I received an evaluation folder for a child with articulation concerns.  When I was testing him it was immediately apparent that there was a lot of language stuff going on.  Did I bring the right tests with me?  You know the answer to that!  Back to the office.

It also looked like he was stuttering quite a bit during the language sampling.  And did I mention he was bilingual?  These are the evaluations where we earn all of those letters and credentials behind our names.

Here’s where it gets interesting though.  His disfluencies were really specific and funky and I was left with a sinking feeling in my stomach that I hadn’t gotten it right.  On the other hand, I had already sunk so much time into this evaluation and had to get it out the door.

Ultimately, I had to decide whether it was Cluttering or Stuttering and that is what this essay is designed to help you do.  I want to share the results, math, process and exact text that I used to write this one up.  This is definitely a post to bookmark.  Because while Cluttering doesn’t show up that frequently, the right diagnosis means the right goals.  And the right text to write the report means a few hours saved back to our life.

Capturing Disfluency and Articulation with the Language Sample

The first thing I want to point out is that we will WASTE OUR TIME if we test each communication area separately.  When you have a child that has multiple areas, I suggest doing the language sample first.  This is your:

1) Informal Language Assessment

2) Informal Intelligibility Rating (count the Xs)

3) Fluency Data (record with your phone and type at the same time)

Here’s a small snapshot of what it looks like:

Story “TELL” English   Once there was a boy saw, see a frog And I see a boy I see a boy was (abandoned) The frog was gone I see I see I see holding a boy holding, putting a hat (boot) I see a boy calling “frog”…

Story “RE-TELL” English (after an example)   The the the boy and the and the dog was put the frog in the jar When the boy was sleeping the frog went went out to the jar The next day the the the boy was was waking up and the frog was gone…

Story “Retell” – Spanish   Un niño está allí en la casa Y y un perro está allí está allí está allí “how how how do you say watching in Spanish?” [Mirando] Está mirando la rana…

Capturing Disfluency

To find out if cluttering or stuttering are at the root of disfluency begins with standard fluency testing.  This should feel pretty comfortable for most of you but I wanted to provide some of the text that we use for perception of  fluency and the formulas. 

FLUENCY:

Fluency of speech was below normal limits.  CHILD’s fluency was assessed by analyzing language samples that were collected during a story telling activity and during conversation.  Student’s family and teachers also reported on CHILD’s fluency as well as CHILD being interviewed about his perception of his own fluency.

Perceptual rating of Fluency:

CHILD’s two teachers and his mother reported that he is disfluent during his academic day and at home.

Self-perception

CHILD appeared confused when asked if he repeated himself and didn’t seem to know what the examiner was referring to.  He shared that everyone at home and in school understands him.

Describing the data

Check out this next paragraph.  Stuttering is a small portion of what we do.  How often do others see it or understand it?  We include this next paragraph so that the data make sense.

Disfluencies are classified into two categories: instances of stuttering and instances of more typical speech disfluencies. Any of the following aspects may be indicative of stuttering: a score of 3% or greater of stuttering instances, 10% or greater of total disfluencies, or 72% or greater of stuttering instances per total disfluencies. It is important to note that these percentages are for monolingual English speakers but are pretty comparable in other languages. However, judgments of stuttering cannot be made on frequency alone. Analysis of the disfluency types is as follows:

Fluency Tables

In the next few tables you will see what I think is really robust testing.  To be honest, because I used the language sample it wasn’t that hard to do.  What we want is 2-3 interactions totaling over 300 words.  Adding each language sample up you can see that I am well over that.  You:

1. Count the number of words in your language sample
2. Code your language sample
3. Separate Stuttering-like from Non-Stuttering-like behaviors
4. Divide the instances from the sample total
5. Insert the percentage

Conversational Sample:

A 140-word sample was analyzed from a dialogue with the clinician.

Instances of Stuttering	Number of Occurrences	% of Sample
Single Syllable Repetition   (e.g. “tea,tea,teacher”)	0	0
Whole Word Repetition   (e.g. “I was-was there.”)	9	6.4%
Audible Sound Prolongation   (e.g. “Mmmmore please.”)	0	0
Total stuttering instances:	9	6.4%
Non-stuttering disfluencies
Phrase Repetitions   (e.g. “I was- I was there.”)	6	4.2%
Interjections   (e.g. “I will um, be late.”)	0	0
Revisions   (e.g. “He was, They were driving.”)	0	0
Total Non-stuttering   instances:	6	4.2%
Total disfluencies:	15	10.7%

 The percentages observed during Student’s interaction with the clinician are indicative of an individual with a fluency disorder.

English Story- RE-telling Exercise:

A 259 word sample was analyzed from a dialogue with the clinician.

Instances of Stuttering	Number of Occurrences	% of Sample
Single Syllable Repetition   (e.g. “tea,tea,teacher”)	0	0
Whole Word Repetition   (e.g. “I was-was there.”)	17	6.5%
Audible Sound Prolongation   (e.g. “Mmmmore please.”)	0	0
Inaudible Sound   Prolongation   (e.g. “(M—) More please.”)	0	0
Total stuttering instances:	17	6.5%
Non-stuttering disfluencies	Number of Occurrences	% of Sample
Phrase Repetitions   (e.g. “I was- I was there.”)	11	4.2%
Interjections   (e.g. “I will um, be late.”)	0	0
Revisions   (e.g. “He was, They were driving.”)	1	.4%
Total Non-stuttering   instances:	12	4.6%
Total disfluencies:	29	11.1%

Spanish Story–telling Exercise:

A 304-word sample was analyzed from a dialogue with the clinician.

