Cluttering Assessment and Treatment with Dr. Kathleen Scaler Scott

doctor Kathleen Scalar Scott is a practicing speech language pathologist, board certified specialist in stuttering, cluttering, and fluency, and professor of speech language pathology at Miseracordia University. She has been a practicing clinician for thirty years in hospital, school, and private practice settings. doctor Scalar Scott's research interests are largely encluttering, atypical dysfluency, and child language and literacy disorders.

She has spoken nationally and internationally and authored peer-reviewed articles, book chapters, and books on the topic of fluency, literacy, and pragmatic challenges. She was the first coordinator of the International Cluttering Association and is the recipient of the twenty eighteen D D D Des O Weiss Award for Excellence in the Field of Cluttering and the 2018 Professional of the Year Award from the National Scattering Association.

In twenty twenty, doctor Scalar Scott received the Judge Max and Tilly Rosen Excellence in Teaching Award from Ms. Recordy University. In twenty twenty two, she became a Fellow of the American Speech, Language and Hearing Association. She is co-editor of Cluttering, a handbook on research, intervention, and education, co-author of Managing Cluttering, a comprehensive guidebook of activities, author of Fluency Plus, Managing Fluency Disorders in Individuals with Multiple Diagnoses.

and co-author of the recently released second edition of The Source for Stuttering and Cluttering. She is also co founder and co-host of the podcast Cluttering Conversations, which is a free podcast available on SoundCloud, and I will also link in the description to that. Well, we are really honored to to have you with us today and thank you for taking the time to lend your expertise with all of us.

So let's c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c-c- kinda get into it and I wondered if we could start with just

a general overview. I know that's a tall order. And again, we will be referencing a previous episode that we recorded that will will go over some of the cluttering 101 and then versus now pieces in maybe more detail than we will today because uh the chunk of of our episode we're hoping to really dive into assessment and treatment. But could you give us an overview and and maybe we can get started in in to Talking about cluttering.

So I just wanted to start with that. And then also I guess when we're saying kind of to put us all on the same page, since we're gonna be really diving into assessment and treatment I do like to start with that overview. So thank you, Sarah, of where I'm coming from because for my assessment and treatment I really rely heavily on

the lowest common denominator definition of cluttering, which is the most commonly used, but you'll find that, you know, people use other aspects of things as I do as well. But I feel like it's a great starting point to determine is my client cluttering or not. So just to kind of go over that, that is the definition of cluttering that was put forth by Dr. Ken St. Louis and Dr. Katrine Schulz.

And that was released, I think, in two thousand eleven. So it's been out a while and it was many, many years in the making. The problem before we had that accepted definition was that the definition of cluttering was so broad and there were areas upon which experts agreed and then areas where they disagreed, does this define cluttering?

So what Saint Louis and Schul did was try to say, let can we pair this down to the lowest common denominator, that is the components upon which Experts agree if I think about cluttering, this is a possibility. for everyone who clutters. So not just for certain people who clutters, but all of these are possibilities. Like for example, whereas difficulties with writing or difficulties with language

like a language disorder could be a possibility, but those would be concomitant things and they wouldn't be universal. So these symptoms in the L C D are universal as possibly existing in someone who clutters. So

What the what the definition states is that the mandatory criterion to even think about a diagnosis of cluttering is that the person has to sound fast to

There the person may be speaking faster than average, but they may not be, and maybe sometimes they are and sometimes they're not. That's the e the irregularity and rapid rate. But what happens, and we don't fully understand all the reasons why, is that there are times when the listener thinks to themselves, wow, that person speaks really fast.

Right. And there are footnotes in the definition that are also really important, which is that it does not have to occur all of the time or even a majority of the time. It just has to have some functional impact. And I feel like we've come a really long way in everyone wrapping their head around just because a person who stutters doesn't stutter during your evaluation doesn't mean they're not a stutterer, right?

a person maybe like further assessing to see if they are a clutterer. In order for you to to start to go there with that, you need to have some type of you know, report from them, report from a parent, a teacher, that sometimes this person sounds quick, but it does not have to be all of the time. And you know, I think that that's having some type of an impact upon the person getting their message across. So it's significant, even if it only happens sometime.

So that first part is perceived rapid or irregular rate of speech that does not have to occur all of the time. And if you if your client checks that box, you move forward to say, okay, let me further investigate whether or not this is cluttering. So that's the first part of the L C D. But we know that there are people who speak quickly and there's no breakdown in their message getting across to the listener.

So if someone were considered to be just a fast talker, then we wouldn't move on any further through the definition. But

The first part of the definition is the mandatory criterion. And then there has to be some breakdown in communication. from that rapid or irregular rate of speed. And the breakdown can occur in only has to occur in one of these three areas, but these are the three areas that are in the L C D definition. The first is excessive normal in the definition if you read it it says normal disfluencies, which is what many people know as non stuttering like dysfluencies. So the things that we all use

as we're gathering and organizing our thoughts. Interjections. Phrase repetitions, maybe whole word repetitions without tension, like I I think I need a break now, um, or revisions of thought. So what defines excessive is there's not there's not a set number or criterion for this because it's a perceptual definition, it varies person to person. But speech pathologists know this when they hear it. There are so many non-stuttering disfluencies.

that the client doesn't get their message across as efficiently as they could. Um so to give you an extreme example, I had a client who the when I asked him about something that happened over his weekend. It took him 23 minutes to tell me. And then I summarized it back to him in three minutes. So it's the idea that and that's an extreme example, you know, but it's the idea that when someone is speaking, there are so many revisions and interjections and other things.

that it becomes excessive for them to communicate their message efficiently. So that's the first one, excessive normal disfluencies.

