Monday, March 31, 2008

Money, money, money

I am NOT stuttering on the title. It is just a recurring thought! I am spending much time and money on stuttering, but have exactly zero revenue: money-wise that it. I also have hidden costs of loss of opportunity, because I am spending my intellectual energy at age 35 (where you are apparently most productive?) on an area where I do not have a career. I am neither a speech therapist/pathologist nor a scientist working on stuttering. Instead I could be spending my time on more "productive" work and earn more money as a consultant. Of course, I get a lot emotional revenue (also from your posted comments and emails), because I am driven to understand what stuttering is about, and what helps most. And 1000 weekly readers is a great but unhelpful stimulation of my ego... ;-)
My goal is to make my efforts a zero-cost affair, but I am not quite sure how I can extract money from you, my readers, to cover costs. :-) Surely, no-one will pay to read me. My only chance might be to ask the few wealthy or charitable for donations but I am not sure how I should do this. My best bet is probably advertising. But, I have chosen not to advertise on my blog via goggle AdSense because most adverts are really fake promises of cures and I kind of find it difficult to rail against them and at the same time to get revenue from them! I might change my mind, and do it but only for a few selected one. I can certainly make the case that I have over 1000 unique readers per week and I am high on google search. So there is good exposure for the advert. This strategy is already working well for getting free books and reduced conference fees.

Going to Oxford Dysfluency Conference

After some long thoughts, I have decided to go to the Oxford Dysfluency Conference. There are several people coming that I want to talk to, for example: Per Alm (he works on neuroscience and theory), Jerry Maguire (I think, he led the Pagaclone Phase II trial), Kate Watkins ( I would guess as she is from Oxford, experimental brain imaging work) and other good people. By the way, Michael Palin is coming to the conference. So I feel like I cannot afford not to be there. I didn't enter any talk proposal, but I sure will ask questions to the poor presenters! And maybe I get invited to a panel discussion...
I am also stingy about the costs involved: 500 pounds. I am not saying it is not a good deal for the services offered, and I am sure Dave has done his best to keep the price down. But still combined with the travel, it is as expensive as a one-week holiday if not more. Though I have to mention that for the last ODC conferences, the British Stammering Association paid the full or half of the conference fees, for which I am very grateful. They usually have a few grants for the conference, and might have it this year, too. And I have also started trading with the organisers of recent conferences for a reduced fee in return for full coverage on "the by far most read stuttering blog on the Internet". As you can see I have started to use you as a bargaining tool! :-)

Friday, March 28, 2008

Chess: a sport for stutterers!

You probably don't know that I played a lot of chess when I was a teenager. I even managed to participate in the World Junior Chess Championships in Chile in 1990, in Romania in 1991, and in the Netherlands in 1992 for my country However, let me tell you straightaway that I am no Kasparov or Fisher and I always finished up in the bottom of the tournament. Being from Luxembourg, your chances of being one of the best is a bit larger than in the US or Germany, for we only have half a million inhabitants! :-) So I am a strong club player on the local level with an international rating of 2040, but the weakest on an international level. I only started to play in a club at the age of 16, far too late. All grandmasters and international masters start at 12 or earlier. The reason I didn't post for a few days is that I qualified for and played at the national championship, after a pause of more than 10 years of real competitive chess. I did OK against semi-professional chess players with relatively little preparation.
In a sense chess is an ideal sport for someone who stutters. You don't have talk, you just need to move your pieces around. It is a very good practise for mental control, strategic thinking, concentration, patience, willingness to accept risks, handling difficult situation and so on. Chess also allows you to build up self-confidence, and very importantly prevents you from blaming your defeats on your stuttering. My only issue is when I want to propose a draw ("a remis"). It even happened to me once, that I just couldn't say it and so I just told myself: f**k it, I am going to win this game and continued playing. :-)

