Cluttering guidance

What is cluttering?

Cluttering is complex and there has been debate about the key features that need to be included within a core definition (Ward, 2018; St. Louis & Schulte, 2011), propose a lowest common denominator which includes:

• Rapid, jerky speech (S Louis & Schulte, 2011; Van Zaalen and Reichel, 2015) accompanied by at least one of the following: language organisation and planning (Ward, 2018; Van Zaalen and Reichel, 2015);  stuttering

Individuals who clutter may realise that the listener is having difficulty understanding them. This is because they may be speaking quickly or unclearly or the message they are trying to convey is not organised. They may receive feedback from listeners such as their speech sounds mumbled or that they seem anxious.

Onset of cluttering

Data about the age of onset of cluttering are limited. It is believed that the age of onset is like that of stammering: in the pre-school years (Howell and Davis, 2011). However, cluttering is not typically identified until children are at least eight years old (Ward & Scaler Scott, 2013). This is because cluttering becomes more evident when children have more developed language skills and when demands on their organisational, language and speech skills increase.

Rapid, jerky speech

For cluttering to be diagnosed, there must be a perceived rapid and erratic rate of speech (St. Louis and Schulte, 2011). This needs only be present for some rather than all the time. Typically, people who clutter are not able to adjust their speech rate to the linguistic and motor demands in the moment of speaking (van Zaalen-op’t et al., 2009). Rapid, jerky speech is accompanied by at least one of the following:

• a high frequency of non-stammering-like disfluencies
• frequent irregular articulation (Lasalle and Wolk, 2011); co-articulation (van Zalaan et al., 2009) or deletion or collapsing of syllables (e.g., “I wanwatevision”)
• difficulties with speech rhythm or syllable stress.

Planning and formulating thoughts

People may also present with one or more of the following differences in their speech and language:

• pausing and hesitation that is not linked to syntax or meaning (St. Louis & Schulte, 2011)
• Syntax may not always follow typical patterns
• articulation may be unclear (van Zaalen-op’t et al., 2009)
• frequent use of fillers
• semantic errors without insight (eg saying Saturday when meaning Sunday and not noticing) (Ward, 2018)
• word finding
• maze behaviour (repeated false starts, hesitations and revisions)
• sequencing skills such as when re-telling a story (Ward, 2018).

People who clutter typically are unaware of the differences in their communication in the moment (Teigland, 1996). In addition, some people who clutter may have pragmatic communication difficulties relating to conversational turn taking.

Cluttering and other needs

It is unusual for cluttering to present in isolation (St. Louis et al., 2011). More commonly, it presents alongside ADHD, dyslexia, dyspraxia, autism, auditory processing disorder and stammering (Preus, 1996, Sommer at al. 2021). Estimates are that between 14-32% of people who stammer also clutter (Scott, 2017; van Zaalen-op’t et al., 2009).

Cluttering that starts suddenly in adulthood may have an underlying medical cause and require an immediate medical referral.

Factors to consider

What are the causes of cluttering?

In general, research into cluttering is limited and evidence relating to its causes is dated.

It is believed that cluttering:

• is influenced by genetic factors and therefore family history (Luchsinger and Arnold, 1965)
• is associated with other neurodivergent conditions
• has a neurophysiological component (Luchsinger and Arnold, 1965)
• has been explained by some as a condition relating to time perception (Van Riper, 1992).

How are people affected by cluttering?

Cluttering may impact people in various ways:

• It may be undiagnosed or misdiagnosed as a speech sound or language disorder meaning that people may receive no support or not the right help.
• Despite the limited awareness in the moment of speaking (Weiss,1994), it has been shown that there are psychosocial consequences to living with cluttering (Daly, 1986; Reichel, 2007).
• Cluttered speech may be difficult to follow so the listener needs to work hard to understand what is being said and sometimes may be unable to do so
• It can negatively impact mental health through being misunderstood (Scaler Scott and St Louis, 2011).
• The experience of not being able to make oneself understood can lead to feelings of anxiety, anger and sadness for the person who clutters (Van Zaalen and Reichel, 2015).
• Depression and psychosomatic symptoms are associated with cluttering (Icht, 2023; Zukerman et al., 2024).
• The difficulties a person who clutters might experience in organising their thoughts can lead to frustration for both the individual and the listener.
• Cluttering can have an overall negative impact on quality of life (Flack-Pederson & Sonsterud, 2023; Van Zaalen & Reichel, 2018)

Role of speech and language therapy

Speech and language therapists play a key role in supporting children, young people and adults who clutter. People who clutter will have varied needs across their life and may benefit from different types of support, including speech and language therapy. People who clutter may seek support from speech and language therapy at transition points when speech demands change. This might be times such as starting secondary school or university or beginning a new job.

