Cluttering framed: An historical overview

3.1What should the problem be called?

Earliest efforts to describe this disorder involved viewing the varied symptoms associated with this problem as a cohesive cluster and giving that cluster a name. Prior to the twentieth century, descriptions of cluttering symptoms were found in different European medical journals. In keeping with the medical traditions, physicians listed commonly occurring features of cluttering. Some, like Bazin, stopped at the level of description, without assigning a name to the condition (Bazin, 1717, cited in Weiss, 1964).

Other investigators in the early to mid-twentieth century went on to name the group of symptoms, choosing a name that focused on the features that distinguished cluttering from other speech disorders and that were most characteristic. The terms used until “cluttering” became widespread were created as Latin or Greek descriptions. This was in keeping with a tradition in medicine of using Latin or Greek root words to label diseases. Descriptive labels for cluttering found in the literature at this time included: paraphasia praeceps (unintended and overhurried speech) (Liebmann, 1900); tumultus sermonis (jumbled speech) (Liebmann, 1900); agitophasia (Greene, 1916); tachyphemia (rapid speech) (Stinchfield & Robbins, 1931); and barylalia (slow or indistinct speech) (Stinchfield & Robbins, 1931; Stinchfield, 1933; Arnold, 1960).

The first known use of the English term “cluttering” appeared in a paper written by Thomas Sheridan, who published his “A course of lectures on elocution” in 1762. Sheridan described the condition as follows:

To this hasty delivery, which drops some letters and pronounces others too faintly; which runs syllables into each other, and clutters words together; is owing that thick, mumbling, cluttering utterance, of which we have too many examples (Sheridan, 1762, p. 33, italics added).

Cluttering has since become the English name of choice for the condition (St. Louis et al., 2003). The word cluttering may have become the descriptor of choice because it encapsulates the salient and observable speech characteristics that are associated with this diagnosis. In its more common meaning, a cluttered space is one that is scattered or disorganized such that it impedes movement or reduces effectiveness, for example, a room that is cluttered with toys (Merriam-Webster, 2021). Calling this disorder cluttering, evokes and emphasizes such images of disarray.

3.2What kind of problem is cluttering?

Another way cluttering has been approached throughout its history is to locate it in a taxonomic system. It has been considered a fluency disorder, a language disorder, and an articulation disorder, depending upon which symptoms were considered most defining by a particular investigator.

The assignment of cluttering to one diagnostic category upon which all can agree has proven to be difficult. One reason for this difficulty is that cluttering’s most prominent and reliable characteristics cross our traditional category boundaries. People who clutter exhibit symptoms that would, if occurring in isolation, fit into several different clinical categories. For example, some symptoms associated with cluttering involve a disruption of fluency, others are linguistic in nature, and still others involve compromised articulatory precision.

A small number of papers that addressed the classification of cluttering appeared late in the 19th century when physicians and elocutionists in Britain began specializing in speech disorders (Thelwall, 1810, 1812; Hunt, 1861; Clouston, 1891; Wyllie, 1894). John Thelwall wrote about cluttering as early as 1810. He was an elocutionist, an orator, and a politician, and had a private elocution practice in London, England. Thelwall described cluttering on one occasion as a problem of melody (Thelwall, 1812) and another as a type of enunciation difficulty (Thelwall, 1810).

A bit later in the 19th century, in his book on stuttering, James Hunt, a physician practicing in Scotland, treated cluttering as a kind of articulation problem (Hunt, 1861, p. 33). And still later, in 1891, Thomas Clouston, provided a detailed description of cluttering in one of his patients. Clouston was a physician who worked in an institution for the mentally ill in Scotland. When describing different kinds of speech disorders, Clouston divided them into two main types, mental and physical, with cluttering being cast as a type of mental disease (Clouston, 1891, p.33). John Wyllie (1894), a British physician specializing in speech disorders, classified cluttering as a problem of rate, along with another kind of rate problem, bradylalia, a term meaning slowness of speech.