Thursday, March 20, 2008

Primary and corrective-feedback phase of stuttering

From time to time, I have these flashes of enlightenments which either quickly vaporise or stay and I see clearer. Actually, it becomes so clear that I am wondering whether not everyone knows that anyway because it is so simple, and that I was just too stupid to have realised.
Stuttering goes through two completely different phases, the moment of onset being the phase transition. In the first phase (the primary phase), the subconscious brain, the person that lives with the brain, and its environment knows nothing about the abnormal nature of the brain. It is functioning happily. Still, the abnormality is there and detectable, and caused by either genes or a neurological incident. The phase transition happens at onset of stuttering. The moment of onset per se is nothing special at all, as its causes go back years, back to the genes or the neurological incident. It is like the emergence of a rock when the tide goes out again. The moment of the rock emerging looks special but it is not the rock that is not emerging, but the water that is receding and for the water it is nothing special at all! Still, something dramatically has changed that triggers a feedback loop leading to the corrective-feedback phase. Suddenly, the subconscious brain, the person of the brain, and the environment realise the abnormality, because it leads to atypical and functionally disruptive behaviour: dysfluent speech plus secondary effects. Immediately, corrective behaviour sets in by the brain, by the person who stutters, and by its environment. The future development of the disorder now depends on two things: the severity of the underlying abnormality, and the correcting ability of the brain (brain plasticity), the person who stutters, and its environment. And, the goal is clear, too: to change the atypical behaviour to within normal and functional behaviour. Note that the emphasis is on correcting behaviour, whether the brain is still abnormal is irrelevant as long as it produces normal behaviour. Of all the children who start stuttering, a majority of eighty percent manages this task well, the others like myself go on to become adult stutterers.

Wednesday, March 19, 2008

Idiotic introduction to stuttering article

If you are ever looking for an idiotic introduction to an article about stuttering, how about the introduction to this otherwise good article Verbal Bottleneck in Scientific American Mind from October/November 2006:
Greg K. was only three when the problem began. During a family vacation he saw two crashed cars burning. Soon after that, his parents recall, the boy began stuttering. Even today, at the age of 40, Greg is more likely to order lasagna in a restaurant and forgo his favorite pizza, capricciosa, because he cannot manage words that begin with explosive sounds like the letter "k."
Again and again, stuttering is linked to an accident story. And again and again, I am saying that MILLIONS of kids had traumatic experiences like a accident and only 1% is stuttering today, the same percentage as the general population! And MILLIONS did not have traumatic experiences and still stutter!

To the author's defense, I vaguely remember her saying that the editors sexed up the story without telling her, and this migrated from the German version to the US version. This might include the accident part.

Tuesday, March 18, 2008

The collapse of Bear Stearns

You might have heard about the sudden and spectacular collapse of Bear Stearns, one of the largest investment banks in Wall Street. But, what you probably did not know is that I have worked for Bear in 2001! Namely in Risk Management, of all departments! :-) Risk management is a relatively small but important department of an investment bank that very carefully studies the risks taken by all trading desks and incorporates them into a firm-wide risk analysis. It is staffed only by quantitative PhDs and very experienced ex-traders, and uses a lot statistical and financial modeling tools.
After a post-doc in Manchester and a visiting researcher grant at Trinity College, I started working at Bear Stearns in London at the central tower of Canary Wharf with a fantastic view of London. I was responsible for monitoring the equity derivatives desk in Tokyo. I worked on/next to the busy trading floor, and every week we had a video-conference to discuss the risk exposure for Bear. I have to say that I didn't get off to a good start: I had serious back problems (a prolapsed disk) and couldn't sit for longer than 20 minutes, house mates from hell, my stuttering was quite bad due to my back and high pace, and didn't get on well with my supervisor.
Bear is quite different to the other investment banks. They are more of a creative chaos led by talented traders rather than a well-structured bank with a systematic risk management approach supported by strong IT. We completely lacked IT integration of firm-wide data into a risk management system. There was always a concern for the credit derivatives that are very difficult to price, and this concern grew over the years as what I heard from former colleagues. My guess is that the reason for the collapse lies within senior management and their failure to limit exposure to difficult-to-priced securities, and the (political) weakness of risk management to make this case.
It is quite dramatic for the people who work there, as many received bonuses via company shares that are locked for 3-5 years and it was considered bad taste to sell them even after the lock-up period finished. By consequence, the Bear employees own 33% of their company and lost most of it. The top people were millionaires or billionaired, and their fortune dropped by 90%! However, I have no pity for them. It is insane to hold stocks at the same company that you are working. It's the most obvious mistake of diversification. Still, there is a perfectly reasonable argument for why they did this. Bear Stearns is the most aggressive investment bank on Earth dominated by trader mentality. Their ethos was: Show us loyalty to the firm by keeping your stock, and we are proud of you. They want to bind you, and make you part of themselves. They might have lost, but I wouldn't be surprised if they say to you: "So what? We played though and lost. I am proud of what I have done. Life goes on. I took the risk. Others run." For that, they deserve respect: they have all taken common responsibility for their actions or lack thereof, unlike CEOs who get outrageous bonuses without taking any risks and even get golden parachutes for messing up companies.

