cluttering./ kunnampallil gejo
TRANSCRIPT
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CLUTTERING
KUNNAMPALLIL GEJO JOHN, MASLP
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Introduction
Skills in the timing and integration of speech andlanguage functions are basic to the fluent outputof oral communication
A great deal has been written about the fluencydisorder of stuttering. The fluency disorder ofcluttering however, has received only peripheralfocus.
In America and British literature, relatively littleattention has been paid to it, beyond descriptionof typically hurried and often unintelligiblespeech pattern produced by this group ofspeakers
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Froeschels, Freund, Luchsinger and Weiss have not onlyoutlined the disorder in detail but less fortunately,contrasted the cluttering and the stuttering in termsof personality and behavior in a way which takes noaccount of the wide Varity and complexity of factorsinvolved in stuttering and reduced all clutterers to astereotype
The definition if cluttering adopted by the fluencydisorder division of the American speech language
hearing association is: Cluttering is a fluency disorder characterized by rapid
and/or irregular speaking rate, excessive disfluencies,and often other symptoms such as language orphonological errors and attention deficits
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In the predawn darkness in which scientifically orientedspeech pathologists is now stumble, perhaps theconfusion (between stuttering and cluttering) is to beexpected though not to be tolerated indefinitely {VanRiper 1970}
St.Louis and Hinzman (1986), presented a sampling ofreported symptoms from the literature on the syndromeof cluttering
A syndrome is a constellation of symptoms which co-occur but which may or may not be manifested in agiven individual
It was immediately clear from even a cursory review thatcluttering is not clear identifiable entity
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Weiss 1964, Luchsinger and Arnold 1065,Wow 1970, Van Riper 1971, Dalton and
Hardcastle 1977, Daly 1986 did a analysis,they found at least 65 different symptomsor descriptions of this disorder.
Rapid sequences rates was reported by 5out of 6 authors and there by reflected thehighest level of agreement.
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4 out of 5 authors reported articulatorysymptoms
St. Louis Hinzman and Hull (1985),reported that lack of research in the areaof cluttering seriously hampered by the
lack of an adequate definition Clinical management of cluttering has
suffered from the same as well
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At west Virginia University, recognized the needfor research designed to defined cluttering inempirical behavioral terms (St. Louis et al 1985)
Their logic in attempting to develop such abehavioral definition was as follows First they assumed, as do most of the authors (e.g.
Weiss 1964; Van Riper 1971, 1982), that clutteringexists, either in isolation or in conjunction withstuttering.
Second, they assumed that cluttering is primarily aspeech and language disorder and such, it mostappropriately dealt with by speech languagepathologist
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The speculative literature available indicates thatclutterers are most likely to be confused with stutterersand other speech and language problems such asmisarticulations, are quite common in the disorder
Again, however, they recognized that otherprofessionals, such as learning disability or remedialspecialists, were likely to have considered researchinterest in clutterers as well, because impairment inareas such as attention, reading, or writing may result in
greater problems for clutterer than speech or languagedifficulties
Third, since they assumed the most appropriatebehavioral dimensions to be used in a definition shouldmainly consist of speech language characteristic
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A working Definition of Cluttering
NSHS (national Speech and HearingSurvey) working definition of cluttering is
as follows Cluttering is a sp & lang disorder and its
chief characteristicsAbnormal fluency which is not stuttering Rapid and irregular speech rate
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Van Riper (1954) descried cluttering ascharacterized by slurred and omitted
syllables, by improper phrasing andpauses, due to excessive speed
Luchsinger (1970) says that repetition ofsyllables and word as the most importantfeature and remarks on an imperfection infinding words amongst these speaker and
a striking monotomy of speech melody.
