Treating Patients with Stuttering and Cluttering Disorders in your Speech-Language Pathology Practice

Stutter is a fairly common fluency disorder, and one that you’ve probably encountered at some point in your life even before your interest in the field of speech-language pathology. We all know that when someone stutters they usually repeat certain sounds or words. Sometimes they might draw out a sound beyond what is normal.

Though much less common than stuttering, you may eventually come across the often-misdiagnosed condition known as cluttering. Often mistaken for stuttering, cluttering is a distinct disorder that first shows up during the preschool years.

Symptoms and Risk Factors for Stuttering

The most common examples of stuttering disfluencies include:

• Sound/syllable repetition (ex: Wh-Wh-Wh- When will you get here?)
• Monosyllabic whole word repetition (ex: Why-Why-Why was she late?)
• Prolongation of sound (ex: IIIIIIIII forgot my homework.)
• Blocks when no sound comes out (ex: I________________I_______________don’t know.)

The most common risk factors for all these various forms of stuttering are the same:

• Age: 75% of those who stutter started during the preschool years
• Sex: Males are twice as likely to have a stuttering disorder
• Genetics: Stutter often runs in families
• Co-Occuring Disorders: Those who already show language delay, learning disorders, and speech-sound disorders are at greater risk
• Environment: Those raised in an environment with someone who stutters may “pick up” stuttering

Symptoms and Conditions the Co-Occur with Cluttering

People who clutter often speak with rapid, “machine-gun” like speech. Other common sign of cluttering include:

• Pausing at the wrong times
• Repeating phrases or words
• Leaving some words unfinished (“welc” instead of “welcome”)
• Collapsing words, saying “elant” instead of “elephant”
• Omitting words
• Rapid or irregular rate
• Excessive interjections/filler words (um, uh)
• Speech can sound slurred, usually corrected with slowing speech

When treating a patient with cluttering you’ll want to watch out for signs of co-ocurring conditions. The more common ones include:

• ADHD/ADD
• Learning Disability
• Speech Motor Discoordination
• Auditory Processing Disorders
• Asperger’s Syndrome or Autism Spectrum Disorder
• Apraxia
• Sound-Specific Articulation Disorders
• Language Formation Difficulties
• Thought Organization Difficulties

Part of what makes cluttering difficult to diagnose is that people who clutter do sometimes also struggle with stuttering.

Recognizing the Differences Between Stuttering and Cluttering

Here are some differences to watch for between the two:

• Stuttering: A person dealing stuttering knows what they want to say but struggle with executing speech. Cluttering: A person with a cluttering disorder start off knowing what they want to say but get derailed in the process.

• Stuttering: A person dealing with stuttering knows there is an issue.
  Cluttering: A person dealing with cluttering is much less likely to recognize the problem.

• Stuttering: Demonstrates a slower rate of speech, usually as a result of trying to compensate for stuttering.
  Cluttering: A slower rate of speech is central to the issue and often not intentional.

• Stuttering: Disfluencies tend to be repetitions, prolongations, or blocks.
  Cluttering: Disfluencies tend to be interjections, phrase repetitions, and revisions.

• Stuttering: Demonstrates no slurring of speech unless there is a separate, co-morbid issue.
  Cluttering: May have slurred speech.

• Stuttering: Prosody (rhythm and melody) of speech isn’t usually affected
  Cluttering: Prosody is often affected.

Considerations When Treating Stuttering  Disorders

Your goal as an SLP is not to eliminate stuttering completely. Instead, your role is to help decrease the impact or severity of stuttering.

Stuttering is highly individualized and it may take some experimenting for you to find the best treatment plan for your patient.

Some key things to remember in the process include:

• Age Appropriateness: Explore treatments directed at the specific age group you’re working with; the treatment list that fit your preschool patient will likely not fit your high school patient.
• Early Intervention: In the past, researchers believed stuttering shouldn’t be treated during the preschool years. Now, however, early intervention is the standard.
• Starting Place: Start with the area of stuttering that seems to be impacting the individual’s quality of life the most.
• Treatment Styles: Include indirect treatment as well as direct. Indirect treatment is when you educate the families of the stuttering individual on how they can adjust communication at home to support the individual. Direct treatment is the actual therapy that takes place during sessions.
• Social Issues: Help the individual decrease their own negative reactions to stuttering, as well as giving them some tools to respond to bullying. Roth and Beal offer related resources here.

