

in responses

listed

in

to questions

questionnaire.

Table 8. Reasons for Inadequate Training in Cluttering by SLPs Who Felt Znadequutely Trained (percent of total listed) SLPS

Reason Unsure what cluttering is Insufficient academic training in cluttering Lack of information published No therapeutic experience with clutterers Other * The Table on

number

6 as those

of respondents inadequately

do not

trained

Public School (n = 85)*

Other (n = 7)*

Total (n = 92)*

11.7 34.0

5.9 29.4

11.2 33.6

21.3 29.4

35.3 17.7

22.4 28.5

3.6

11.8

4.2

convert

to the

due to inconsistencies

exact

percentages

in responses

listed

in

to questions

the SLP questionnaire.

apeutic experience were the most frequent reasons cited by school clinicians, followed by lack of published information. In contrast, of the seven SLPs in other settings who answered this question, the main reason for perceived inadequacy was lack of published information. Half (49.7%) of the educators felt adequately trained to teach clutterers; half (50.3%) did not. However, by specialty, differences were evident. Regular teachers felt inadequately trained by a 64.7% to 35.3% margin, and SE teachers by a 54.3% to 45.7% margin. Learning disabled specialists, on the other hand, felt adequately trained to teach clutterers by a 62.3% to 37.7% margin.

PERCEPTIONS OF CLUTTERING

143

Sixty percent of the educators indicated that they had enough cluttering children in their caseloads to justify some form of instruction to teach them to better deal with such children. The results were quite similar for the three groups here analyzed: SE = 64.6%, LD = 57.6%, and REG = 53.1%. Of those respondents who expressed the need for further instruction in cluttering, 65.3% suggested a workshop, 13.3% recommended a class covering cluttering, 6.1% suggested a demonstration, and 15.3% made other suggestions.

Remediation Speech-language pathologist respondents were requested to provide information on the type of therapy techniques that they provided to individuals matching the description of cluttering. Seventy-two percent of the SLP respondents listed individuals for whom they were involved in providing therapy. These respondents reported treatment techniques for a mean of 1.81 children (1.79 children public school SLPs and 1.94 clients for other SLPs). The overall mean number of types of therapy listed was 2.49 (2.34 and 3.24 for SLPs in public school and other settings, respectively). Table 9 summarizes the percentage of SLPs reporting various types of therapy (for the first child listed). Rate, articulation, and language therapy were listed about equally by 60 to 65% of the respondents. Stuttering therapy was reported much less frequently, by 34.5% of the SLPs, with a lower percentage for hospital/clinic/university professionals (23.5%) than public school clinicians (36.5%). Voice and aural rehabilitation techniques were infrequently reported, but 17.7% and 41.2%, respectively, of the public school and other SLPs reported other techniques. Nineteen “other” techniques included: three fluency shaping techniques (speech awareness, relaxation, and breath control); four language-related

Table 9. Therapy Techniques for Clutterers Conducted by SLPs (percent total respondents for first child listed) SLPS Type of Therapy

Public Schools (II = 96)

Other (n = 17)

Total (n = 113)

Rate Stuttering Articulation Language Voice Aural rehabilitation Other

56.3 36.5 61.5 63.5 2.1 6.3

88.2 23.5 64.7 70.6 0.0 0.0

61.1 34.5 62.0 64.6 1.8 5.3

17.7

41.2

21.2

144

K. 0. ST. LOUIS

and A. R. HINZMAN

areas (vocabulary, syntax, pragmatics, and listening); and six perceptualcognitive skills (attending, auditory and visual discrimination, auditory memory, sequencing, “chunking,” and “cognitive behavior modification”). Also, rhythm, suprasegmentals, auditory training, written language, confidence building, and counseling were listed.

DISCUSSION The results of this survey indicate that cluttering is a category that warrants further attention and study. An average of three to four individuals matching the description of cluttering were reported by SLPs and educators. Clutterers were generally distributed by age or grade as expected. As seen in Figure 1, clutterers reported by SLPs showed the typical decline in frequency from first grade through high school years, but responses from educators showed clutterers to peak during junior high school years. Speech-language pathologists knew more clutterers in preschool and adult categories than did educators. A number of interesting comments pertained to respondents’ awareness of the problem. Many, such as the following SLP, described individuals they knew who matched the description: “One clutterer had fast and irregular rate, poor syntax, and not getting to the point. He was defiant about slowing rate, and viewed slight degrees of a slower rate as unacceptable. He couldn’t talk deliberately in phrases. His normal speech was a constant string of thoughts in endless succession at a rate which required close attention to understand him.”