The second is excessive overco articulation, which just means the sounds are blended too much together so that when the person speaks rapidly, it sounds like sounds might be left out. So somebody might say, communication. So all the syllables may not sound like they are there. So that's the excessive over co articulation. And then the third is pauses. Well, it says um

In the actual definition, it talks about the atypical pauses. And what it is is that pauses are in places you do not expect them grammatically. So I'm going to the store to get some chips. you wouldn't expect the pause after the. You would expect I'm going to the store to get some chips.

Um, you only need one for a diagnosis of cluttering. But the first would be the normal dysfluencies, excessive normal dysfluencies, then the excessive over co-articulation, then the atypical causes. So that hopefully that kind of puts us on the same page because we'll delve into how I use that for assessment and treatment, but that's kind of the overview of that definition.

Okay, so we will then dive into how I use this definition for assessment. And many people have heard me say this over and over, but I it's true for me as a clinician. I just feel like this definition was game changer because It's so straightforward. You can kind of just follow it through to say, is my client cluttering? And we'll talk about how to methodically go through it. And just in thinking about this, I was thinking about how years ago Um, I was speaking with someone about cluttering.

And they said to me, you know, it's not really rocket science this cluttering. And I really wasn't offended at all. I don't think it's rocket science. However, one thing that that just always resonates in my mind to think about is

you can do these things and figure these things out. So in that way it's not rocket science. But I also encourage you to just really think carefully through these things and always to be willing to evolve and change because that I feel like makes me a better therapist. And I'm going to talk to you about some of the cases I'm talking about are very recent.

that I just keep evolving. So so that's my little caveat. Just you can do this. You have all the skills to do it. And think through it carefully. And I'll give you some examples.

So first of all, if I'm assessing someone for cluttering, all I'm really doing is following this definition. I'm first saying to myself, okay, the mandatory criterion is rapid or regular rate as perceived by the listener or the speaker can say that themselves, but you know, it's n it a lot of times it's a report from a parent, from a teacher.

Um, with adults most of the time coming in that they're even if they're not realizing it, they're coming in saying other people are reporting this to me that they can't understand me or I'm getting these reactions from listeners.

or a parent saying that or a teacher saying that, I am taking that FA's value, right? So even if they can't give me a sample, they don't necessarily have to prove it to me. You know, I'm going based on their report. And I do that with stuttering too, but My husband's an auto mechanic and I always will tell parents who come to me, it's not like taking your car to the shop where you say it makes the noise and then they tell you, Oh, sorry, I can't hear the noise. Right.

Just because I can't hear it, if you're coming, you're taking the time to come to me and explain it to me. you know, then that's enough for me to say, okay, I'm going to investigate this more because you check the box for rapid or regular rate.

as perceived by others or yourself. So that's the first thing. And then I then just follow the rest of the definition. Like, do I see at least one of A, B, and C? And can I find examples of that? Now for each one, that's where I'm saying it's not rocket scientist, but it is complicated and you need to kind of think it through. And sometimes you don't always find the answer right at the beginning or during one evaluation session. If you're seeing the client ongoing, other things may evolve.

So like if I'm looking at the excessive normal disfluencies, right? Your interjections, your phrase repetitions, your revisions. Then if I see lots of them, it's not as simple as for me to just say, okay, that's it. Checks the box, cluttering, right? We have to think of all the possibilities why this could be happening.

that yes, cluttering is definitely one of them. The person is speaking quickly and the the thought behind cluttering is that you're speaking at a rate that's too fast for your system to handle. So it causes, you know, some breakdowns in communication. It may be causing these excessive normal disfluencies.

But there could be other reasons as well. So we need to rule out the other reasons. And so I always think about what are the possibilities here. So One of the major ones is Does the clutterer or potential clutterer, the client, have a language disorder that is making it really hard for them to organize their discourse? And that's something that if I really am listening to them and I'm saying, boy, I'm having a really, really hard time following them, maybe I'll consider

Once I get through looking through the L C D definition, doing some language testing, I feel like we as SLPs really will have a gut for our clients with language disorders. And it's That's where I think it's a little bit complicated because a lot of the clutterers I've worked with, I've done different language tests and they score within the average range, but they're having a hard time just organizing their discourse.

I don't know that everyone's the same in this, but I my bias is I don't look at that as a disorder. I look at that as an organizational piece. overlaying the language, something that I think is unique to cluttering. And so some things that will help me tease it out is that if I just try to have the client, either I watch for moments where their speech is not as rapid,

Or I even try out having them tell me a story once but then tell me again with putting more natural pauses in it. If it takes care of a lot of those non stutter disfluencies, it might give me more of a hunch that it's related to cluttering because cluttering, the thought is it's a rate based disorder, right? So cluttering is like the only disorder in communication disorders where if you adjust rate things normalize.