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Weiss (1964) outline the speechsymptoms in greater detail. Excessive
speed (tachylalia) has always beenconsidered the maintains
Froeschels (1946) that they only speakrelatively too quick for their ability to findwords and formulate sentences
Drawling and interjection are seen asresulting from this difficulty
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The unintelligibility of the speech of manyclutters is caused by Ommissions of sounds, syllables and whole words
Displacement of sounds
Inversions of the order of sounds
Anticipation of sounds
Post position of sounds
Repetition of initial sounds
Telescoping of several syllable of a word many
Many of features seem to be an exaggeration ofcoarticulation and elision of normal speech
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All these articulatory deviations improvewhen speed is reduced and, indeed, many
disappear altogether Weiss also noted the clutterers jerky
respiration and short respiratory span and
the monotony of the speech-melodypattern (presumably referring tointonation and pitch range)
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Wohl (1970) described the prominentfeature and cluttering as festinating (i.e.
becoming faster and faster as speechproceeds) which leads to elisionarticulation disorder of an erratic and
unstructured type, omission andsubsequent spelling and writing errors.
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Wessis heading lack of rhythm and musicalability and yet to admits to knowing cluttererswho, despite dysrhythmic speech have anexcellent sense of rhythm in other respect
Although poor pitch and poor sense of melodyare often found with clutteringsome clutterershave a good sense of musical elements.
Poor concentration and short attention span areclaimed as the basic symptomatic elements ofcluttering, but the evidence cites for this is slight
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Liebmann (1900,1930) proposed 2 groups, one beingmotor in form and having lack of attention to kinestheticand somato-motor performance as its basis, while the
second was said to be receptive in nature, with thedisorders of audition, and attention predominating
Froesches (1946) was one of the earliest to relatecluttering to a disturbance of thinking. He described thesequence of preparatory steps before a phrase or
sentence is uttered. There is a psychic urge or attitudetoward expressive a thought
This is followed by a planning of the sequences andchoice of words to be expressed
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SYMPTOMS
REPETITION EXCESSIVE SPEED DRAWING & INTERJENCTION VOWEL STOP ARTICULATION AND MOTOR
DIASABILITY RESPIRATION MONOTONY LACK OF RHYTHEM AND
MUSICAL ABILITY CONCENTRATION AND
ATTENTION POORLY INTEGRATED
THOUGHT PROCESS
INNER LANGUAGE READING DISORDER WRITING DISORDER GRAMMATICAL DIFFICULTIES UNAWARENESS OF
SYMPTOMS RESTLESSNESS AND
HYPERACTIVITY DELAYED SPEECHAND
LANGUAGE DEVELOPMENT ELECTROENCEPHLOGRAPHIC
FINDINGS HEREDITY PSYCHOLOGY OF CLUTTERER
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REPETITION
Repetition of one syllable words or thefirst syllable of polysyllabic words is an
important symptoms of cluttering In normal or clutterers speech is a sign
that the speaker is uncertain of the wordor phrase to follow
The speech motor are idling while thebusiness of speaking continues withoutbeing filed by words
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Repetition is common especially in the childrenbetween the ages 2-5yrs
During these yrs substance of what the child
whishes to communicate is too complex forexpression in his limited vocabulary
The rate of speed of clutters repetition is theexact syllabic speed of his non repetitive (or
free-following) speech This is also true of the repetition of normals
under stress and is an important factor indifferential diagnosis
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The clutters characteristic unawareness of hisspeech deviation accounts for his continuing to
make syllabic noise (repetition of syllables)instead of stopping the speech process while hedecides on the words follow
Children who are unaware of the fact they
repeat will have same but when they are awareand tries to correct it, the rate becomes slower(Froeschels 1975)
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EXCESSIVE SPEED
Excessive speed was considered the mostsignificant symptom of cluttering, and someinvestigators even considered it the basicelement
However normals speech too speed but withperfect order and articulation
And there are some clutters who speak at thenormal rate
Therefore excessive speed must be ruled out asthe one of the primary indicator of cluttering
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In cluttering, on the other hand when there isexcessive speed it is accomplished by poorformulation and delivery, and is therefore anindicator that the speech mechanism cannotcope with its function of communication
A clutterer will sometimes begin polysyllabicwords at an acceptable rate, but his speedincreases as he progress, resulting in a
telescoping of the word
He apparently has an global impression of aword and hence pronounces it in a single spurt.
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He spells as he pronounces, omitting thesame letters.
This is also occurs in some speechdisorders that are a result of brain lesions(e.g. postencephalitic speech).