Another SLP wrote the following description: “I know two male clutterers. Both are obnoxious and overbearing, but neither are aware of it. One is very intelligent and his oral and written language is good. He dominates conversations, always has several points to make, is working on Ph.D. in communication, and has worked in broadcasting. The other is a school administrator and is unorganized and not liked.”

A regular teacher gave this personal description: “I am a clutterer. I had a speech problem in school, but no one would help. I was labeled shy and backward because I didn’t talk in school unless I had to. I am still called shy because it’s hard to talk in social settings. I’m afraid I’ll confuse my words. I have tried to slow down and think, but I often lapse into cluttered speech when tired or excited. I often have a hard time understanding what people are saying. I ask them to repeat often, and English seems like a foreign language at times. I still prefer disarray, but have practiced being organized.

PERCEPTIONS OF CLUTTERING

145

One SLP who specialized in treating stutterers commented that he did not know, in any meaningful way, what cluttering is and had not seen a clutterer in 15 years of practice. An LD teacher reported never having seen a clutterer in 94 years of teaching. That opinion was not common, however. A public school SLP wrote, “I had a child in therapy for 2 years and could not pinpoint the problem until I read your definition.” A SE teacher said many of her children “fit the definition perfectly.” The most common educational placements for clutterers were reported to be either regular or learning disabilities classrooms, and most respondents agreed with those placements. Speech-language pathologists and REG teachers reported more clutterers in regular classrooms; SE and LD teachers reported more in learning disabilities settings. Few clutterers were in educable mentally impaired classes, but most who had such placements were reported, not surprisingly, by SE teachers. The small number of clutterers in such classes and, by inference, the apparent unlikelihood of mentally impaired clutterers suggest that cluttering need not be the predominant fluency disorder in mentally impaired groups, an issue reviewed recently by Cooper (1986). One SE teacher remarked that there is a “need to address regular teachers’ view that they [clutterers] are retarded. They aren’t.” Relative to their perceived adequacy of training in cluttering, respondent groups differed (Table 6). Public school SLPs felt the least adequately trained, followed by REG teachers, SE teachers, LD teachers, and other SLPs. Considering the fact that cluttering is often neglected in training programs, it was not particularly surprising that 70% of public school practitioners were unsatisfied with their training. Nor was it surprising that SLPs who were most likely to teach or do research in fluency disorders were the most satisfied with their training. Following are some comments related to training by SLPs. “I feel inadequate. I had diagnosis training, but no therapy training in college. Help!” “ I feel cluttering has been ignored in coursework.” “There is a great lack in my training regarding stuttering and cluttering therapy techniques. ” “I am ill-informed on cluttering.” “I don’t know enough about cluttering. ” “I looked but found no useful information [on cluttering].” Educators also commented on their lack of training. An LD teacher wrote that, “[Cluttering] must be new. I haven’t heard of this.” Another commented, “In [my] university class, we called the disorder linguistic nonfluency and [it] was considered a pragmatic language problem.” Several SE and REG teachers asked for information on cluttering. In light of the perceived inadequacies of SLPs in training to deal with cluttering (with public school respondents outnumbering the others by more than four to one), the results relating to knowledge of cluttering symptomatology and etiology are quite interesting. Speech-language pathologists in both groups had very similar preferences for essential and optional symptoms (hence, the data were combined in Table 4), and these