Right. So you can adjust your rate in dysarthria, but your clarity of speech won't be you know, completely typical as it would with someone without dysarthria, right? It will get clearer, but it won't normalize. Whereas things do normalize in cluttering, So that's something I always will try out is if I can get them to regulate rate just to try it out, does that?

maybe decrease these non stuttering disfluencies. And maybe that gives me a hunch, hey, it's more related to cluttering than a language disorder. So that's one thing. I mean another thing to keep in mind is if the client speaks multiple languages.

right, are the interjections or repetitions because they're trying to find a word they're not as familiar with, not because they have a word finding problem, but because you know, they're trying to retrieve it from maybe a language that they're not as proficient in or, you know, there's a lot going on when a kid is learning multiple languages. So could that be a reason for the non-stutter disfluencies, something to keep in mind.

And on that note, I know Sarah, you and I talked about last time how it gets a little bit confusing and this is where somewhere where I'm evolving as well. in that we used to kind of say, oh, cluttering commonly goes with stuttering. And a lot of the clients I'm seeing, they have maybe some part word repetitions, some whole word repetitions, but no tension. And if we adjust rate, they often go away. And I know they can go away for stuttering a little bit too if you adjust rate.

And that's what I'm finding with cluttering as well. So when we're looking at, you know, maybe there's excessive whole word repetitions, but there's not tension. Well Maybe that's just something that's part of cluttering. It's not doesn't necessarily mean it's a red flag for stuttering. Um So I kind of want to put that out there for people to think about. The other thing that I can get into more in treatment, but related to these whole word repetitions.

Is that let's say even to play devil's advocate, it's stuttering because it's a stuttering like disfluency. So it's stuttering. I don't know that at the end of the day, if someone mumma. moves very quickly through a part word repetition. Are we gonna bring in a strategy to address that? Because It's gonna be a lot of cognitive load and I don't think it's going to be something that people who clutter are really going to want to deal with. Like it's just not gonna be that functional overall.

Okay. And then the third thing that I do consider when I'm looking at these excessive non-stutter disfluencies is Is this something that a person is using as a strategy to avoid stuttering? And so I do want to make it clear that if someone were to put in excessive ums or uhs or talk around words because they were avoiding stuttering or speed up. because they were avoiding stuttering. If they end up having more cluttering symptoms,

not necessarily these, but some of the other two categories that we talk about, then they probably are a stutterer and a clutterer, right? They can't cause their cluttering to happen by trying to hide their stutter.

And always, you know, especially with kids, but really with anybody, your ha you need to be really careful to have this non-judgmental conversation, like you know, first of all what I'll do is I'll model Stuttering like disfluencies, partward repetitions, prolongations, blocks, and I'll say, I just wanna understand from your perspective, do any of these ever happen to you? Right? Because that's kind of your first

I guess your first line in to really have more of a conversation about stuttering. And I I have found that when I talk to kids in just a very, you know, hey, you're the expert on your speech. different things happen to different people. I'm gonna, you know, show you some different types of speaking and sometimes I'll use the word stuttering or not. I'm not avoiding the word stuttering, but it just depends upon what we're talking about.

you know, there's different types of stuttering and I just wanna see if any of these happen to you. And then you can kind of get a sense from the child. But I can, you know, do the same thing by asking parents as well. I usually do. And I find it's really important to model for them. Like this is what a part word repetition looks like. This is what a prolongation looks like. This is what a

might look like so that it's not there's no misunderstanding. Like this is what I'm asking you about. Do you ever see this happen? So then that kind of opens the door if the client is, you know, maybe avoiding, and then I can ask in a very non-judgmental way, are there any things you've ever done to to get around? moments you have like that when you feel like you're stuck in your speech. You know, sometimes people might change the words or sometimes people might change how they say the sentence.

And just asking in a very nonjudgmental way, um, we can have this discussion that makes would make me say, okay. No, there's probably not a covert stuttering going on here. I mean, it's not the end of the story'cause the client might not feel comfortable enough talking about it at this point. Or or yeah, this might be something that I want to investigate a little bit more. So really just trying to tease out if those excessive non stutter disfluencies

might be covert stuttering and t attempts to conceal stuttering. And one thing that I think makes this even more A parent is I do use the stuttering severity instrument as part of my assessment. Because first of all, I want to see if anything comes up in the area of stuttering. But then also not that you have to use this. You could use any reading passage, right? But they have the reading passages there. And this is where it really can bring to light what could be going on. But there are

numerous possibilities. So I've had two cases recently where when the client was reading passages from the SSI, And we were thinking cluttering during the evaluation. I'm starting to say to myself, Hmm, well, they're kind of tripping over that word. And then I'm thinking, you know, it could be especially with kids, but it can be with adults as well. that I'm thinking, is it a something to do with reading? Is that why they're tripping over that word because they're having a hard time decoding it?

sounding out the word. Um or are they, you know, kind of trying to dance around it because now they can't just talk around the word. It's in front of them. So now they're trying to avoid stuttering. And I think I used to think about those two things. But then I had a recent case. where I'm still trying to tease out um this is a school age child. So is it is it a reading decoding problem? Is it more that They're trying to avoid moments of stuttering or

Are they just anxious about performance in general? And what made me start thinking about this is I had a discussion with the caregiver and they said You know when they do the reading testing in school it it becomes really, you know, my child becomes really anxious with that. So many of you who work in schools may be familiar with the oral reading fluency testing.