More recent efforts to classify cluttering appeared in the American literature early in the 20th century. These later taxonomies of speech disorders coincided with the emergence in the 1930s of speech correction as a professional field. Sara Stinchfield and Samuel Robbins were two early influencers who served on a “nomenclature” committee within the American Society for the Study of Speech Disorders. They and others were part of a committee formed to create a taxonomic dictionary for identifying, naming, and describing the various disorders of speech that were being referred and treated by speech correctionists (Stinchfield & Robbins, 1931, revised edition, 1939; Duchan, n.d). These early 20th century authors divided speech problems into seven overarching types, all with the same Latinized prefix meaning disorder or defect: dysarthria, dyslalia, dyslogia, dysphasia, dysphemia, dysphonia, or dysrhythmia. They chose to classify cluttering as a type of dyslalia, a defect of articulation. Ten years later, in 1942, Mardel Oglivie published her dissertation on Terminology and Definitions of Speech Defects, in which she identified various ways cluttering had been depicted historically (Ogilvie, 1942). Her own classification preference for cluttering was to describe it as a “defect of speed,” echoing the approach of Wyllie from nearly 50 years earlier.

Beginning in the middle of the 20th century, several researchers and clinicians argued that cluttering should be considered a type of language disorder (e.g., de Hirsch, 1954; Arnold, 1960; Weiss, 1964). In his influential book published in 1964, Weiss proposed that cluttering was a “verbal manifestation of a Central Language Imbalance, which affects all channels of communication” (reading, writing, rhythm, and musicality)” (Weiss, 1964, p.1). This language imbalance was seen as the common underlying deficit that led to a range of problems, including cluttered speech.

Following the publication of Weiss’ book, others began to regard cluttering as primarily a disorder of the language system, citing problems with various aspects of language expression and pragmatics that are often seen among persons who clutter. These language-related symptoms included difficulties with linguistic organization and cohesion, word-finding problems, excessive verbal mazing, overuse of non-specific referents, syntactic formulation problems, and various pragmatic deficits (Myers & Bradley, 1992). Despite these observations, cluttering has not been classified as a language disorder in most recent taxonomies of communication disorders.

In the early and mid-nineteenth century, cluttering was classified by some prominent authors as a type of articulation disorder, then-called dyslalia (c.f., Hunt, 1861; Thelwall, 1812). Since that time, its associated symptoms of poor intelligibility, excessive co-articulation, and reduced articulatory precision have not been considered prominent nor universal enough to classify cluttering as a distinct articulation disorder subgroup.

The most enduring taxonomic home for cluttering has been within the domain of fluency. Along with other characteristics, difficulties with the rate (speed) and rhythm (melody) of speech have been identified as part of the cluttering profile from the earliest writings (Hunt, 1861 cited in Weiss, 1964; Gutzmann, 1893, cited in Weiss, 1964; Scripture, 1923). It appears that fluency came to be assigned a more significant role in cluttering following the publication of works (most in German) by Henry Freund and others (Freund, 1934, cited in Weiss, 1964). Drawing upon these early authors who reported on the co-occurrence of cluttering and stuttering, Weiss and Freund hypothesized that these two problems were not merely co-morbid but were in fact causally connected.

In his 1964 book, Weiss discussed at length his hypothesis that stuttering (which he referred to as stammering) is an “outgrowth of cluttering” (p. 68). Based on the “ample therapeutic experience” (p. 68) of himself and others, Weiss posited that the “great majority” of stuttering cases began with cluttering-like symptoms that evolved over time to become what is recognized as primary stuttering, with or without the presence of concomitant cluttering. Weiss went on to assert in his seminal text that this clutterer to stutterer progression had been “corroborated in many countries” and should be “considered a consensus of the investigators of cluttering” (p. 69). It is notable that his attempts to tie cluttering and stuttering together as a progressive disorder included efforts to incorporate Wendell Johnson’s then-popular semantogenic theory (Johnson, 1958) by proposing that “the majority of stammering cases are the result of the patient’s misdirected attempt to overcome the basic cluttering component “ (p. 76).