Seeman called it interverbal acceleration Luchsinger added the concept of
intraverbal acceleration in cluttering
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Gerstmann and Schilder and Seeman attemptedto localize the anatomical site of this speed drive
and concluded that it is in the striopallidarsystem, especially in encephalities, but there areno available histological findings at this time forclutterers.
The hereditary factor in typically cluttering,however it is not anticipated that structuralchanges in the brain will found to causeexcessive speed.
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DRAWING & INTERJENCTION
The clutterers inability to find the words he need insufficient time to maintain a smooth flow of speechcauses him to prolong vowels, most often at the ends ofwords
When they prolong a vowel at beginning of a word, theyare in the process of searching for the next word beforecompleting verbalization of the word they have begun
This is consistent with the clutterers over acceleration ofspeech and disharmony of reading and verbalization
rates when reading aloud He reads much faster than he verbalizes The clutterers complains that they often seemed to be a
head of themselves
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The frantic quest for the next word also causesclutters to interject single vowels as ah,consonant such as mm, articulatorycombinations often than ahem, and words suchas well and you know more often than normalspeakers
Clutterers some times prolongs the interjections(ah or mm) and remains unaware of theirpresence in his speech although his listeners findthem utterly tire some
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VOWEL STOP Vowel stop consist of a stop before pronunciation of the
initial vowel with the mouth open as if frightened.
Liebmann considers it a decisive symptom in thedifferential diagnosis.
It is especially common at the beginning of a newphrase or sentence
Blocking on the initial vowel exists among stammers butit is not a common occurrence
The essential difference between the stammerersspasmodic blocking and the clutterers simple vowel stopis the fact that the clutterer is that unaware of hesitationand consequently does not develop a fearful attitudetoward the sound
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ARTICULATION AND MOTORDIASABILITY
Every investigator has noted the clutterers poorarticulation
Alber Liebmann specifies these deviations as:
Omission of sounds, syllables and whole words
(ellipsis)
Displacement of sounds (heterotopy)
Inversion of the order of sounds (metathesis)
Anticipation of sounds
Post position of sounds
Repetition of initial sounds and
Telescoping of several syllables of a word
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Liebmann says that these deviationsimproves when speed is reduced, where
as articulation is normal speech does notchange as a function of speed
Seeman & Novak tested the articulatory
ability of 52 clutterers and 52 individualswhose speech was normal. Age genderand intelligence were held consonant
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The test consisted of quick repetition of syllablespah and tah.
The performance of the youngest subjects (ages
7-11) in each group did not differ Clutterers overage 11 performed better than
normals over age 11 The investigator concluded that poor motor skill
is not the cause of poor articulation in cluttering,a conclusion which seems a but toocomprehension for the simple experimentaldesign
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RESPIRATION
Arnold says that respiratory dysrhythmia is thecause for the clutterers jerky and explosive
speech Froeschels reported that before we speak we
automatically inhale an amount of air sufficientfor the length of sentences or phrase that we
intend to pronounce Clutterers attempt only short phrases and hence
must inhale more frequently
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MONOTONY
Many therapists have recommended on themonotony and uniformity of the clutterersspeech melody pattern
Scripture was the original investigator whoreported on the caquse of this monotony, first inepileptics and then in stammerers
He concluded that monotony of speech melodyis related primarily to lack of musical sense
Arnold, Pearson, roman-Goldziener concurred
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Analysis of the clutterers speech melody andexamination of their speech curves by Arnold and byLuchsinger and Dubois indicated that in fact they doesnot lack variability in pitch.