Um, where they're just looking to flag children who may need more support in the area of reading. And many of you may know, um, we have publications out through Asha about this. I was on the Asha task force for this years ago on testing oral reading fluency in kids who stutter, right? And that sometimes kids who stutter get flagged as having reading difficulties when in fact

the it's just their stuttering that's slowing them down. They really don't have any trouble decoding. But I bring up this testing because I had a student who did her master's thesis on this testing and she interviewed kids, kids who stuttered, kids who didn't stutter, kids who had communication disorders, kids who didn't have communication disorders. And there was just overwhelming themes of how anxiety provoking it was to have to read as fast as you can aloud.

So now I have a case where we are teasing out this very thing right now. Is it cluttering? Is it avoidance of stuttering or is it just they're so anxious about their performance that it's really kind of throwing them when they're reading? So I think you really have to keep all of those factors in mind when you're trying to tease out where are the non-stuttering like disfluencies coming from.

So we've we've kind of looked at what else could be causing the excessive non stutter dysfluency. Now if we're looking at the overco articulation, the part where um the client is less intelligible in terms of the actual words. You're having a harder time understanding the actual words they're saying. That can be cluttering. But again, what would happen with that is If they were to reduce their rate and emphasize, then their speech would completely normalize and there'd be no articulation errors.

Sometimes just to either prove the point or to rule it out for myself, I might use an articulation test. And then in my report, I'll be able to say, look, there are no articulation errors in this context, but in connected speech, there is difficulty with intelligibility and that's the hallmark of cluttering because they're speaking at this rate that makes them over co-articulate so you don't hear all the sounds and it's less clear.

one thing about that in terms of the overco articulation that I've been thinking a lot about is that you know, what other things could cause trouble? Speech sound disorders, right? An articulation problem. If someone has a severely distorted R, it can make it very difficult

for you to understand them, especially like the vocaligar, right? So that's why you have to separate that out. Even though you can have cluttering and an articulation problem, what is, you know, is there is it really cluttering or is it something else going on. Um so with the overco articulation Yes, it could be cluttering, it could be an articulation disorder, it could be a phonological disorder as well. Things like final consonant deletion. Like if you think about that.

When a clutterer speaks quickly, the their endings may get clipped. And then you may end up saying, oh, is it final consonant deletion? Is it syllable reduction? Right? And of course there are tests to help you try to weed that out. Of course there are kids. who may if you give them the test at the single word level, they don't exhibit that phonological process, but maybe they haven't mastered it in conversation.

So there is that possibility, but I one thing that I've been trying to talk with my students about is to just think logically about potential red flags. So we had a case recently where the student is nine. And they're working on final consonant deletion and weak syllable deletion. And the student is coming to me saying, but every time we do this. in single words or they're fine.

Well, I think it's a little bit of a red flag if we're working with a neurotypical child and they still have final consonant deletion and they're nine. Like that's just not what you typically see, right? So If you if you hear those kinds of things, that might be a flag to you as the SLP to say, eh, I d I don't think that's what it is, right? And to investigate it further, see if adjusting rate

really helps with the overco articulation. The other thing I always like to bring up is the cul-de-sac resonance, which a lot of people say to me, What was that? Because I know it's a long time since grad school or

Some programs you don't even have that a lot of exposure to the craniofacial um part of the curriculum, but where they call it the potato in the mouth. So if there's um some type of blockage going on, um, then maybe that's creating this mumbled or muff muffled or m muffled sounding speech. or mumbled, that is me demonstrating overemphasis, which we will get to later.

But you want to make sure there's nothing structural going on. And we've had a couple of clients in our clinic who have in fact been cluttering, but they also have this structural difference. So you want to make sure that you rule that out. And I guess those are really the things that you might see that might overlap or or you have to try to differentiate. Is it overco articulation due to cluttering or is it some type of a speech sound disorder?

And then the third characteristic is the atypical pausing. So clients are putting pauses in places you don't expect them grammatically. And for me, um That is something that I usually want to get a really good like five minute monologue sample of them talking about things they're interested in, things they're passionate about. And then I would go back and probably just kind of take some pieces of that and see where they're pausing. Um

And are they pausing in places that are unexpected? Now what I will say is in the cases that I have The atypical pausing tends to be not the most prominent feature of cluttering. The other two are the characteristics that I'm seeing. But you can have the atypical pausing. Many clients who clutter don't pause naturally as much as your non cluttering speaker. So once you teach them to put pauses in, all of this jerkiness tends to lessen.

So I think with the atypical pausing, I would just really look at, am I really hearing this jerky kind of sounding speech and then maybe analyzing some sample? of their speech just to see if the atypical pauses are present. If I hear them, even if I haven't analyzed it, maybe now I teach the client just to put some natural pausing in and see if that helps things.

