|About the presenter: Lynne Shields is a professor in the communication disorder and deaf education department at Fontbonne University in St. Louis, Missouri, where she teaches courses in fluency disorders, language disorders, counseling and phonetics, and supervising in the university speech & language clinic. She is a board recognized specialist in fluency disorders.|
This paper summarizes a case study of a seven-year-old girl who presents with speech patterns that are consistent with cluttering. I will provide some background information about this child, whom I will refer to as "Claudia", and then outline the treatment strategies that we are using to help her communicate more effectively.
Claudia was initially evaluated through her public school district when she was 3 years 1 month of age, with a follow up re-evaluation at the age of 3 years 11 months. She was diagnosed with significant delays in speech, language and fine motor development and was subsequently seen for speech and language therapy and occupational therapy through the public schools. Claudia's mother first brought her to our on-campus clinic at Fontbonne University when Claudia was 5 years 1 month of age to supplement the therapy she was receiving at school, in particular to give her additional help with speech sound development since Claudia's speech was highly unintelligible.
During Claudia's first two semester of enrollment in therapy at the Fontbonne speech and language clinic from January through July of 2008, treatment focused on helping her acquire speech sounds. While progress was noted at the end of this period, Claudia continued to show poor speech intelligibility. Recommendations for treatment included addressing her fast rate of talking through encouraging "turtle talk", in addition to continuing to address the development of speech sound production patterns.
Claudia was next seen at our clinic beginning in January of 2009. This was my first encounter with her as supervisor to the student clinician assigned to her case. Claudia presented as a pleasant and active 6 year old who loved to talk, but continued to be largely unintelligible in connected speech, both in the clinic setting as well as at home and school. A re-evaluation of her speech sound skills indicated that Claudia was able to produce most age-appropriate speech sounds at the word level, yet her speech intelligibility deteriorated in connected speech due to an apparently fast and irregular rate of speaking. In conversation, she frequently underarticulated words (sounding indistinct to the listener) and was also observed to omit sounds, syllables and function words. She showed frustration at not being understood, but did not demonstrate the ability to self-correct errors. In addition, she presented with social language concerns including poor eye contact, inconsistent responses to questions, and difficulty initiating and maintaining verbal interactions. When asked to describe an event or explain how to complete a familiar task, Claudia had difficulty organizing her response in a logical sequence. Re-evaluation through the public school district in March of 2009 resulted in the addition of mild autism to Claudia's educational diagnosis. At our clinic, her mother assisted us in completing A Predictive Cluttering Inventory (2006). Claudia demonstrated a number of behaviors that are consistent with cluttering. Scaler Scott & Ward (2008) noted that the diagnoses of cluttering and Asperger Syndrome, a disorder on the Autism Spectrum, present a shared difficulty related to self-regulation. As a result, a child presenting with characteristics of both cluttering and a disorder such as autism are likely to benefit from treatment that focuses on improving self-regulation. It was decided to modify Claudia's therapy to more directly help her organize her speech and language. Following is a summary of the modifications that were implemented.
Treatment concentrated initially on improving overall speech intelligibility in connected speech. Once this was achieved with some measure of success, other components were added to the treatment plan. The initial focus was on establishing "clear speech" in short phrases, expanding the length of utterances and reducing the degree of structure gradually. Beginning in September of 2009, appropriate eye contact was added as a goal, to increase Claudia's ability to attend to her listeners, and eventually to attend to listener cues regarding whether or not her message was communicated. At the same time, cues for correction of unclear speech were modified to more natural cues that might occur outside of the clinic setting. In November of 2009, treatment began to address Claudia's omission of function words in sentences. These three goals have continued to be addressed during the current treatment period, which began in January of 2010.
During the time that she has been enrolled in our clinic, Claudia has continued to receive services at school. She is not receiving speech therapy at school at present. However, the resource teacher works with Claudia on social skills, individually and in group settings at lunch and recess. Claudia has recently begun attending social group therapy one afternoon per week outside of school.
Reminding Claudia to slow down or use "turtle talk" had been attempted as a treatment method with relatively little success. It was decided to introduce the concept of "clear speech" to direct Claudia's attention to getting her message across to listeners rather than focusing on her rate of speaking. "Clear speech" meant that the listener could understand all of the words spoken. The clinician cued Claudia when this did not occur by saying, for example, "use clear speech" or "I can't understand what you said". When her speech was intelligible, the clinician continued the activity, responded to her request, or provided verbal feedback such as "I understood you" or "that was clear speech". When cued to produce "clear speech", Claudia typically produced speech at a somewhat slower rate with more distinct pronunciation. While speech sound errors were still present, they were fewer in number. Early in therapy, activities involved the use of highly structured speaking tasks, with Claudia initially producing 2 to 3 word utterances, progressing to producing 4 to 8 word sentences. More recently, this has expanded to about two sentences per speaking turn. The focus is always on using "clear speech" rather than producing correct speech sounds. Examples of the highly structured tasks used at the beginning of treatment included sentence repetition, use of a carrier phrase (e.g., "I found a . " during a grab bag game), and sentence completion during story reading. As therapy progressed, less structured activities were used, included taking turns describing pictures, giving instructions one-at-a-time during art or snack-making activities and, more recently, making short movies with a video camera and routine play activities that allow for more spontaneous talking. So, the progression has been the production of intelligible speech in increasingly less structured tasks using longer utterances.