There is a short melodic pattern confined to a range ofonly several notes of the scale
This pattern repeated continually
The clutterers speech, therefore, is not characterized by
monotony in the strict sense of the word (one tone), butby continual repetition of short melodic pattern
It is stereotype but not monotony in the sense ofunchanging pitch
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Since lack of musicality does not account for lackof melodic variation in all clutterers
D.A.Weiss investigated the possibility ofpsychological basis for this monotony
He found that clutterers thoughts progressivelyproceed by clusters of 2-3 words at a time
where as thought of normals speakersapparently proceed by whole phrases orsentences
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LACK OF RHYTHEM AND MUSICALABILITY
Lack of rhythm in speech is one of themost readily noticable symptoms ofcluttering
The majority of the clutterers havedifficulty both in perciving andreproducing rhythmic
However, there are clutterer with excellentsense of rhythm and dysrhythymic speech
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G.Arnold believes that dysrhythmia is onlya part of what he calls the clutterers
congenital amusia Poor pitch and poor sense of melody are
often found with cluttering
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CONCENTRATIONM AND
ATTENTION SPAN Poor attention and concentration are the
basic symptomatic elements of cluttering
(Hermann, Gutzmann)Attention span appears to be a function of
concentration and together they constitute
the basis of other symptoms of clutteringsuch as reading and writing disordersbecause of this their memory is severely
limited
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Attention span in verbal performance canbe measure by ascertaining how many of
a series of meaningless syllables a patientis able to repeat correctly after examinerhas pronounced them
POORLY INTEGRATED THOUGHT
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POORLY INTEGRATED THOUGHTPROCESS
Thinking too quickly
Thinking too slowly
Unorganized thinking
Inner language
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Thinking too quickly
The supposition that a clutterer thinks faster than heis able to speak
Interpreting clutterer who has reached an articulatorydead end because of what appears to be an attemptto speak as quickly as he is thinking, and ask him tostate his thought slowly and clearly find that he is still
unable to proceed with facility
Either he has no clear thought to express, or he hasseveral indefinite and amorphous ideas
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There fore it is not so much an accumulationof thoughts that speeds him on, but vague
and tentative ideas Froschels calls them thought that are unripe
for speech
These germs of thought occur to the
clutterer and he is driven to express theminstantaneously
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Thinking too slowly If thought in preparation for verbal communication is conceived
of as an orderly process of clarifying ideas, then clutterers thinktoo slowly for a normal speed of speech
In addition to the pause in search of concrete thought forexpression there are gaps while the clutterer search for aparticular word.
His limited knowledge of grammar also slow his thinking lack ofaccentuation leaves long words without integration, and thesewords are then misaccented, mispronounced, misspelled, and
often even misunderstood by the clutterer himself The tachylalia rapidity of verbal utterance manifested by many
clutterers worsen the effect of slow preparatory thought, oftenreddening speech grotesque
As a result an intelligent clutterer may appear considerablyunintelligent then he actually is
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Unorganized thinking Poor intergrated and incomplete thought
process, rather than the rate of speed ofthought, is a factor in cluttering.
The clutterers haphazard and tentativethinking in perception for speech reflects his
general approach to all understanding This is the basic characteristic of cluttering
and hence one of the prime target of therapy
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Inner language In normal speech, verbalization does not seem to take place
until the speaker has a clear thought to express, he can inhalethe necessary amount of breath to pronounce the length of the
sentence he intends to speak Thus the normal speaker does not run out of breath, nor is he
left notes with an excess of breath The clutterer speech lacks this inner harmony one of the basic
characteristic of cluttering is a lack of clarity of inner formulationand as a result delivery is hackneyed haphazard, and studded
with moment when the clutterer seems to lose the thread ofthought completely or forget what he said or the next word tobe spoken
Normal speech reflect inner order and cluttering in the minor ofinner disorder
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In performing a highly skilled movement theindividual generally recalls his previousexecution of the same movement, and this is
dependent upon kinesthetic sense There is also a purely motor type of fluctuating
in which movements are performedautomatically, without recall or imagination of
past performance The clutterers speech process however, is rather
automatic performance
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Clutterers seem to need to exert mental effort even toformulate the idea of the sentence they are about toverbalize, where as normals apparently perform thisinner formulation without conscious effort, as a functionof their predominant type of imagery
Even the most intelligent clutterers are apt to remarkspontaneously that they are often surprised bysomething they say, being unaware of havingentertained the thought before saying it speech