And the only other thing I can think of as far as you may want to rule out with the atypical pausing is In, for example, the oral reading fluency testing, I have had clients who stutter and have just paused.

places you wouldn't expect because they're waiting out the tension before they produce the word. So that may be something to think about as well when you're trying to do like a differential diagnosis. Um In general for all of these things, I can get most of the information from parent report from video samples. Um, like I said, from doing like a monologue sample, I try to get a really good five minute monologue sample and they can switch topics, but just more connected speech.

I try to get a five minute conversation sample, which is really easy when you're talking to a client about all, you know, how their speech affects them and other things with kids, right? But I'm relying mostly on matching the symptoms that I'm seeing or hearing or getting reports of from the client, from caregivers, from teachers, and then what I'm seeing in person or from videos. seeing and hearing and then seeing and hearing in monologue and reading samples that I would do as part of the SSI.

w what might be other components uh of a comprehensive assessment and cluttering?

um of cluttering just because the client might not be aware of the term for it or they may not be aware in every moment they clutter, that doesn't mean that there is no impact. So we want to really, you know, have a good chat with them about understanding how they feel about their speech. And, you know, maybe we're not even using the term cluttering because we're not even sure at this point, but just in general, how do they feel about their speech, about communicating with others?

And then a big thing is we may be working with kids or adolescents who either number one, they may just not really be aware. of what's going on. They but they are aware that other people are asking them to slow down or repeat themselves and they're really frustrated by it. So not just asking them about

how they feel about their speech'cause maybe they say, you know, I feel fine about my speech, but how do you feel about listener reactions? You know, does anyone ever ask you to slow down? Yes. And it's really annoying. Right. So just understanding that there can be a life impact and what is that impact?

And and understanding that it can affect things like their participation in class, just like it can for stuttering. Um, you know, I've we talked about this in the last episode, but I've had clients who say I just keep it short. 'cause no one's gonna understand me. So that's kind of what they're leading with. Or or, you know, I'm I'm not I'm gonna withdraw from the conversation'cause I feel like people won't understand me. So

Um, there's that that we really need to understand. And of course I've said this a thousand times and every time I say it, we do get closer. We are so, so close, but We are working on the OASIC now, which um the overall assessment of the speaker's experience of cluttering and really looking at what's a little bit more unique.

to people who clutter and we've had people who clutter kind of help us be very generous with their feedback in terms of like the unique needs. And a big component of that tool when it comes out will be a listener reaction component. So maybe it doesn't bother you about your speech, but what does does it bother you about people's reactions?

And then also a partner checklist because a lot of times people who clutter, even adults who are full aware that they're cluttering, but they may not be as aware. of everything as maybe a significant partner would be. So we um are going to also have partners fill that out. And we feel like that'll be a great tool too, even for kids and teens where

you know, they're kind of at odds with each other, the caregiver and the the child are teen. So maybe this can be a discussion point. Like let's talk about the differences that you see here. Um, so that's a piece I think we absolutely at bare minimum we need to really understand, even if we're just asking a few questions in an interview.

what impact does this have on your life? And and interviewing caregivers too. Like what impact do you see that this has on your child at this time? And the other one that again we're standing on the shoulders of giants, but I have for years since I feel like it was in twenty eighteen that Trisha Zabrowski first brought this model to my like awareness, the stages of change is model. And then of course people beyond that, like Naomi Rogers and colleagues, have taken it

and branched it out um the stages of change model for people who aren't as aware. It's based on addictions literature and it's more just about that everyone All of us as humans, if we're considering making a change in anything in our lives, we wanna lose weight, we wanna exercise more, we wanna um quit smoking, whatever it is, we go through these

stages of readiness in making that change. And I have found that this has really been like an amazing tool once Trisha and Naomi applied it to stuttering to use with cluttering. especially with cluttering because I feel that I've seen that in my clients. They may they may not be ready for treatment right now. But but they may be ready and they're just a little bit defensive about it. So it's again, this is the part that gets complicated, like teasing out

Where are you? And it used to be thought of as black and white. Like they're aware of cluttering or they're not. They're ready for therapy or they're not. And I just think it's so much more nuance than that. So we're working on, um, my student and I were working on a readiness for change scale as applied to cluttering. And again, just like the Oasic, finding there are unique differences.

in cluttering versus stuttering, but since that's not available for you right now, but stay tuned, we'd love to have people test it out and tell us what they think about it. That's at least understanding from the client, like how aware are they of this. What do they even think about speech therapy? Like what do they know? What have they heard? What are their assumptions about therapy? Right? Oh, they're just gonna make me talk slow or, you know, um And what are the cost benefits to them of

treatment and I feel like just having a little bit of that information in the beginning helps you say, okay, this is where we're going to start working treatment. Or maybe the client is truly not there yet. But it's it's not as simple as they're not aware, they're not ready, end of story. It's much more nuanced. So kind of exploring what they what they think about it, what their awareness is.

what the impact is on them and exploring that with the caregiver helps us understand kind of where to start.