Monday, March 17, 2008

My first speech at Toastmasters

Tonight, I have done my first speech at Toastmasters. Toastmasters is an association for people who want to become effective communicators and leaders. It is an excellent way to become a better speaker and overcome those butterflies. I heard about Toastmasters before, from people in the stuttering community and from Einar, a friend of mine who stutters, too. The group meets twice a month in an hour and a half long session. The first part consists of interpromptu speeches called the table topics, the second is a set of 4-5 speeches, and the third is an evaluation of the speeches.

Coming back to my speech, it was rather surreal. I had already attended two sessions and I introduced myself and mentioned my stuttering. The old story: I stutter, I have to work on it, Toastmasters might be a good way to practise, need to have patience with me and so. And then, I gave my speech and my evaluator said afterwards: Not sure Tom mentioned stuttering, because he didn't stutter! So I had to interrupt and say that I do stutter! My mentor who heard me stutter a lot from when I talked to her, was amazed that I was able to talk fluently. My trick was of course to: 1) write down the speech, 2) practise it 10 times 3) put on an acting mode. I was fluent... And they all seem to love it. The comments were: good sense of humour, good body language, CLEAR AND STRONG VOICE (give me a break ;-), interesting,...

Anyway, Toastmasters is a fantastic environment to work on your speech and to become more relaxed. I wholeheartedly recommend it to everyone!

Saturday, March 15, 2008

Crackpot Award for EFT people

My next crackpot award goes to the EFT people. Check out this webpage. Unlike the standard crackpots, she is not claiming to understand what causes stuttering rather she seem to say that EFT (Emotional Freedom Technique) helps stutterers deal with the emotional side.

Nevertheless she deserves an Award, because her report of improvement is obviously completely naive (and shockingly unprofessional for someone who studied speech pathology) as stuttering can easily be reduced using ANY method (my favourite one is walking on all four) and she neglected the placebo. I am CONVINCED the improvement is placebo.

(Thanks to a reader for pointing this out to me.)

Friday, March 14, 2008

The bloguette of Mr BSA

The stuttering blogoshere has just undergone a phase transition: Norbert Liekfeldt, CEO of the British Stammering Association, has a blog where he talks about his activities: see here. (I have also put a link in my blog links.) The blog will be a good way for BSA members to see what's going on within the BSA on a day-to-day basis. But of course there will also be the delicate business that will not find its way onto the blog. Or can you imagine Norbert writing: "Today, I again had an annoying call from one of our BSA members. We need to do something about him." or "Today, we finally got rid of XY whom we recruited last year. He was a complete disaster and only cost us money. I need to find a way to exclude trustees from selecting staff in the future. And I still have to write a note for the website, and I am thinking of writing something like >XY has left the BSA to pursue his career at another charity. We thank X for his valuable contribution to the BSA.<" (No allusion intended to any real BSA event from the past year!)

In an email to TheStutteringBrain, Norbert Liekfeldt writes: "Just a bloguette.... Say something nice!" So here it is. Norbert is really Mr BSA, the glue of the BSA. He has been leading the day-to-day business for many years. Trustees (like myself) have come and gone, members have come and gone, financial crises have come and gone, staff members have come and gone, but Norbert is still there, a bit like the Cheops pyramid. So he certainly deserves credit for inducing stability to the BSA. Without Norbert, the BSA might not exist anymore. If there is one failure that I see, then it is the precarious financial situation of the BSA which has persisted for many years. The BSA is never far from the brick despite relatively conservative spending. Norbert but also the trustees (former and current) and especially the last and current BSA chairs have completely failed to recruit and keep wealthy and influential donors. If you could be one, call the BSA!