No empirical evidence to support Weiss’ claims about this sequence of events was introduced in his text or in subsequent publications. Nevertheless, aspects of several of Weiss’ assertions found a supportive voice in Charles Van Riper who agreed, in principle, with many of Weiss’ claims about cluttering and its relationship to stuttering. (Van Riper did, however, stop short of endorsing the view that stuttering almost always emerges from cluttering.) In his 1963 textbook, Van Riper classified cluttering as a disorder of time or rhythm, which is where he also placed stuttering (Van Riper, 1963). In a subsequent work, he reinforced Weiss’ model by emphasizing cluttering’s multidimensional nature; specifically, he noted that persons who clutter frequently had associated problems with symbolic language, articulation, reading, and writing (Van Riper, 1982). By this time Van Riper and most of his contemporaries had determined that cluttering was primarily a disorder that belonged in the fluency domain, thus cementing its place there.

Like Weiss, Van Riper also believed that cluttering and stuttering were frequently intertwined within individuals. He identified four typical pathways (or tracks) that he believed captured the natural progression of stuttering for most cases. Track II in this system was the “clutterer-to-stutterer” progression (Van Riper, 1982). Persons who fit into this category were characterized as initially displaying the features of cluttering that had been emphasized by Weiss, including disorganized speech and language, poor articulation, poor self-monitoring, poor musicality, and a lack of awareness (Van Riper, 1982). Over time, however, the core behaviors of stuttering-primarily “runaway repetitions” would begin to emerge and these would typically become the most pronounced feature of the person’s nonfluency.

In the decades that have followed, cluttering has continued to be classified as a disorder of fluency by virtually all cluttering researchers as well as by the American Speech-Language and Hearing Association (ASHA 2020) and an ad hoc committee of the International Cluttering Association that was charged with creating an ICA-sponsored definition of cluttering (Myers et al., 2018). Researchers and clinicians who are today’s experts in the field of cluttering tend to identify themselves as fluency specialists. This tendency is manifest not only in how they define cluttering but also by where they publish their work (e.g., The Journal of Fluency Disorders; Perspectives on Fluency and Fluency Disorders), where and with whom they present their ideas and research on cluttering, and where information about cluttering is included in the graduate curriculum, which is almost always within courses on fluency disorders (Tetnowski & Douglass, 2011).

3.3What are cluttering’s defining features?

There have been long-standing efforts by researchers and clinicians to identify specific pathognomonic signs and symptoms that define cluttering. This effort goes beyond describing, naming and classifying the disorder. The idea here is to determine which of the many symptoms associated with cluttering serve to capture its essential nature. These primary symptoms, once identified, tend to be treated as criterial; that is, they become reified as behaviors that must be present for a cluttering diagnosis to be made. Other symptoms that are often associated with cluttering are relegated to being optional or “co-morbid” and therefore are not required for identifying the presence of the disorder or differentiating it from other disorders.

Answers to the question about what features are essential for diagnosis require the use of a criterial framework. The question itself reflects the use of a conceptual frame in that it presupposes a classical view of categorization. The classical view has long been part of the diagnostic procedure associated with the medical model. The aim has been to find and use a set of required symptoms to identify a condition and to distinguish it from other conditions. Cluttering, because it has so many associated characteristics, creates the felt need for reducing symptoms to an essential few. These essential features are not only treated as diagnostic indicators, they also are regarded as areas that need to be assessed and, if found deficient, to be selected as primary targets for intervention. Deso Weiss (1964) identified three such obligatory criteria for diagnosing cluttering: a short attention span and its corollary, poor concentration; a lack of complete awareness of the disorder; and an excessive number of repetitions in speech (Weiss, 1964, p. 61-2). What is interesting about these criterial choices is what is left out. Although Weiss identified a “language imbalance” as the primary factor responsible for the emergence of cluttering, deficits in language do not appear as an obligatory symptom in his definition.

A likely explanation for this omission was that Weiss considered attention span to be part of a general language ability. Problems with attention and self-monitoring, which are at the core of his definition, are separated from language in today’s thinking, and considered as part of executive functioning. When Weiss wrote his text, areas of executive functioning, including attention, were grouped as “higher functioning” abilities, including language (Goldstein et al., n.d). Thus, by including attention span in his definition, he was, in his view, including language.

Other investigators in the 1990s decided to take a different approach to defining the disorder of cluttering. Rather than emphasizing a small set of essential symptoms, these investigators developed checklists of symptoms that covered the broad range of speech and non-speech problems associated with cluttering. A diagnosis of cluttering was made by counting the number of problems a client exhibited: the more items that were checked, the more confident a clinician could be in making a diagnosis of cluttering.