With a bit of hard work, you can help your patient improve not only their fluency issues but also their over-all quality of life.

Treatment for Cluttering Disorders

Your patient may arrive frustrated after months or years of working with another therapist to treat his “stuttering problem”. Or they may have been referred to you when a co-worker or friend suggested they might have a speech problem.

A person who clutters often doesn’t realize they have a problem until others point it out.

“Why do you speak so fast?” a friend or family member might ask. “Do you know that it makes you stutter?” The person in question is usually surprised to learn that someone is observing an issue since they are themselves unaware of it in most cases.

Statistics student Joseph Dewey had no idea anything was wrong until his university years when an instructor in the speech department asked him to listen to a recording of his own speech. “I was shocked. I was shaken,” he writes. “I had never realized my speech was different and now I had proof, shoved in my face.”

Working with someone who clutters requires you to think outside the box a bit and pull from various areas of speech and developmental therapy.

In his book Stuttering and Cluttering Dr. David Ward, Director of the Clinical Language Sciences Speech Research Laboratory at The University of Reading, emphasizes that “cluttering is a multifaceted disorder and there is no single method of intervention.”

Because of the complex aspects involved with cluttering (and at times co-occurring disorders), therapy needs to be highly individualized. Aspects of therapy will likely follow a general pattern, though:

• Evaluation: You’ll need to take a comprehensive case history and look at family history or speech problems, linguistic milestones, onset, behavior at school/work, motor skills, and previous treatment. In the online version of his book, Dr. Ward offers a cluttering checklist that can help you clarify where the individual falls on the cluttering spectrum.
• Explanation: It seems obvious, but sometimes practitioners miss the opportunity to give patients a clear explanation of the disorder and what the path ahead might look like. Taking time to help the patient come to an understanding of the problem can help influence their compliance and attitude towards therapy.
• Monitoring and Self-Awareness: Patients that see video of themselves speaking or hear a recording often develop a new understanding of their issues. Like Dewey, many express surprise when they hear the rushes of speech or dropped syllables. Some, however, won’t immediately recognize the problems and you’ll need a few video or audio sessions for things to click.
• Modification: This is where “the real therapy” starts. You’ll work on things like slowing the rate of speech, over-articulation, work on pausing and phrasing, shortening sentences, relaxation, and continued awareness of their speech.
• Maintenance: Unlike stutterers, those who clutter don’t seem to need as much ongoing therapy once they’ve hit their speaking goals. Not all clinicians agree on maintenance plans, though, because sometimes individuals see themselves as “fixed” but have actually lapsed into older patterns without realizing it. You may consider inviting individuals to come in for occasional “tune ups”, just to make sure things are still on track.

Because awareness is such a huge part of the treatment for cluttering it’s important not to skip ahead to the modification phase until you feel convinced that the individual recognizes their overall problem. With early intervention, children who clutter often make significant strides. Adults, however, tend to need more time and some severe cases of cluttering, especially when co-morbid conditions are involved, may not show significant progress.

Don’t Wait to Start Therapy

Cluttering or stuttering in a three year old is often cute. In the teen years it may generate some teasing. Out in the work world, however, where first impressions, speedy interchanges, and clear communication are expected it can be detrimental.

Unfortunately parents and educators sometimes accept cluttering and stuttering as a natural variation in abilities…some kids hit a baseball with ease and others trip over their own feet, so why wouldn’t the same be true for speaking?

This mindset, however, may be setting these children up for unnecessary work-world challenges in adulthood.

Dewey shares that until his college-years diagnosis, he “felt alone in life”. Even though he hadn’t been formally diagnosed, he intuitively sensed that something was wrong, and that he wasn’t able to express himself with the same ease as others around him.

As Dewey worked on his speech and learned more about others with the same condition he writes that he “began to connect with people in ways that I had never thought possible.”