It's before the task, stupid!

Weber-Fox's team has looked at school-age children's brains while performing a visual rhyming task. They used ERP (event-related potential or evoked potential) which is a range of methods that record electrical activities in form of potentials in the brain due to a stimulus: see picture above. They want to understand why kids who stutter have lower accuracy on rhyming judgment (not sure exactly what they did; I guess the kids were given two words on a screen and had to judge quickly whether the words rhyme or not). They did not find any differences in electrical activity for the task, but they found atypical activities before the task itself. This observation makes sense to me. Many of the non-speech related deficiencies like in dual tasks or rhyming judgment are probably due to a sub-optimal coordination between the different brain regions, which is probably due to the brain having to compensate for some failing region(s). Think of a transport system of a big city. Imagine a bridge must close and be re-built. The impact on the transport system can be dramatic and impact not only the local area. For example, the heavy lorries now have to use another bridge which is less equipped to handle heavy traffic and therefore fast deteriorates, too. Or there are suddenly traffic jams in unexpected parts of the city, and for example disrupt the functioning of a big factory or hospital.

Atypical neural functions underlying phonological processing and silent rehearsal in children who stutter.

Speech, Language, & Hearing Sciences, Purdue University, USA.

Phonological processing was examined in school-age children who stutter (CWS) by assessing their performance and recording event-related brain potentials (ERPs) in a visual rhyming task. CWS had lower accuracy on rhyming judgments, but the cognitive processes that mediate the comparisons of the phonological representations of words, as indexed by the rhyming effect (RE) ERP, were similar for the stuttering and normally fluent groups. Thus the lower behavioral accuracy of rhyming judgments by the CWS could not be attributed to that particular stage of processing. Instead, the neural functions for processes preceding the RE, indexed by the N400 and CNV elicited by the primes and the N400 elicited by the targets, suggest atypical processing that may have resulted in less efficient, less accurate rhyming judgment for the CWS. Based on the present results, it seems likely that the neural processes related to phonological rehearsal and target word anticipation, as indexed by the CNV, are distinctive for CWS at this age. Further, it is likely that the relative contributions of the left and right hemispheres differ in CWS in the stage of processing when linguistic integration occurs, as indexed by the N400. Taken together, these results suggest that CWS may be less able to form and retain a stable neural representation of the prime onset and rime as they anticipate the target presentation, which may lead to lower rhyming judgment accuracy.

Thursday, March 13, 2008

How to tackle complexity

Stuttering is a very complex disorder, and I want to talk about strategies to control this complexity in order to understand the underlying dynamics. They are mostly inspired from methods or tricks that I learned from fellow physicists.

- Always remember that every phenomenon no matter how complex is ultimately an interaction of atoms! There are no ghosts or paranormal forces or magic at work. There are better explanations for why something happens, but sometimes it is damn difficult to achieve understanding. In some cases, it might be (nearly) impossible, like in fluid dynamics, climate models, social interactions, but nowadays computer simulations are very helpful in reproducing complex phenomena whose internal dynamics we do not understand theoretically.

- Do not talk to people who advocate a "holistic approach" or "to view every person as an individual" consciously or unconsciously acknowledging defeat to complexity. They are like the ancient tribes assigning a God for every phenomena they do not understand, or the 18/19th century scientists inventing concepts like elan vital as the fluid that makes matter come to life, like the calorific fluid that transfers heat, or the ether to give classical physics alive. They are only stating the obvious that we already know, namely that stuttering is a very complex disorder. Very rarely, do they have to say anything deep. We must strive for better explanations and not give up.

- Construct theories up to a first order approximation first. For example, we conveniently talk about males and females, but there are some people who are different physically or genetically. Or, let's take planetary orbits. At a first order approximation, they are circles, at second order they are ellipses, at third order they are ellipses with some correction due to the other planets, and at fourth order, these corrected ellipses have corrections from general relativistic effects.