He's been to stuff and they've done this and he told me he doesn't like that and he doesn't like this and this doesn't work for him. So, you know, and it sounded like it just wasn't a good match where he was maybe being treated for articulation when it wasn't articulation and He might not have been able to articulate what was not working, but he knew it wasn't working. And Dad was kind of like, so I gotta be sure that you're gonna be able to that you know how to tease this out because

If if you're a no go, it's the end of the road, you know? Yeah, for sure.

with him, he was kind of like ready, but still a little defensive. So he wasn't completely ready. So when he started, he's like, okay. I yeah, I know why I'm here. I'm working on this, but just to let you know, my parents are older and they do have hearing problems. And nobody else gives me a hard time about But yet he did want to work on it. His action showed he wanted to work on it, but his words were not right. And that's kind of a teen thing.

So just another example of like where they are in terms of readiness. And then just to give you like another end of it, I had a client who, when I evaluated him, He was like when I would ask him to repeat something because I didn't understand, he would repeat it louder and go, now do you hear me? And he truly was not being a jerk. He truly thought, Why can't all these people here? What's wrong with them? So in the beginning, like for him, we needed to work on

some awareness and like understanding of what was going on as well. So, you know, that's where he was in his readiness for change. And I don't know if I can think of a specific example right now of a client, but there are clients out there where maybe they're like, Hey, you know Sometimes people ask me to repeat. Sometimes I clarify what I say. And it's never been a problem for me. So they might check the boxes for cluttering, but they're not really.

feeling like they need anything. So I just kinda wanna give you, since there is no tool out there, some examples of different like Areas of readiness so that you can kind of put that in your mind in doing the assessment to see where they are.

to to gather and if they're if they're feeling a little skeptical or they're feeling l a l little bit of speech therapy fatigue as they might be if they have been in speech therapy for a while. I think that can help send an antenna signal, so to speak, that maybe this person is like really wanting to get to know what's important to me.

So in moving on to treatment, you know, I've used that whole L C D definition to determine is my client cluttering, right? And kind of looked at the whole piece. If there are other components, like there's a language disorder, there's an articulation disorder, of course we're going to work on those in treatment. But I think the things that I'll I'll talk about here are just kind of

how we're working on the other pieces that are specific to cluttering. So in my mind I'm a pretty I'm a pretty low tech I'm a pretty natural pragmatic person where I just feel like, you know, how can I make the things that I'm Teaching my client just the most practical for them and the least cognitive load. And my main rationale for that is that We really don't have any reports. There may be them out there, but of cluttering just being something that resolves.

they happen more frequently. But there's ways that people handle these communication breakdowns if you look around. that just occur naturally, seamlessly, throughout the conversation. You may be doing some of them now, and let's just capitalize on those to help you. So For me, I'm really looking at helping the client navigate like what are some strategies that I can use to manage my speech so I can be the most understood.

to the listener. That's really the first part. So it's kind of looking at those core symptoms of cluttering, right? Over car articulation, the excessive non stuttered disfluencies. And so when I'm thinking about that cluttering is a rate based problem and that things tend to normalize if we're able to regulate rate. But of course we don't want to ask someone just to slow down. Easier said than done. Very annoying. Not really natural. How do we do that? We do know that clutterers pause.

less frequently than non clutterers. So teaching them where to put pauses in natural places is something that's very helpful.

And so that's probably my first line. Just here's a fur here's a way. to regulate your rate in a natural way, right? And we work on it through reading where they don't have to think about what they're saying and they've got punctuation where they can pause. And I'm talking about natural pauses, not anything unnatural. Um, I did have a client once who when I started with her, she said, I'm not doing that pausing. I did that pausing with my last therapist and nope, nope.

Nope. And I said, okay, but just show me how the pause was. And she said, Okay, I am going. And then she gets up and walks the entire walks around the entire table. to the store. I said, I can assure you we are not going to pause like that. So just telling clients, you know, to pause like a count of one or one two in their head, right? And for clutterers, a lot of them say they feel like they're driven by a motor. So they may think they're putting pauses in and they may be.

But we can't perceive them. So I always tell them let's work on perceptible pauses like pauses that I can tell, but that are not weird sounds. They're just natural. So that's one thing to try to help regulate rate. And as I said with the um

atypical pauses where the pauses are in places we don't expect them grammatically. A lot of times that putting the pauses in natural places, it takes care of that. Um A lot of times if the excessive non stuttered disfluencies are just because of the cluttering, then regulating the rate, the pauses take care of that. One thing that I will say it's kind of something that as I mentioned about evolving and changing.

the more just lately I've really been thinking about school age kids. And we can teach pausing and reading. And I think that's actually important. And I think when sometimes people are working on oral reading fluency in schools for clutterers, they need to actually work on pausing, not trying to go faster when they're reading.

But so I think you can work on it in that context. You can work on it in structured conversation like in would you rather? But I'm starting to really feel like It's not that functional for them to spend their time thinking about pausing in conversation or when they're playing with their friends. Some can do it, but some that's just way too much to think about and they don't wanna do it.

So for some, um, I'll talk about how instead I've done more where um the listener and I train parents to do this. is asking them specifically what they did not understand and then they are repeating it not with pauses but with overemphasis. So, like my two big strategies, probably my two big ones are pausing and overemphasis, right? So

With the overemphasis, I just use a number line and say zero is very mushy speech. Ten is like a robot where you can understand all the syllables, but it is unnatural. Five is where we wanna be. And seven is a lot of times where we practice just to kind of exaggerate in practice. So I might talk to my clients about emphasizing at a level seven or a level five that then becomes a good cue. A parent can just hold up like a five to them.