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symptoms were quite similar to common cluttering symptoms in the literature (Table 1). This suggests that SLPs were better acquainted with cluttering than they may have believed.’ It is particularly noteworthy that there is no overlap in the first seven most frequently chosen symptoms in the essential and optional categories. Almost certainly, there would have been overlap if respondents had known nothing of the concept of essential versus optional symptoms. Also, it is striking that fluency symptoms were consistently the most frequent and only speech characteristics considered pathognomonic of cluttering (i.e., rapid and irregular rate and repetitions [of sounds and syllables, words, or phrases]). Misarticulations and language delay were believed by SLPs to be common but optional symptoms in cluttering. The remainder of the “average” number of essential and optional symptoms (above the dotted lines in Table 4) are among those most commonly mentioned by authorities such as Weiss (1964) and Luchsinger and Arnold (1965). The same can be said of most SLPs’ views of etiology, which suggests a significant “organic flavor” (Weiss, 1964; Dalton and Hardcastle, 1977) in the causation of cluttering. Some evidence of a lack of accurate knowledge of the cluttering literature by the SLP respondents is suggested by the fact that there were typically more essential than optional symptoms checked. In addition, sound/syllable repetitions, ranked seventh in the essential column, and struggle during speech, ranked ninth in the optional column, are more likely symptoms of stuttering than cluttering (St. Louis et al.. 1985). Furthermore, monotone speech and poor music abilities, symptoms mentioned by Weiss (1964) and others, were ranked low in both categories. Results for therapy with clutterers (Table 9) are not encouraging. It is clear that most clinicians (about 65%) are aware that clutterers should not be treated as stutterers. Beyond that, however, there is little consensus except that most prefer therapy for rate, articulation, or language, and many use other techniques. The comments relating to the effectiveness of therapy reflected, for the most part, a dismal outlook. Sample comments were: “I have no success with cluttering; they have problems monitoring speech change. ” “For 2; years, this clutterer has not improved. ” “Carryover is very limited (in therapy, speech improves but not outside).” “ Rate is the biggest problem and hard to remediate.” “Working with him is frustrating but interesting.” One SLP was very positive,” I have had great treatment success treating it as related to rate, rhythm, auditory feedback, and oral musculature control.” Two additional questions can be addressed from the results of this sur-

’ It is possible that our ircsmption of cluttering had a strong equalizing influence on the responses of public school and other SLPs. The reason a common description was given is that there is no widely accepted definition of cluttering (Daly, 1986; St. Louis et al.. 1985). and that we needed to have the same definition for SLPs and educators.

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vey. The lirst is, “Are clutterers learning disabled?” The second is, “Should cluttering be differentiated from stuttering?” Relative to the question of the co-occurrence of cluttering and learning disabilities, the answer is a qualified “yes.” The frequency of responses associating the two conditions seems more than coincidental. Numerous respondents identified “learning-disabled” labeling and educational placement for clutterers as well as cluttering symptoms and etiologies similar to those suspected for learning-disabled individuals. Also, the apparent familiarity of LD teachers with cluttering, whether or not they preferred that label, suggests overlap between the two conditions. It appears, therefore, that many, though probably not all, clutterers have learning disabilities (Tiger et al., 1980). By inference, then, it is reasonable to hypothesize that a joint effort by SLP and LD specialists would be a fruitful avenue for clinical research into the treatment of cluttering. Should cluttering be differentiated from stuttering? The data reported here clearly indicate that SLPs do not view cluttering the same as stuttering. Whereas the clutterers reported are distributed by a 3: 1 male to female sex ratio, similar to that observed in stutterers (Hull et al., 1976; Bloodstein, 1981), it is there that the similarity appears to stop. The lowest category of respondents (3.6%) preferring the label “stutterer” for the individual described as a clutterer was the “other SLP” category, consisting heavily of teachers and researchers in stuttering. This suggests that even those professionals with the most experience in this area differentiate between cluttering and stuttering. Moreover, only 12% of the public school SLPs and from 5 to 22% of the educator groups preferred the label “stuttering” for this group. Classical stuttering symptoms, with the exception of sound/syllable repetitions, were not frequently chosen by SLPs as essential symptoms of cluttering (that is, struggle or tension during speech, prolongations, and secondary behaviors were all ranked in the bottom third of the 30 symptoms listed). Finally, in spite of the fact that SLPs believed cluttering to be primarily afluency problem with rate and repetition abnormalities, only one-third of them reportedly utilized stuttering therapy techniques in remedial attempts. Some SLPs commented on the cluttering-stuttering differentiation as follows. “Stuttering and cluttering are two distinct disorders which may overlap in some people. Causes of cluttering are as varied as causes of stuttering.” “ Clutterers are baffling. [We] often see stuttering behaviors and ‘stutterer’ is often the applied label.” “[We] rarely see a pure clutterer. [We] see a few stutter-clutterers.” “I worked with one ‘classic clutterer’ years ago: many articulation, language, learning, coordination problems. He had a fast rate and was unaware of it. A couple of stutterers also were similar, but their breaks were a function of speed and not stressful awareness as often seen in stutterers.” “ Stutterers and clutterers respond quite differently to most speaking situations.”

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CONCLUSION In general, the results of this survey on cluttering indicate that “cluttering” is a viable label that is a distinct from “stuttering.” Most SLPs and educators are required to remediate or teach a few clutterers, although many feel inadequately trained to do so. Speech-language pathologists appear to be reasonably familiar with published accounts of cluttering symptoms and etiology, but their remedial attempts appear to be less systematic and effective than would be desirable. Finally, many clutterers appear to have learning disabilities.

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