Models of disability

Historically, cluttering has been viewed through the medical model of disability. This impairment focused model situates the “problem” and responsibility to change with the individual. Aligned to this model, the role of speech and language therapists is to support children, young people and adults who clutter by assessing speech and language difficulties, diagnosing and treating using a range of techniques to improve rate and fluency.

This model neglects the role that societal barriers play in making communication difficult. The social model of disability suggests that cluttering is only disabling when environments fail to accommodate diverse patterns of speech. The social model shifts the focus from the individual’s speech differences to societal barriers that make communication difficult. However, sometimes, it is difficult for the listener to understand cluttered speech and this too, forms a barrier to effective communication.

Neurodiversity

Cluttering comprises a complex combination of speech and language differences and often presents alongside neurodivergent conditions such as dyslexia, dyspraxia, autism and ADHD. There has been consideration as to whether cluttering is a difference related to executive functioning rather than a speech or language difference per se (Preus, 1996; van Zaalen-op’t et al., 2009a, Ward, 2015).

The neurodiversity movement therefore has relevance to work with this client group. This has emphasised a shift away from a binary view of “able-bodied” versus “disability” toward a more inclusive discourse that both recognises and values neurodivergent and neurotypical ways of being.

Within this context, the role of the SLT would be one of affirming cluttering, promoting an understanding of these speech and language differences, reducing stigma and enabling the voice of these individuals to be heard as equals.

Reconciling different philosophies

When working with children, young people and adults who clutter, SLTs need to base practice on the current evidence base as well as consider the wider context of factors influencing the profession and the future directions of the cluttering community. Reconciling the evidence with other theories and philosophies is challenging as there are potential tensions between these different perspectives.

Decision making can be especially challenging for SLTs who are yet to gain significant experience in working with this client group and may require supervision from more specialist clinicians to support their skill development and grow confidence in their clinical reasoning skills. However, irrespective of the approach taken, it is vital to keep the client at the centre, working in partnership to decide upon the most appropriate plan.

It is also the role of all SLTs to undertake the following:

• provide information to other professionals and to the public about cluttering
• provide information about and how to access local services and how to refer to them
• educate other professionals such as GPs and teachers and employers about cluttering and the role of SLT in screening, assessing, identifying, supporting and providing therapy for people who clutter
• screen, assess, identify cluttering, offer support and provide therapy as required
• provide therapy that is evidence based
• provide support and therapy that is holistic and derived from goal setting in partnership with the client
• ensure that there is focus on creating a strong therapeutic alliance with the client including with parents when working with children
• refer to other services as appropriate
• signpost to forms of support such as third sector e.g. International Cluttering Association, STAMMA, Action for Stammering Children, especially at the point of discharge from speech and language therapy services
• ensure services are culturally and linguistically relevant
• ensure the role of parents and families is an integral part of support and therapy for children who clutter.
• work with others such as teachers to ensure a supportive and inclusive environment
• support and promote awareness and acceptance of cluttering.

Statistics

The following data are derived from a range of research studies and so are based on different populations and potential differences in the way in which cluttering as diagnosed.

• Data on prevalence are limited (Howell & Davis, 2011; Van Zaalen & Reichel, 2015)
• The gender ratio is 4 males to 1 female (St Louis and Hinzman, 1998)
• Data about the incidence and prevalence of cluttering is limited and further research is needed.
• It is estimated that between 1.1% and 1.2% of school-age children clutter (Bloodstein & Ratner, 2008) Van Zaalen & Reichel, 2017)
• One third of children and adults who stammer also present with some features of cluttering although this evidence is mainly anecdotal (Daly and Burnett, 1999; Preus, 1996; Ward, 2006).

Ensuring access to speech and language therapy services

Public health and partnerships

The role of the SLT is to:

• advocate for the needs of people who clutter by ensuring services are available
• develop care pathways that meet the needs of people who clutter who want support
• collaborate with the cluttering community and organisations that support people who clutter to provide accurate information and advice.
• provide training and support to colleagues in Education and Health to increase the identification of cluttering and referral. This ensures timely support and increases the likelihood of positive outcomes Work in partnership with parents to increase their awareness of the things that they can do to support their child’s communication confidence and participation
• support children, young people and their families with the possible psychosocial and emotional aspects of cluttering.

Awareness raising and early identification

Our understanding of cluttering is limited and therefore it may be under-identified as a result. SLTs working with children who clutter need to ensure SLT colleagues working with children on other caseloads (e.g. developmental language disorder, autism, ADHD, stammering) know how to recognise cluttering and the appropriate support to provide.