Instances of Stuttering	Number of Occurrences	% of Sample
Single Syllable Repetition   (e.g. “tea,tea,teacher”)	0	0
Whole Word Repetition   (e.g. “I was-was there.”)	27	8.8
Audible Sound Prolongation   (e.g. “Mmmmore please.”)	0	0
Inaudible Sound   Prolongation   (e.g. “(M—) More please.”)	0	0
Total stuttering instances:	27	8.8
Non-stuttering disfluencies	Number of Occurrences	% of Sample
Phrase Repetitions   (e.g. “I was- I was there.”)	9	2.9
Interjections   (e.g. “I will um, be late.”)	0	0
Revisions   (e.g. “He was, They were driving.”)	1	.3%
Total Non-stuttering   instances:	10	3.2%
Total disfluencies:	37	12.1%

Summarize your Findings

With robust data you can immediately see the difference between:

1. Stuttering-like from Non-Stuttering-like behaviors
2. Cluttering or Stuttering

We write up that summary really quickly and move on to choose the goals

Fluency Summary:

CHILD can be described as being moderately disfluent and exhibiting behaviors that are typical of cluttering (see below).  His phrases typically have multiple word and phrase repetitions.  Occasionally he would revise his statements.  Student used non-descriptive language (this, that, there, here, it).  This might indicate that he is resorting to easier, non-descriptive language and is avoiding vocabulary that he perceives that he has difficulty with.

Cluttering or Stuttering ?

Stuttering is rare.  Cluttering is even less heard of.  I will go as far as to say that it was only covered briefly or I don’t remember that well from grad school.   If you find that your child’s sentences typically have multiple word and phrase repetitions then you might be dealing with Cluttering. We include the following description to help us choose between the two and education everyone that works with the student. 

Stuttering vs. Cluttering

Stuttering:

1. Disfluencies on units smaller than the word level, such as sound prolongations and sound/syllable repetitions
2. Effort/physiologic tension associated with disfluent moments
3. Typically person has awareness of disfluencies and a sense of loss of control
4. Difficulty making fluent transitions from one sound or syllable to the next.

 Cluttering:

1. Disfluencies typically involve units larger than the sound or syllable level, such as word and phrase repetitions, incomplete phrases, and revisions.
2. Little apparent physiologic tension
3. Often demonstrate poor self-monitoring skills and decreased awareness of speech errors
4. Difficulty making smooth transitions from one syntactic unit to another or one lexical choice to the next or sequencing his/her message cohesively and coherently
5. Do not typically produce prolongations or tense pauses
6. Fast and/or spurty speaking rate
7. Linguistic encoding difficulties leading to poor cohesion and coherence of connected speech
8. Reduced speech intelligibility due to articulation errors secondary to fast rate

Differential diagnostics with other disorders

Cluttering usually co-exists with other disorders such as stuttering, articulation disorders, attention-deficit disorders/hyperactivity disorders and learning disabilities.

The available literature as a whole suggests that an essential difference between cluttering and stuttering lies on the speaker’s level of preparedness for saying intended utterances. Stutterers know what they intend to say but experience interference at the motoric level in their attempts to produce various words, whereas clutterers do not necessarily know all of what they want to say (or how to say it) but continue talking anyway. Part-word repetitions, prolongations  and blocks are typically produced by stutterers, whereas excessive but normal disfluencies often characterize the speech of clutterers. The latter include interjections, incomplete phrases/words, and revisions.

Specific Learning Difficulties have been reported to co-exist with cluttering, especially difficulties in oral expression, reading, writing, handwriting and music; however, corroborating data for these observations are anecdotal.

Summary and Goals

By this point you have a solid sense for what should be focused on in therapy.  Summarize it and write up some goals.  For examples of fluency goals in Spanish and English you can check out our Speech Therapy Goal Bank.   Please keep in mind that stuttering is multifactorial (Kristin Chmela 2012, Smith & Kelly 1997).

o There are the motor impairments (Repetitions of sounds, syllables, and words; Prolongations of sounds, Blocks of airflow)

o The link between the motor impairments and the potential negative consequences of stuttering is due to the speaker’s reactions. This includes:  Affective: Feelings & attitudes, Behavioral: Avoidance, tension, struggle, Cognitive: Thoughts, self-evaluation (from Yaruss)

As a result, we need to address the motor impairment and the Affective, Behavior and Cognitive (ABC’s) aspects that support Student’s negative reactions to stuttering and, as a result, his feelings about his own communication abilities.  Here is a sample of two goals related to behavioral aspects of fluency :

SUGGESTED GOALS:

Will independently use fluency strategies to produce smooth and intelligible speech at the sentence level with 90% accuracy.

Utilizarán de forma independiente estrategias de fluidez para producir un discurso suave e inteligible en el nivel de oración con una precisión del 90%.

Will name and describe stuttering modification techniques (cancellation, pull-out, preparatory set) with 70% accuracy.

Nombrará y describirá las técnicas de modificación del tartamudeo (cancelación, extracción, conjunto preparatorio) con el 70% de precisión.

Excellent Resources to Identify Cluttering or Stuttering:

Cluttering | Stuttering Foundation

Distinguishing Cluttering from Stuttering – Leader Live

Fluency Assessment: Tasks, Tips and Tools

As speech-language pathologists, we perform fluency assessments far less frequently than we do assessments of language or articulation. In this presentation, I’ll share some of the tasks I include in my fluency assessment, tips for analysis and goal settings, and a cool tool I created to speed up your analysis.

Reference:

Yaruss, J. S. (1997). Clinical measurement of stuttering behaviors. Contemporary Issues in Communication Science and Disorders, 24(Spring), 27-38.