And just really making sure that they're emphasizing. However, once again, it is not about doing it in an unnatural way. So sometimes I have had, you know, students start to work with the client and they're and the client is going, Chrysanthemum and I'm like, no, no, no. You gotta get all the syllables, but it shouldn't sound strange. It should be chrysanthemum. Chrysanthemum. They're all there. Um, but it's not sounding abnormally slow or anything like that or robotics. So

We work on that as just a natural way to repair. And what I found for a lot of these like school age kids where it's just too much. for them to expect them to be thinking about pausing all the time. They don't want to do that. They might just deal with moments of cluttering. So Sarah, you asked me about, you know, what is my favorite flower? And I said chrysanthemum.

And instead of you saying, what? That was really fast. I didn't understand it. Can you say that whole thing again, which drives kids crazy, right? Parents say it. You say to me, Wait, you told me your favorite flower, but I didn't get it. What was the name of that flower? So you ask me a very specific question and then teaching kids that You don't just repeat it, but you need to change something to make it clear. So you're gonna now repeat it, but at a level seven. Chrysanthemum.

And you go, oh yeah, okay, I got it. So it kind of becomes this piece where they're working on using the overemphasis. But then at the same time, listeners. are learning, let's ask for specific clarification. Let's not ask the child to repeat the whole thing. Let's figure out what did you miss? Ask them for specific clarification, and then the child will repair. So it kind of blends now with.

More with the advocacy as well, because then that lends itself to us, you know, having discussions, the child and the parent. How do you want mom to respond if she doesn't understand you? And then they can learn to, you know, say, I just want you to ask me the word you didn't get. Like Please don't ask me to repeat the whole thing again. And then, you know, we can branch that to kids asking their teachers, advocating for themselves with their teachers. I have a client who stutters and clutters.

And he's in high school and so what he did this past year in the beginning of the year is he sent an email to all of his teachers and he explained what stuttering was, what cluttering was, and this is what, you know, please just ask me the words you don't understand. So I feel like advocacy is such a big part of it as well.

And a lot of times I've found that's not anything to do with like a pragmatic language disorder.

Some theories um I have are that they're trying to organize what they're saying. So it's kind of hard for them to look and think about what they're saying. But it could be a multitude of reasons, but like just teaching kids, teaching adults that, you know, you might for the kids I don't know if they'd wish this, but the adults will say to me over and over, like, I wish that person would just tell me they don't understand.

And we talk about how that's the right thing to do. And of course you can advocate for that. Like that can lead into, hey, sometimes I speak quickly. If you don't get me, please ask for clarification, right? But if you haven't done that, a lot of adults just don't know how to react. They don't know what's going on and sometimes

Maybe they ask you once or twice, they still don't get it, and it's awkward for them, so they fake it. I'm not saying that's the right thing to do. I'm just saying that's maybe the reality. So sometimes you know, if you can tune into their facial expressions, a lot of times even though someone doesn't ask you for clarification, you can kind of see on their face like, hey, they're not getting it. So you might be able to make a repair.

or say, hey, are you missing anything right now? And I do feel like all of that again is so much that you can do in therapy. to really get someone to feel comfortable with how can they advocate for themselves. Because as much as I could tell you, just say this, it has to feel right. to you. Like we're working with a student now who really

says that they're not really sure. Like they they're kind of still on the fence with I'm not really sure if I want to say too much about my speech because I'm afraid people will will expect less of me. So there's lots of, you know, layers to it. And I can kind of see, having worked with these cases, that Oh, I'm like, I see this person a year from now. They are gonna be a fierce advocate for themselves, but they're not there yet. And I feel like we have to meet them where they are.

and say, okay, let's talk about what you could say, because they did say to me you know, um, I'm having a little more trouble with people understanding me and I don't know if they're not understanding what I say,'cause they have trouble with organization. Um or how I say it. They also have trouble with overco articulation. And then I just get lost and I I d you know, so we've talked about what do you wanna say to them at the outset before the conversation happens proactively.

And maybe they'll say, you know, with this person I'm not really comfortable. Like I'm just you know, but then we say, okay, who are you comfortable with? And then what do you want to say? And and really just having these back and forth discussions about How do you want to navigate the situation? And so I think like looking for the listener feedback can be part of it. But then how also do they, if they feel like the person's not understanding

But they're not sure what went on. Well, how do they want to navigate saying to the listener, Mm, did you get everything I say? Are you confused? Um, because this client in particular I think said something like Sometimes people will just say, Well, I really didn't get any of it. And again, I do think that that's probably not true, but it's reality sometimes, you know, and then the client says to me, Well, just forget it because

I I think I've kind of lost the thread myself. So I feel like it all opens up, you know, for discussion and role play and helping them navigate. When and how do they wanna use strategies and when and how do they wanna handle um listener reactions.

But he's not gonna explain what cluttering is. He said he'll just say, sometimes I talk fast. If you don't get me, please ask me. And that's kind of how they handle it. So it's a little bit different in I feel like the education just in my experience, a lot of people who clutter just don't wanna get into it, like you said.