Access and referrals / requests for assistance

All SLT services should provide information about their referral criteria for children, young people and adults who clutter. Details about how to refer should be available in-service literature and/or website. Information must be accessible in accordance with the Information Accessible Standard.

Information should be provided about other forms of support available to people who clutter including signposting to STAMMA.

The RCSLT recommends that:

• consent guidance is followed (see RCSLT guidance on consent)
• referrals for cluttering are processed in a timely manner
• an assessment is offered as soon as service priorities allow, and that both the referrer and client are informed of the waiting time
• when the waiting time will be significant, it is recommended to offer some general advice to be implemented during this waiting time and signpost to available resources.

Please see RCSLT information on screening and referrals for general details about referral management.

Assessment

Assessment of cluttering is a detailed process. It aims to establish whether cluttering is present and if so, its impact on the client. A comprehensive assessment would be individualised for the client and typically involves gathering information linked to relevant medical, developmental, communication, psychosocial, environmental and family history factors.

It may be helpful to video assessment to facilitate analysis. An assessment of cluttering includes:

Children and young people

• reasons for seeking help and hopes from, therapy
• presence or signs of other related conditions e.g. ADHD, stammering, autism
• impact of speech at home, socially, at school and academically
• variability in speech
• awareness of communication skills
• overall academic attainment.
• impact of speech at school
• impact of speech at home and socially

Speech motor:

• rate of speech in reading, monologue, discussion
• clarity of speech in reading, monologue, discussion
• telescoping of words
• presence of disfluencies, fillers

Language and organisation:

• word finding difficulties
• information from parent/carer about narrative skills
• language assessment
• assessment of narrative skills which may include a sample of written narrative

Adults

It may be helpful for an adult to attend assessment with a significant other to enable the gathering of information about communication skills in everyday life.

• reasons for seeking help and hopes for therapy
• presence or signs of other related conditions e.g. ADHD, stammering, autism, dyslexia, dyspraxia
• impact of speech at home and socially
• impact of speech on employment
• variability in speech
• awareness of communication skills
• current coping strategies and their usefulness
• previous therapy

If appropriate, video record to facilitate analysis.

Speech motor:

• rate of speech in reading, monologue, discussion
• clarity of speech in reading, monologue, discussion
• telescoping of words
• presence of disfluencies, fillers

Language and organisation:

• narrative skills and maze behaviours
• topic maintenance and ability to indicate a topic shift
• word finding difficulties

Decision making and therapy

Therapy takes different forms over time and people who clutter may access it across all transition points and stages of life.

The process of decision making when working with people who clutter is complex. In deciding about the best way to support a child, young person or adult who clutters, the following questions need to be addressed:

• What are the priorities or best hopes for therapy for the client or parent?
• Will speech and language therapy help to reduce any negative impact of cluttering?
• Will therapy for the child support parents to reduce their concern about their child’s speech?
• Could a reduction of any negative impact of cluttering be achieved through working with others to create a more supportive communication environment?
• What level of support is needed to facilitate the client’s (child, young person, parent, adult) knowledge and understanding of cluttering?
• Would group therapy support be beneficial?
• Are there any other areas within the child or young person’s speech, language and communication profile which require support?
• Would the individual benefit from being a member of the cluttering supported community?
• Will working directly on speech be beneficial or could we inadvertently reinforce ableist views about cluttering and fluency?
• Will this client’s needs be more appropriately met by another service or professional?

The above questions can support collaboration between the SLT and client to formulate an agreed joint plan which needs to be discussed with the client/child and/or parent. Where it is considered that the client’s needs will be most appropriately met by another professional or service, the SLT will make an onward referral or contact with the GP to request a referral.

Therapy for cluttering is individualised, based on the client’s priorities and best hopes. Areas to be prioritised in therapy will be agreed with the client and may include psychological change, speech modification, language strategies and facilitating changes in the speaking environment.

Therapy

Therapy for cluttering typically addresses both the psychosocial aspects and communication-skills development and may include any combination of the following:

Psychological factors

• Support around thoughts and feelings around cluttering
• Self-advocating
• Desensitisation
• Self-compassion

Speech motor:

• Awareness of rate and clarity of speech
• Rate control and pausing
• Articulation – over articulating to emphasise word boundaries and increase intelligibility
• Syllable counting/tapping for multisyllabic words
• Rhythm and stress using rhymes/limericks/poetry
• Intonation and volume

Video or audio recording may support direct speech work.