- Cut out sources of complexity that are not fundamental to the disorder. Here, I would put psychological and social consequences of stuttering in this group. I am purposefully ignoring them, not because I think that they are not important in other areas like therapy but because they add considerable complexity without adding much insight into the underlying causes. A clearer example is hair loss. There is a wide range of complex reactions in males and females and their environment, but they tell us nothing about hair loss itself.

- Throw out any atypical cases. In stuttering, we need to "get rid" off people who started stuttering after age 7, who have undetectable dysfluencies, who have other disorders, and even who are females in the case of brain scans. This relates to the first order approximation in that we need to first try to understand the typical cases. Clearly, this atypical group might well be a source of inspiration and explain the typical behaviour better.

- Look at every possible dimension you can think of independently. Here are a few: brain imaging, self-reports, genetics, therapy, phenomenology, linguistics, child development, and so on. But, it is clear that a full picture only arises once you look at all dimensions at the same time and look for the interactions between the dimensions. Nevertheless, you should first understand each dimension independently.

- Concentrate on more quantitative dimensions where you can get clearer and more OBJECTIVE results. Genetics is the king here, because the DNA is well-defined. For example, we know due to twin studies that genes have a big influence, but how it happens we have no clue. Still, we can identify genes and bypass the enormous complexity.

Wednesday, March 12, 2008

Stuttering hijacked for bird lobbying

Check out this webpage on bird conservation. The authors want to convince us that bird conservation is essential for stuttering research! I think this argument is a bit far-fetched, but I would certainly support the conservation of birds:
Bird studies are constantly helping us advance scientifically.

Researchers at the Methodist Neurological Institute (NI) in Houston and Weill Cornell Medical College in New York City used functional MRI to determine that songbirds have a pronounced right-brain response to the sound of songs, establishing a foundational study for future research on songbird models of speech disorders such as stuttering. - Science Daily

The argument might actually go against the aim of the authors, because such stuttering research would involved animal experiments. In research, scientists need to be very careful as not to endanger the human experimental subjects, but such a restriction is not needed for animals especially non-primates. So having an animal model is certainly useful, but I am not convinced that such an animal model exists for stuttering. Stuttering starts around the age of 3, when grammar develops and I just find it hard to see an animal having similar abilities.

Crackpot award for Jerry Halvorson

I received emails from Jerry from, and as you can see below he is propagating statements about stuttering that is not supported by hard evidence and has no intention to change his mind. As I have done in the past, I am rigorously exposing such people. (I am not saying he is a bad person intentionally, but he clearly has a responsibility of checking facts before "educating" people who stutter.) I give him my crackpot award: see here.

Hi Tom,
Noticed your blog…thought you might benefit from reading my new book on stuttering, Regression Therapy For Stuttering. Check out my website for details

Hi Jerry,
>>> The wrong word, spoken at the right time to a vulnerable child can be devastating. People who develop speech avoidance are victims of accumulated traumas that are shuttled into hiding.
1) How do you explain that genetics research has shown that genes contribute about 70% to the occurence of stuttering. For example, twins which share the same genes (monozygotic twins) are 3-4 times more likely to stutter both than dizygotic twins?
2) How do you explain that the vast majority of kids who experience trauma do not become stutterers?

Hi Tom,
Great questions…ones asked often…Short answer=all depends upon STUTTERING DEFINITION
Jerry Halvorson

Hi Jerry,
sorry but that answer is not good enough for me. So what is your definition of stuttering?
You also claim that the Monster Study has caused children to stutter. This is factually not correct as the claimants of the compensation trial were rewarded damages not for existing stuttering but for psychological trauma and others.
Best wishes,

Hi Tom,
My book, Regression Therapy For Stuttering, will answer your questions.

Hi Jerry,
With all respect, but that is a very cheap answer and you are avoiding the answer which of course you cannot have because what you say is not supported by evidence. You should be more careful what you write, because there are many real people out there who suffer from their stuttering and it is my duty to present them with hard evidence. Stuttering is not caused by traumatic events in childhood. That is the opinion of all leading therapists and scientists.

-no more emails-

Knew what to say but...