One widely used checklist of this kind was the Predictive Cluttering Inventory, developed by Daly and Burnett in 1996 and revised in 1999 (Daly & Burnett, 1999) and in 2006 (Daly, 2006). The final checklist contains 33 potential symptoms that were placed into four assessment sections: pragmatics, speech-motor functioning (covering problems with articulation, rate, and fluency), language-cognition, and motor coordination and writing. An alternative checklist was developed by Myers and Bakker (2011). Their protocol identified symptoms in eight diagnostic areas: intelligibility, rate regularity, rate rapidity, articulatory precision, typical disfluency, language organization, discourse management, and prosody. The point of these informal checklists was not only to diagnose cluttering, but to highlight its clinical heterogeneity. During this time, cluttering began to be described as a multifactorial disorder with many possible clinical profiles (Myers, 1996; Daly & Burnett, 1996; 1999). This conceptualization of cluttering was useful for intervention planning by helping clinicians create client profiles that made it clear what symptoms needed to be targeted for each individual (e.g., Daly & Burnett, 1996; 1999; Duchan, 2021).

St. Louis and colleagues returned to a more circumscribed approach to defining cluttering in the early 2000s. These investigators introduced what they called their “lowest common denominator” definition of cluttering in 2003 (St. Louis et al., 2003) and refined it in 2011 (St. Louis & Schulte, 2011). While acknowledging the symptom heterogeneity that exists for this disorder, these investigators argued that it is important to reduce the many potential cluttering characteristics into a “minimum number of necessary and sufficient” behaviors that are needed for the problem to be defined or diagnosed.

Like most current investigators, St. Louis and colleagues place cluttering in the fluency domain. In their definition, they identify fast and/or irregular speech rate in conversational speech as its single obligatory symptom (St. Louis & Schulte, 2011, p. 241-242). Notably, they emphasize that it is the listeners’ perception of fast or irregular rate that is important, and this may or may not correlate with objective speaking rate measures. In order for a speaker to be classified as a person who clutters, at least one of three additional criteria must be present: excessive “normal” disfluencies; excessive collapsing or deletion of syllables; and abnormal pauses, syllable stress, or speech rhythm (St. Louis & Schulte, 2011, p. 242). Again, what is notable about this definition is what is not present. Neither cognitive/executive features of the disorder nor the presence of disorganized or atypical language are considered essential for a cluttering diagnosis. The “lowest common denominator” definition has taken hold and appears to be the definition that is currently most widely cited by those attempting to identify diagnose cluttering for clinical and research purposes (Scaler Scott, 2019; St. Louis & Schulte, 2011).

3.4What causes cluttering?

Soon after the taxonomies of speech disorders were delineated in the 1930s in the United States, there came a period in which academics and clinicians called for using diagnoses to signify causality. In 1936, Robert West, for example, argued for moving from naming and classifying disorders to determining their etiology. West wrote as follows: “In the field of speech correction it is very important to make a diagnosis. . ., since to classify disorders of speech on the basis of their speech symptoms is often meaningless. No real diagnosis can be arrived at in this field without arriving at the causes” (West, 1936, p.1).

The older historical literature on cluttering is replete with different causal frameworks. In what may be the very earliest of these writings (published in Latin), the Swiss physician David Bazin wrote eloquently that be believed cluttering occurred as a result of a temporal processing mismatch between thought and speech (Bazin 1717, cited in Weiss, 1964, pg. 2). Others have since proposed the same mismatch of timing between thinking and speech as a cause of cluttering symptoms (Greene, 1916; Scripture, 1923; Froeschels, 1946). In a representative quote describing this causal association, Scripture wrote the following:

“The nervous hurry of his mind makes him (the person who clutters) form and combine the sounds imperfectly. Sounds, syllables, and words are mumbled together (Scripture, 1923, p.187).”