performed without the stabilizing effect rendered byprevious imagery of the act can be called abstractaction, as opposed to concrete action in which imageryis involved
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REDING DISORDERS
One of the characteristic symptoms ofcluttering is reading disability
Virtually all clutterers manifest a reading
problem The dyslexia of the clutterer may apper at
all age levels
In young clutterers, poor reading is aresult of having learned to guess at thetext
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Speaking problems in reading and writing may persistthrough and beyond the highest grade of schoolattended
This is closely related to the clutters lack of attentionand result in his ignorance of many words with highfrequency usage scores
The clutterer, as a rule, does not actually read he skips When he reads we may observe him trying to glimpse
the end of the sentence before he has reached themiddle, or looking back at the beginning because he haslost trend of thought
The quality of the usual dyslectics reading the cluttererusually does not fulfill his reading potential
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WRITING DISORDER
The clutterers had writing is a characteristic ofhis generally reduced motor skill, his ratherformless imagination, and his disregard for the
reader Occasionally repetitions of his speech is seen in
writing as well
Klara Roman-Goldzieher discussrs the generalcharacteristic of the clutterers handwritingrepetitiveness, frequent transposition oromissions of letters and frequent revisions
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The clutterer is capable of much betterperformance when he focuses hisattention upon the task
The most complete and lucid discussion ofthis problem, together with the result ofpsychological tests
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GRAMMATICAL DIFFICULTIES
The clutterers spoken grammar is alsonotoriously poor
Throughout his speech there are minor
deviations such as confusion of he andshe and the use of the singular when theplural is indicated
There is often total confusion in thestructure of long sentences
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The clutterer attention span is so short and hisconcentration so weak than he often gives theimpression that his hearing is impaired, or he is
day dreaming, or even that he has a basicdisorder of perception
Clutterer may forget how he started and so thegrammatical structure of his sentence suffer
The rather fuzzy thinking of the clutterer lead toa less than satisfactory structuring of hissentences
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UNAWARENESS OFSYMPTOMS
The typical clutterer is of his speech disorderand may even react with surprise when hisattention is brought to the problem
The clutterers unawareness of his speech
difficulty is a specific case of his speech difficultyis a specific case of his general lack of selfawareness
Speech as in action, the clutterer proceeds with
sudden impulsive spurts, uncontrolled by thesmoothing influence of modicum of selfawareness or an appreciation of the needs ofother
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Libermann suggested delimiting asubgroup of clutterers based on
perceptual difficulties Froeschels suspected sensory aphasia in
some cluttering children
Arnold considers the poor perception asevere aphasia like symptom which hecallsperceptual dysgnosia
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RESTLESSNESS ANDHYPERACTIVITY
The typical clutterer fidgets by day andrestless even while sleeping according toSeeman
Clutterers seems to be alert and interestedin his surroundings, but a short time only,since his focus of interest changescontinually
During interview they are apt to squirm intheir chair, occasionally assuming addpositions, to play with objects on the desk
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There are many cases of proven lesions ofthe basal ganglia with restlessness of sort
The Seeman school assumes thatsubmicroscopical lesion in this area thecause of the clutterers hyperactivity
The clutterers is not aware of hisrestlessness, but if it is brought to hisattention, he will exert effort to control it
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DELAYED SPEECH DEVELOPMENT In many of the clutterers families it was foundthat they begun to speak rather late This has consider to be the constitutional
weakness of there speech disposition
A late start in speaking does not necessarily leadto cluttering There are factors of maturation involve in the
development of cluttering Most of the clutterers start speaking late but they
ultimately develop satisfactory speech There are no indications that minimal and discrete
lesions are involved in cluttering
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ELECTROENCPHALOGRAPHICFINDINGS
In 1951 Luchsinger and Landolt were first toattempt determination of the speech pathologyof clutterers by electroencepholographicexamination
They found abnormalities in almost 100% oftheir cluttering sample
They found that more irregularities in the EGG
recording in clutterers than in stutterers than innormals
The significance of these recordings are stillquestionable
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HEREDITY
It was found that heredity is a basicfactor in cluttering
Reasons Only small 5 of clutterers
Cluttering has not been included in manystatistical analysis
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PSYCHOLOGY OF THE CLUTTERER
Klencke charecterizes clutterers ascarefree, careless, and lacking inpersistence and sense of responsibility
Pleasant temperament Lifes problem very seriously
Alas
Short attention span
Overactive