Currently, Claudia is able to produce intelligible 4 to 8 word sentences with up to two sentences per talking turn on an average of 70% of her utterances in the clinic setting. When engaged in a longer speaking turn (e.g., describing an event or telling a story), Claudia's speech intelligibility continues to deteriorate over time.
Claudia responded well to overt comments about "clear speech" or "I can't understand you". However, she did not attend to typical requests for clarification that occur in natural settings, such as a questioning look or a short verbal response (e.g., "What?"). Improved eye contact was targeted to help her attend more fully to her speaking partners. Initially, the clinician commented positively on eye contact when Claudia happened to look at her. For example, she might say, "I like it when you look at my face" or "I can tell you are listening to me (talking to me) when you look at my face". Occasional direct requests were also used to elicit eye contact at appropriate times. For example, when Claudia asked the clinician for more glue without making eye contact, the clinician prompted her to "look at my face" and ask. Claudia is currently making eye contact in approximately 60% of appropriate contexts with occasional verbal reminders and/or comments about eye contact. Her level of success varies across different types of speaking situations and remains a focus of treatment.
In addition to addressing eye contact, we began to modify the verbal cues used to elicit increased intelligibility to those that are more likely to occur in her environment. Typical responses to unclear speech by her peers include "huh" and "what", so it was decided to gradually begin replacing "use clear speech" and "I can't understand you" with these natural listener requests for correction. At first, the clinician paired the old and new responses saying, "Huh? Can you use clear speech?", and then gradually faded the direct request. Currently, Claudia responds with a more intelligible production when cued with "huh" or "what" at a rate approaching 100%. Once Claudia's eye contact had improved, we added the use of nonverbal cues such as a quizzical look or a shoulder shrug with "huh" and "what" when Claudia is looking at the clinician. Recently, the student clinician noted that Claudia is beginning to respond to a questioning facial expression without an accompanying verbal cue by repeating her sentence with greater clarity.
As noted previously, Claudia frequently omits function words from her speech. For example, she may say "I want go with you" rather than "I want to go with you". When provided with written sentences that lacked function words (pronouns, articles, prepositions, etc.), she readily identified the missing words and was able to state where those words should appear in the sentence. Once it was established that Claudia had a good grasp of basic grammar, the student clinician began to address errors that occurred in Claudia's speech or in the clinician's own speech. When the clinician produces an error sentence she follows it with, "I think I left a word out. Can you help me?" When Claudia deletes a function word during a speaking turn, the clinician cues her, "I think you left a word out. Can you think what it is?" At this time, Claudia is able to correctly identify at least one omitted function word per sentence an average of 60% of the time when provided with a verbal cue. When she is not able to identify the missing word on her own, she is given a further choice cue, which always results in successful identification (e.g., Is it "in", "at" or "a"?). In the near future, we plan to further reduce the verbal cue provided, asking Claudia, for example, to "say that again with all the words".
Claudia's mother stated that there has been good transfer of skills outside of the clinic setting. She reported that the classroom teacher and resource teacher are aware of the cues being used in treatment and these cues are used at school. Claudia's mother also uses the cues at home. Claudia's grandparents, who live in another region, commented during a recent visit that they find her speech much easier to understand. Based on the mother's observations when she has been at school, Claudia's teachers and classmates appear to understand what she says much of the time. Both the classroom and resource teacher report to the mother that Claudia's use of eye contact is improving at school. Contexts in which Claudia's speech is less clear include times when she is excited or anxious, and when engaged in a lengthy talking turn.
Claudia has made significant progress since the focus of treatment changed from addressing speech sounds specifically to a focus on well-organized, clear speech. At present, her speech is primarily intelligible in many speaking situations both in and outside of the clinic setting with some support. In addition, Claudia is showing the ability to attend to her listener and regulate her speech when needed. While it is tempting to attribute all of this change to treatment, I would like to point out that Claudia's personal desire to interact with others and her maturation are vital contributors to the changes we have witnessed. She has been, and continues to be, a wonderful teacher for us, as we work out ways to help her communicate more effectively.
Daly, D. (2006). A predictive cluttering inventory. Available online at: http://associations.missouristate.edu/ICA/Resources/dalycluttering2006.pdf.
Scaler Scott, K., & Ward, D. (2008). Treatment of cluttered speech in Asperger's Disorder: Focus on self-regulation. Presented at the Annual Convention of the American Speech-Language-Hearing Association, Chicago, IL, November 18.
SUBMITTED: March 12, 2010