Another causal framework applied to cluttering emerged late in the 19th century. It grew out of research relating areas of the brain to different human abilities and disabilities. A group of neuroscientists, including Paul Broca, Carl Wernicke, and Adolf Kussmaul identified specialized sites in the brain that, when damaged, produced particular predictable speech and language disabilities. Broca’s area of the brain was associated with speech/motor production problems in aphasia, Wernicke’s area was paired with auditory reception problems in aphasia, and Kussmaul identified an area related to word deafness that was associated with reading disabilities.

What followed from these studies was an effort by scientists to identify the functions of different areas of the brain, relate them to one another, and associate them with different behavioral deficits (Lichtheim, 1885; Bastian, 1887). One of the more complex causal frameworks of this sort was that of Godfrey Arnold (1960). Arnold argued for a hereditary cause of cluttering, that, in turn, caused weakness in different areas of the brain. He then assigned symptoms of cluttering to particular cortical locations, grouped the symptoms into two general types, receptive and expressive, and argued that those two types were connected with one another through feedback mechanisms.

Arnold was not the only one to use a causal chain to explain cluttering. Perhaps the best-known chain-like explanation is that of Deso Weiss, whose book on cluttering in 1964 followed closely on the heels of Arnold’s influential article. Weiss also argued for a three-stage causal chain to explain the etiology of cluttering. Like Arnold, he assumed that cluttering was an inherited disorder, citing as evidence both its tendency to run in families and the fact that it affected boys more frequently than girls. The heredity factor in turn caused the second level in his causal chain, the “central language imbalance” previously described. The third link in Weiss’ chain was the emergence of the diverse observable symptoms that resulted from this central imbalance. These symptoms were varied, and included delayed speech, dyslalia (articulation problems), reading and writing disorders, cluttering, disorders of rhythm and musicality, and problems with disorderliness and restlessness.

Frameworks that included specific brain centers in their causal accounts took hold and were expanded upon by later researchers and clinicians who studied cluttering. Brain centers, like Broca’s and Wernicke’s areas, were treated as hubs for processing specific kinds of information. A long-lasting era of “box-and-arrow” processing models emerged from this, growing out of and along with the newly developing field of psycholinguistics. Information processing frameworks were sometimes portrayed as causal chains, with one processing center affecting the next. Problematic connections between the various centers were also seen as causing problems that resulted in observable symptoms or impairments such as those found in cluttering.

The first information processing depictions of cluttering based on psycholinguistic principles, contained a small number of mostly sequential processes or stages involved in dyadic communication. The stages most often included in these models, where breakdowns were presumed to occur, were in the areas of speech reception, language formulation or conceptualization, and speech production (Wepman, 1953; Osgood, 1957; Denes, 1963). Some of these early frameworks also contained an information feedback loop, similar to the feedback loop proposed by Arnold (Arnold, 1960).

These box-and-arrow models are still commonly used by investigators who study the etiology of cluttering, although the processing models that are cited to support current work have become more sophisticated and complex. Myers, for example, has proposed a causal model that is similar in philosophy to the earlier serial “communication chain” models just described. In her model, cluttering symptoms are thought to emerge from “weak links” in a language formulation box. . . and “poor self- monitoring of speech and language output” (Myers, 1996; p. 181).

Per Alm has recently proposed a neurobiological model of cluttering etiology that is also built upon an information-processing framework (Alm, 2011). Alm’s model focuses upon breakdowns that are hypothesized to occur in various inter-related structures in the brain, primarily regions in the anterior cingulate cortex (ACC), the supplemental motor area (SMA), and the basal ganglia circuits. Presumed anomalies in these brain regions are viewed as the first links in a causal chain that trigger a sequence of disrupted message initiation, assembly, and sequencing events. The final outcome of these complex disruptions is the disordered speech production we identify as cluttering.

David Ward (2011) has also based his motor control theory of cluttering etiology, in part, on a psycholinguistic processing model, one proposed by Van der Merwe (Van der Merwe, 2008, cited in Ward, 2011). In Van der Merwe’s model, there are four levels of speech processing whose actions occur largely sequentially: linguistic planning, motor planning, motor programming, and execution. These levels can interact with one another via feedback loops. According to Ward, breakdowns may occur in some or all of these processing levels or feedback loops among persons who clutter. The end result of these breakdowns is presumed to be a loss of speech motor control that results in speech that sounds “motorically disrupted.”