Language and organisation:

• Pausing may help by allowing more time for planning
• Narrative skills
• Working on visual support for structuring explanations and narrative

Pragmatics:

• Conversational turn taking
• Maintaining eye-contact
• Observing listener response to check for understanding

Therapy when cluttering presents alongside other needs:

• The client’s overall communication differences and needs are considered when setting priorities
• Therapy will not aim to work towards neurotypical norms
• It is important to educate others in the client’s environment about communication differences and that all carry equal value

Discharge

Clients will be discharged from speech and language therapy for the following reasons:

• care has been transferred to another service via onward referral.
• therapy is complete and outcomes have been achieved and maintained.
• therapy is no longer meeting their needs.
• they have been unable to engage with therapy through non-attendance (discharge within local policy).

For whatever reason the client is discharged, they should be signposted to organisations and services that can offer support and provided with information about how to re-enter the service if required later. Care should be transferred to the professional with a universal duty of care i.e. GP and/or headteacher along with information about how to re-refer.

See RCSLT guidance on discharge.

Bilingualism

For bilingual clients who clutter, see RCSLT bilingualism guidance.

Professional requirements

Supervision

The RCSLT recommends that all practising SLTs access regular supervision – see RCSLT supervision guidance.

When working with people who clutter, SLTs help parents, children, young people and adults who are experiencing challenging thoughts and feelings. They work in partnership with the client to facilitate psychological change. It is essential that this work is brought to regular supervision sessions to ensure the SLT is well supported in providing high quality care for their clients (Farrell et al, 2024; Maher-Edwards, 2024).

Collaborative working

With consent, SLTs should work with others to ensure that children, young people and adults who clutter are fully supported. This includes but is not limited to:

• providing general advice about cluttering to schools, colleges and universities including in relation to Reasonable Adjustments
• providing information to employers
• working with teachers to support a specific child at school
• supporting clients’ self-advocacy.

See RCSLT guidance on collaborative working.

Workforce

SLTs have recognised variability with their knowledge, skills and confidence levels when working in the field of cluttering. In view of this, CPD and workforce development opportunities linked to cluttering can ensure an appropriate mix of clinical knowledge and skill across services. As part of CPD and support/supervision, it is helpful for practitioners to understand the post registration level that they are working at in order to access relevant learning and development to support autonomous practice. It is advisable for services to consider their current workforce skill mix for cluttering in terms of access to specialist practitioners e.g. for shadowing, mentoring and supervision opportunities.

It can be helpful for service providers to consider their workforce knowledge and skill mix for cluttering across the three defined levels of practice outlined below. Information gathered from a training needs or skill mix analysis can then be integrated as part of local service competencies to facilitate a streamlined and evidence-based approach to CPD, supervision and mentorship within this field.

The following competency level descriptors are based on a project carried out by Northumbria Healthcare NHS Foundation Trust to establish workforce skill mix guidance for Speech and Language Therapist working with children and young people who stammer.

At Level 1, practitioners typically work with a range of cluttering cases. This level of practice will usually incorporate early entry clinicians (e.g. newly qualified practitioners) or those who are new to working in the field, often as part of a more generalist caseload. Depending on case complexity, Level 1 practitioners can usually work autonomously within the field to a certain level with appropriate support/supervision and guidance in place.

At Level 2, practitioners will typically demonstrate an emerging specialist level of knowledge and skill and they can work autonomously with cluttering cases. This may involve undertaking additional specialist training within the field as well as offering supervision and second opinions to more generalist practitioners e.g. with complex cases and decision making.

At Level 3, practitioners demonstrate advanced knowledge/skills within the field of cluttering. Typically, Level 3 practitioners will lead with areas such as care pathway and training development. In terms of workforce development, Level 3 practitioners will be able to identify learning and CPD opportunities for Level 1/2 SLTs as well as offering specialist support and supervision.

Telehealth

Services for cluttering can be provided online. See RCSLT telehealth guidance.

Contributors

Lead author

• Corinne Moffatt, Divisional Lead, Speech and Language Therapy, City St George’s, University of London. 

Supporting authors

• Dr Ria Bernard, Expert by experience 
• Kirsten Howells, Speech and Language Therapist, STAMMA 
• Ali Berquez, Clinical Lead Speech and Language Therapist 
• Catherine Pape, National speech, language and communication co-ordinator for babies, children and young people, Welsh Government 
• Elaine Kelman Consultant SLT and Head of the Michael Palin Centre. 
• Jennifer Ryder, Speech and Language Therapist 
• Kerith McCracken, Paediatric Speech & Language Therapist 
• Kevin Fower, Director, The Stammer Specialist Ltd 
• Simon Henderson, Highly Specialist Speech and Language Therapist. Northumbria Healthcare NHS Foundation Trust 
• Sula O’Duffy, Speech and Language Therapist, NHS Ayrshire and Arran 

Partner Organisations 

We would also like to thank the following organisations for their support during the production of this guidance 

• Action for Stammering Children 
• Stamma