Change their mind frequently
Child like behavior reactions
Th li f h l
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The personality of the clutterer
Pure stutterers Pure clutterers Stutterer-Clutterer
Timed
Restricted
Regressed
Introspective
Compulsive
Over inhibited
Hesitant
Retarded
Aggressive
Expansive
Extroverted
Impulsive
Uncontrolled
Hasty
Over productive
Mixedpersonalities
containingfeatures of bothprecedingcategories
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Wiss generalized typical differences
between clutterers and stutterersCluttering Stuttering
Awareness of disorder
Speaking under stress
In relaxed position
Calling attention to speech
Speaking after interruption
Short answer
Foreign language
Reading well known text
Absent
Better
Worse
Better
Better
Better
Better
Worse
Present
Worse
Better
Worse
Worse
Worse
Worse
Better
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Reading unknown text
Hand writing
Attitude toward own speech
Psychological attitude
Goal of therapy
Better
Hasty,
repetitionuninhibited
CarelessOutgoing
Directingattentiontospeech
Worse
Contracted, forced,inhibited
FearfulRatherwithdrawn
Directingattentionfrom
details
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ASSESSMENT OF CLUTTERING
Several principals are held to be particularlyhelpful in the assessment of clutterers
They should be assed for entire communicationsystem including language, rate, articulation and
fluency Need to assess the nature of the reaction
between the various component ofcommunication system
Since some clutterers may also exhibitperceptual motor and learning difficultiesassessment should be broadly based to includeneuro psychological testing
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Strategies for assessment
Language sample and formal testingAnalysis of language sample should seek to
answer a number of question regarding aspectsof the clients fluency, language, rate and
articulation There should be notations regarding non verbal
speech behavior
Based on the information from the language
sample, the clinician select assessment toolswhich provided a more structured andstandardized mean of evaluation
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Standardized test serve one or more of thefollowing purposes
To obtain, norm reference measure of the variousaspects of speech and language which appear to be
disorder
To compare and contrast the fluency, articulation,rate and language observed in naturalistic vs. formalsituation
To examine in a more controlled and focused way thebehavior judged to be anomalous based onnaturalistic language sample
S di i i id
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Some diagnostic questions to consider
Selected diagnostic questions will beorganized around the major componentsof speech and language system, eachquery attempts to tap a component from a
slightly different point to extract additionalinsight regarding therapy implication
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Fluency
Rate and rhythm
Articulation
Language
Neuropsychological testing
Self awareness
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Case history and interview
Some important information can beextracted from the case history andinterview with the client and family
Other members of the family have speech andlanguage problem similar to those of theclient
Interaction between client and family
members how is it home, working, schoolAttempt to compensate for the problem
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Dalys checklist for possible cluttering
Rating from 0-3
It consists of 33 questions
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Analysis
Speaking rate in terms of syllables per min
They speak 10-15% above the normal This analysis should be among the
articulation, fluency, rate and melody
Diff ti l di i b t
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Differential diagnosis between
cluttering and stuttering
Cluttering StutteringClient is unaware of dysfluencies Aware
Fluent when concentrate onfluency Less fluent
Spontaneous speech less fluent More fluent
Strangers more fluent Less
Verbalization are less difficult tocontrol
More difficult to control
Hereditary Psychological or functional
Fear of specific sound or situationis not present
Present
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Relaxed situation moreproblem
Less
Prognosis is better never
relaps
Prognosis is better but relaps
Occurs only at childhood At childhood or adult
By taking chloropromazine
drug speech will be better
Becomes worst
EGG deviated pattern EGG normal
M t f l tt i
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Management of cluttering Speech rate modification
DAF Increasing client awareness Video tape play back Audio tape Vibro Tactile feed back Cognitive training Letter reading Accent ration Rhythmic tapping Story creativity
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Journal articles
An examination of various aspects ofauditory processing in clutterers
LAWRENCE F.MOLTAim of the study
The present study examined various aspects
of auditory processing ability, utilizing a briefCAP test battery and auditory event relatedpotentials
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Subjects 3normals and 3 clutterers
Results CAP:
All the 3 control group performed with in normal limits
All the 3 clutterers performed below normal establishedcriteria
AEP:Abnormal AEP morphology was noted for all 3 clutteringsubjects an absence of N1 and P2components andlengthening of P3 latency
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Neurogenic cluttering
Language Auditory comprehension 57/60
Repetition 92/100
Articulation 60% for single 18%for sentences
Fluency
Self monitoring skills
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