Table 1 summarizes our findings. It includes the four questions addressed here that were extracted from our analysis of the literature. We have divided the table into two temporal periods: 1964 and before and 1965 to the present. We chose 1964 as our dividing point, because this was the year that Deso Weiss published his seminal text on cluttering creating what is seen as a turning point in cluttering history.

4.1How cluttering has been framed in past and present research and practice

The primary purpose of this paper was to review the ways in which cluttering has been framed since its first known mention in the literature in 1717. Overwhelmingly, cluttering has been viewed as an organic (medically based) disorder. Most often, it has been described as arising from imbalances between thinking and speaking or by difficulties sequencing and organizing language and speech at one or more levels of information processing. Over the years, cluttering has been categorized in different ways. Its most popular renderings have been as a type of articulation disorder, a type of language disorder, and a type of fluency disorder. Beginning in the mid 20th century, cluttering was placed within the fluency domain, where it remains. The defining features of cluttering have been described by many writers. Most authors today agree that, although cluttering has a large number of optional features, its primary (and perhaps obligatory) feature is a rapid or irregular speaking rate, often accompanied by articulatory imprecision. Current views of cluttering portray it as a heritable motor speech disorder, whose pathophysiology has yet to be identified. The impact and influence of the medical model has been ubiquitous in the literature on cluttering. While there is still clearly a place for this traditional framework in advancing our knowledge about this problem, it may now be appropriate to consider alternative ways to frame cluttering.

This review has also made clear that, to some extent, we have been “chasing our tail” with respect to this disorder for centuries. Some of the earliest questions posed about this disorder involved understanding its etiology and identifying its criterial or defining features. As is seen in this review, these questions about cluttering persist into the present.

4.2Future research: Identifying new frameworks for understanding cluttering

Other possible frameworks are available, that could serve as ways to research and view cluttering. In one such framework, cluttering might be re-conceptualized as a communication difference rather than a communication disorder. Consistent with this “difference” orientation, pure cluttering would be considered a phenotypic variation at the far end of a hypothetical “speech effectiveness” continuum, a notion compatible with the cluttering spectrum conceptualization suggested by Ward (cited in St. Louis & Schulte, 2011, p. 240), in which highly fluent speakers and those who clutter occupy the extreme ends of an underlying speech distribution. In this paradigm, cluttering management would not focus on targeting pathological symptoms, such as rapid speech rate and poor self-awareness. Instead, broader constructs such as “vocal image improvement” might be introduced for use in high-stakes communication situations. Modeled after the code-switching literature addressing social dialect (Wolfram, 2004; Wheeler, 2018) “vocal image improvement ” is not founded upon the premise that the person being treated has an inherently pathological system (McCoy, 1996). Instead, through a collaborative process, the person who clutters would be encouraged to learn a natural and more adaptive communication style that could be adopted in situations in which producing mainstream (i.e., non-cluttered) speech would be personally advantageous.

A second alternative to the medical model, called the social model, has been applied to a number of other communication disorders (Forest & Pearpoint, 1992; LPAA Project Group, 2000; Simmons-Mackie, 2000; Buekelman & Mirenda, 2013; Duchan, 2021). The social model originated with people with disabilities who have worked within the disability rights movement (e.g., Oliver, 1992; Barton, 2018).

The social model regards people’s communication disabilities as a function of social conditions surrounding communication impairments. If viewed from this social framework, cluttering would be treated is a disability that can result in a person becoming socially marginalized. The approach to research and practice in cluttering, from within this framework, would be to support the person who clutters in identifying and removing social conditions that get in the way of their communication success. Social model treatment approaches might provide communication support where needed, promote social inclusion of the person in everyday life situations, and work to open up society to accept, normalize, and even celebrate the condition of cluttering (Richter & St. Pierre, 2014; Duchan, 2021). The general aim is to remove barriers that get in the way of communication access.

As is shown in this review, the medical model has played a key role in understanding cluttering throughout its 300- year history, yet its influence has rarely been acknowledged. This finding calls for a need to recognize what frameworks are being used when characterizing cluttering, to acknowledge the ways those frameworks both limit and facilitate the way it is rendered, and to consider the possibility of using frameworks other than a medically-focused one when describing and treating this condition.