All right. So the final piece that I like to touch on is self regulation. It's one thing to be able to pause or overemphasize at you know, in a structured conversation or structured sentences or reading, but it's another thing to think about self-regulation in all contexts. And I tried to teach clients about how to regulate their rate by working on something called fragile rate. So this is just something I've made up. Again, pretty basic, where I talk to clients about how

Everyone has a rate at which they do something proficiently, right? And we can use sports analogies if they're into that. The analogy I always use with myself are burpees because I am not athletic. And I used to take a class at the gym and so in that class they used to do a few burpees in the middle of the class. Now, for me, wow, what I was realizing was, you know, my form was fine in the way I executed it, but my rate was much slower. It was

that I would do one to everyone's two burpees. Now, had I trying to go faster And achieved keep up with everyone else, the whole exercise would have fallen apart. And that's considered, you know, that would be my fragile rate. It's too fast. But the fragile rate is actually the rate at which

you feel like your speech is about to fall apart, the cluttering symptoms are about to occur, but they don't. And so I have clients just read and try to go faster and faster and faster and And I tell them keep reading, but when you feel like your speech is about to fall apart, just stop.

And then we talk about how does it feel? How does it feel in your mouth? Does it feel like anything anywhere else in your body? And it takes a while for them to kind of tune into it. But my point is Teaching them that if you can kind of become aware of, hey, this is what's happening, because for the most part, Yeah, I I would say ninety nine point nine percent of my clutterers are not like, hey, I want to monitor my speech all day and night.

So they just wanna go about their day and they wanna talk and But there may be times that they get talking and they don't realize that they're starting to go really fast and into their fragile rate. Well, if they can tune into what their fragile rate feels like. then they may in the moment, you know, with time and with practice start to feel like, oh boy, like I'm starting to get to my fragile rate. So let me just pull back a little bit. And it doesn't have to stop the flow of conversation.

So like first we talk about what is fragile rate and they identify and what it feels like. Then I try to have them read where they're alternating between fragile rate and a more what we call comfortable rate. So they might be reading at a comfortable rate, but then they speed up and they're talking and they're they're reading and they're reading and they're getting kinda oh, I feel like I'm in fragile rate. Let me pull back.

So that then I can be in a place that's a little more comfortable for me. So it's trying to teach them that you don't have to think about this all the time, but if you catch yourself in a moment and you choose to, then you can kind of pull back without really interrupting the flow of your conversation. And another thing I do with that too, sometimes we'll simulate even mushy speech and then emphasizing it and correcting it.

And moving on. There was an example, at least one earlier in this podcast where I just did that, but you know, it would be like Sarah, I'm not really sure what your recommendation recommendation would be for how we're going to wrap up this podcast. So I can, you know, if I have a moment where I felt like it really wasn't that clear, even if I didn't get the listener feedback, then I clarify it and I move on.

And I will say um one thing that we hadn't touched upon I was just thinking about is I kind of wanna make it clear when we're talking about strategies. Like with your clients who clutter, they You need to help them figure out when they want to use strategies and when they don't. I think it's a little bit more complicated and I think Sarah and I talked about this in the last episode. Or maybe it's not more complicated, it's different complicated.

than in stuttering, where with stuttering it's like, okay, if I'm not using a strategy, I'm just being my authentic self, you as a listener need to wait for me, but you won't miss my message. If a person who clutters decides if I overco articulate, that's on you, and there's this whole complication of where the listener's not gonna ask you to repeat.

Things might get misinterpreted. Um, so I think it's really having a conversation with your client, not to say you should use strategies or people won't understand you, nothing like that. But they have to figure out what's a situation where I think There might be a lot of cluttering and if I'm gonna focus on overemphasis or pausing, I feel like that's just gonna be easier for me or more effective for me because I want my message to get across versus

I'm with these friends and if they miss one word here or one word there, like I don't care. You know, but helping them to understand the potential outcomes of the choices they make. And not judging the outcomes, but making sure they're fully educated about the potential outcomes and they're comfortable with it. And you know, they can change However, they want to react in any situation at any time, but always like exploring you, you know, how that will play out for.

one thing that came to mind that I know we've talked about in the past. on some sort of modality, but is the potential likelihood that there could be a co-occurring diagnosis in addition to cluttering with those that we might be working with?

thinking about impulse control in someone with ADHD, that the whole regulation thing, it just makes it harder or even if someone, if a listener is stopping them to say, wait a second, like in a nice way, you know, wait a second, um, I missed that. What were you saying? Which which um coach was it? you know, who made that call in the game, um, that when you do that, you may need to be prepared to help get them back on track'cause

they have difficulties with working memory. So I think as a general takeaway just thinking about what are some aspects of the disorder. And again, of course everyone's an individual, but what are some traits like working memory is a known difficulty in ADHD, right? So What are some of the pieces that may go with that?

And then how do they interact with the um cluttering and what we're trying to teach and how can we then adjust and adapt to help the clients get the most out of what we're trying to teach them.

In terms of leaving listeners with some areas for further learning or resources that they might want to consider. Why don't I list in the description some future areas of of of learning options, some different resources that you've mentioned in previous podcasts and and that that that if those of you listening want to check out some more things on cluttering, that there'll be some options in that description. Does that sound good?