I came across the disorder called Broca’s aphasia (or expressive aphasia), and I was struck by this statement on the wikipedia entry:
Patients who recover go on to say that they knew what they wanted to say but could not express themselves.
That's exactly what people who stutter experience. We know exactly what we want to say but cannot pronounce the words fluently; as opposed to express themselves:
Sufferers of this form of aphasia exhibit the common problem of agrammatism. For them, speech is difficult to initiate, non-fluent, labored, and halting. Intonation and stress patterns are deficient. Language is reduced to disjointed words and sentence construction is poor, omitting function words and inflections (bound morphemes). A person with expressive aphasia might say "Son ... University ... Smart ... Boy ... Good ... Good ... "
To summarise, the internal thought processes do not seem to be directly related to speech or grammar: We think somewhere else and our thoughts are coded into grammatically correct sentences, coded into speech motor sequences, and send to our speech muscles. But where do we think? That is a deep puzzle in neuroscience.

Thursday, March 06, 2008

Stuttering starts 13.7 billion years ago

I have to share with you this beautiful picture of the temperature distribution of the universe called micro-wave background radiation: see here. It is a snapshot of the start of the visible universe when the universe cooled down sufficiently from the big bang to allow light to travel over long distances rather than being re-absorbed by the hot plasma. This event happened 300'000 years after the big bang which happened 13.7 billions years ago.You can see that the temperature (which is -270 degrees Celsius!) is not completely evenly distributed; there are minute difference of 0.0001 Celsius. These differences are the seeds that made galaxies form, and stars, and planets, and life, and humans, and people you stutter! Without these tiny temperature fluctuations 13.7 billion years ago you wouldn't be stuttering! Isn't that amazing.

Wednesday, March 05, 2008

Stuttering produces no genuises

This Telegraph article describes that Prof of Psychiatry Fitzgerald believes:
"Psychiatric disorders can also have positive dimensions. I'm arguing the genes for autism/Asperger's, and creativity are essentially the same.
I only agree to some degree. A mild form of autism might push people to do extraordinary work, but in the vast majority of cases they just suffer from their disorder without doing any high standard work. Some researchers even view autism as an extreme version of a male brain with more of its strengths and weaknesses!

A reader has sent me the article and asked whether this is also true for stuttering. First, stuttering is not a psychiatric disorder but a motor-control and integration problem that leads to psychological and social issues. We have an average brain with average capabilities. Second, I would argue that any disorder that doesn't kill you and that can be overcome to some degree may be a source of motivation. The saying goes: What doesn't kill you makes you tough. I have seen many people who stutter who were successful because instead of giving up because of stuttering draw an enormous amount of drive and motivation from it. And, it is an open secret that over-protected kids from caring and wealthy families rarely make it big; they just don't have the need to do so. With exception of Paris Hilton, maybe. Of course, we need to contrast this with the many (in fact the majority of people) who live a life below their potential due to their stuttering.

Finally, let me assure you that even if stuttering does not lead to geniuses, stuttering does not prevent you from being a genius either! So there is hope for us all. ;-)

The Hawthorne Effect in stuttering

Have you ever heard of the Hawthorne effect in psychology? A study looked at the impact of the lightening condition on factory workers. They increased the lightening, questioned the workers, and got a positive feedback: the workers enjoyed the improvement. Then, just be on the safe side, they re-did the same experiment but now they decreased the lightening. Results? The workers gave positive feedback again! So any change provoked a positive feedback. Some speculate that workers just reacted positively because someone was finally given them some attention and they wanted to support them.
I am convinced that the same could happen in therapy. Assume that a therapy is made of 5 components A,B,C,D, and E. If you increase any of the five components in importance, you will get a positive feedback from people because they see how much you invest in improving the therapy and they do not want to disappoint you.
Another experiment that I have in mind is the following. Drop one of the five components, lets say A, and do the test but without telling them about the test, I am convinced the therapy outcome will stay stable. OK, then you can argue that A is not needed. Repeat this test with the remaining four and always drop one component. I am convinced you will always get similar results. So at the end, you can conclude that no component is crucial by itself, so what did produce the improvement? You could always first drop A, then also drop B, then drop C too, and so on. Again I would say that the results will not dramatically change. OK, maybe at the last one because you give them no therapy.

Tuesday, March 04, 2008

Oxford Dysfluency Conference 2008

The registration for the Oxford Dysfluency Conference in Oxford, England, is open. You can register here. I have attended the last conference, but I am not sure whether I will attend this summer's conference as I have to pay all the costs myself. I also missed the deadline to submit an abstract, and I always find it difficult not to talk!

The theme is interesting and noble: Integrating the Evidence: Scientist, Clinician and Client. But, have a look at the composition of the organising and review committee and you immediately notice that it's the old socks of the last years! A committee chaired by the main sponsor of the conference the Michael Palin Institute, dominated by the standard UK clique of therapists, by women (a blatant discrimination against men. no wonder men are hesitating to become therapists in the UK!!), and all therapists except Dave Rowley. And if they want to include science, how come that the only person who has a decent scientific background though not involved in ground-breaking science is Dave Rowley, the conference organiser. And if they want to include the clients, how come no-one from the self-help movement or the British Stammering Association, is part of it??? I am not saying that the reviewers are not good therapists. In fact I know most of them personally (though not sure how much longer maybe :-), but they should have added a few international and leading scientists and therapists. I have spoken to a few international leading researchers and they were all not very keen on the conference and dismissed it as too UK-focused, only therapy-focused, and more-like-a-big-feel-good-happening-of-old-friends than a serious conference.

Monday, March 03, 2008

Another example on how not to do an RCT

Here is a second random control trial on the Lidcombe treatment (speech therapy for kids at onset of stuttering) by a German team of researchers. I think it is derived from Tina Lattermann's PhD thesis:
In order to investigate whether the Lidcombe Program effects a short-term reduction of stuttered speech beyond natural recovery, 46 German preschool children were randomly assigned to a wait-contrast group or to an experimental group which received the Lidcombe Program for 16 weeks. The children were between 3;0 and 5;11 years old, their and both of their parents' native language was German, stuttering onset had been at least 6 months before, and their stuttering frequency was higher than 3% stuttered syllables. Spontaneous speech samples were recorded at home and in the clinic prior to treatment and after 4 months. Compared to the wait-contrast group, the treatment group showed a significantly higher decrease in stuttered syllables in home-measurements (6.9%SS vs. 1.6%SS) and clinic-measurements (6.8%SS vs. 3.6%SS), and the same increase in articulation rate. The program is considered an enrichment of currently applied early stuttering interventions in Germany. Educational objectives: Readers will discuss and evaluate: (1) the short-term effects of the Lidcombe Program in comparison to natural recovery on stuttering; (2) the impact of the Lidcombe Program on early stuttering in German-speaking preschool children.

It is frustrating to see that their study has the same flaws than the random control trial published in the BMJ: see my rapid response here.
First of all, they have not taken enough children and have failed to understand that the natural recovery rate is undermining the standard random control trial. They need to take double the amount as I explained in my rapid response. Second, they have only looked at a period of 4 months post treatment which leaves so much room for alternative interpretation. For example, many children might well relapse as is well known in adult therapy, so an observation period of 1-2 years is the minimum. Another interesting alternative interpretation is that those who would recover naturally anyway actually recovered faster due to the treatment and it looks as though there was therapy success! Why on earth would a journal still publish trials with only 4 month post-treatment observation period??
Then, you should look at the results. Just look how variable they were. The kids were measured with 1.3% stuttered syllables at home and 3.6% in the clinic. Assuming the clinic measurement is more reliable, the stuttering rate did drop from 6.8% in the non-treated kids to 3.6% in the treated ones. But 3.6% stuttered syllables means that on average the kids are still stuttering because 3% is considered the borderline! Not very convincing at all, especially because the drop might well be due to the kids being more trained to perform when in the clinic. Even if it is real, the study then confirms that the Lidcombe treatment is NOT effective at treating all kids. And I would even speculate that if the child has remaining dysfluencies above 3%, they will be the seed for full-blown stuttering at some point in the next years. So maybe despite the flaws, the study did show that Lidcombe is not perfect.
But rest assured, we will hear that "Lidcombe has now been confirmed by a second random control trial to be an effective treatment for children". Why can't the researchers get their act together and conduct a proper trial so that we can solid results with no loophole?? My hope is that Marie-Christen Franken's trial which tests Lidcombe against Demand and Capacities therapy will do exactly that: see here!