Mixing reference frames

Regarding my last post, John wrote:

Seriously though ... I see your point but don't totally agree. In my own therapy in October, my therapist really did teach me how to speak effectively. She taught me total control and introduced me to controlling my fluency in the outside world. I suppose she could try to motivate me, and she does to a certain degree in follow up sessions. But really, the ball's in my court. Even if I decide to stick it in my pocket and insist that she has it.

We are mixing different frames of reference.. :-)

I completely agree that in your situation (the patient's reference frame) the best strategy is definitely "the ball's in my court", because you can only change yourself, and not wait for the outside world to change you. I recommend everyone who is "on a therapy" (sounds like "on a diet" :-) to be 100% determined for change and take control of your destiny.

However, once you shift from the first-person to a third-person view, the ball game is a different one. It makes sense to say:

1) the patient did not work hard enough.

2) the therapist was not able to motivate the patient more. (What I actually mean is to give the patient tools to motivate himself.)

3) The therapist did not find the therapy that requires least motivation.

4) The therapist community failed to develop a therapy / treatment that requires less or no motivation.

Another example is diets. Forget all diets, I can tell them "I make you slim. You only need to follow my rules."

My rules are simple:
1) Dont take a second serving.
2) Eat a fruit instead of chocolate or crisps.
3) Do physical exercise twice a week for one hour.

If you follow my rules, you WILL become slim. Virtually all diets follow this pattern. The patients' best strategy is to be 100% determined. However, the sobering fact is that only 5% keep off the lost weight and the average weight will be slightly higher a year about the diet!! Still, your best strategy is to be 100% confident about the outcome. (I am not going into the debate that some people due to their genetic makeup are less likely to relapse.)

Or as Carl Joakim Gagnon wrote:

The basic distinction is an interesting one. It's the one philosopher Thomas Nagel talks about: viewing oneself either as a scientific object, at the mercy of forces we can try to understand, or as an autonomous being with responsibility for ourselves.

Motivation - everyone's loop hole

This post is about motivation and stuttering therapy. Ideally, a good treatment for any disorder does not require any motivation from the patient. For example, if I break my arm, the doctor will fix the bone. There is no motivation required on my part to assist in the treatment. The same is true for one-off pill treatments like to get rid of a headache or worm infections. You take one pill and that's it. The next level is taking pills over a longer period. Again, little motivation is required on the patients part, except of course taking the pill every morning or evening. But you would be surprised how many patients actually do not take their pills either they simply refuse, they forget to take them, they change the dose themselves, stop after symptoms stop or have a fear of swallowing pills. Amazingly, even such a low degree of required motivation considerably reduces the efficacy of treatment! So the lower the motivation required the better.

The next level is treatments that require more time possibly with inconveniences, like doing exercises for your back or going swimming. I still have to meet the first person that has always followed such treatment regime! Finally, the highest degree of motivation is needed for behavioral therapies where you need to change the way you do certain things and implement them in your daily life. To summarise, you need to work on yourself hard. Stuttering therapies are one such therapy. Others are going on a diet and keeping off the weight, and getting off legal and illegal drugs for good.

The fact that motivation is an essential part of the present stuttering treatments is of course unfortunate, but the reality. Our hope is for a better understanding to allow us to reduce the degree of motivation needed. The current situation leads to a very convenient loophole for therapists. Very often unprofessional and professional therapists blame the failure on the lack of motivation on the patient's side. It is obvious and perversely even correct: the more you are motivated, the more fluent you can become. But the situation is more complicated. The reasons for failure are
1) the patient did not by himself generate sufficient motivation, but also
2) the therapist did not succeed in getting the patient to generate sufficient motivation.
3) the therapist's choice of treatment requires a high level of motivation that considerably increases the likelihood of 1) and 2).

I get rather annoyed with people and therapists telling me: "Why did you not practise more?" I often answer to therapists: "Well, why don't you develop a therapy that requires less motivation?" I recognise of course that this line of argument is also a convenient loop hole for people with PDS. I can blame my failure on the therapists. Seriously, couldn't I have done more? So let me, in line with my personality (it seems :-), blame everyone for abusing (lack of) motivation as a convenient way-out. When a person who gets therapy fails, patient and therapists are both to blame.

On brain research

I got an email from George D asking me interesting questions on brain imaging, which might also interest you.

George: It seems to me that there have been a few problems with the approach to the research. 1) All of the studies have been done on adult stutterers, and this will always leave open the question of whether the observed differences reflect acquired characteristics - or *learned* behaviours/strategies - or whether they really do reflect inherent, hard-wired neural differences.

The researchers look for across-the-sample CONSISTENT differences. This eliminates individual characteristics like "I use filler", "you have silent blocks". The pathways and activation would not be the same, and so eliminated.

Thus, individual coping strategies should be eliminated, but not systematic ones not e.g. everyone gets more tense. This makes things more difficult, but at the very least shows us what the core of stuttering is.

So what you see are correlations. The interpretation is of course more difficult, but by adding theoretical reasoning, including non-brain findings and varying experimental designs you can start to distinguish between what is a consequence and what a cause. This is currently underway.

George: Obviously, doing brain scans on little children (thus exposing them to radiation) is not ethical.

fMRI does not give out radiation, only a strong magnetic field. I think that researchers are now comfortable scanning younger children. But I dont know the details. Sounds like an interesting post for my blog! :-)

George: Most (if not all) brain imaging appears to have been done with fMRI or PET. PET and fMRI have inherently very limited temporal resolution, and to research stuttering, higher resolution is required because speech/language processing takes place in a matter of milliseconds. One idea is to use PET/fMRI together with magnetoencephalography (MEG), which has excellent temporal resolution. I guess this may already have been done??

Yes, there is a paper by Samelin. See here. But I am also surprised why so little MEG work has been done. I need to find out.

George: The number of imaging studies done on stutterers seems to be small, so the results may not be a true indication. Actually, I don't know whether the number of studies is small, but I suspect that it might be.

No, I have counted more than 10 studies. So it is pretty safe. In any case, it would be highly strange if brain imaging hadnt found any functional difference because our brain is sending the stuttering signal to our muscles. Structural abnormalities is another issue.

See here.

Myth propagation: Lidcombe

The stuttering research literature and its transition to the mainstream have always frustrated me. I hear people making statements based on research articles or some magical consensus view. However, the research rarely proves what people interpret from its findings, and its findings are often flawed due to weak methodology. And, the consensus view either does not really exist or is a good example of how the strength of an argument is not related to a majority supporting it (but you can argue that the likelihood of the statement being true is higher). Following up the lead of the source, and the source's source, and so on, decreases the certainty on who the source is and the accuracy of the interpretation of what the source actually said. As a teenager I spent my Christmas holidays in a youth winter camp in the Swiss Alps, and in the evenings we often played an interesting game, that I am sure most of you have played, too: You sit in a circle, and the first person whispers a message to the next person, and round it goes through the circle. The first person never got his first message back.

A recent example of my frustration is the random control trial research article on the Lidcombe treatment program for stuttering children. The mainstream talk is that this article has shown that the Lidcombe program effectively cures stuttering children. (Please note that I am not actually claiming that the authors say this.) I have spoken about the stats obsessively in several posts: see here. Today, I re-visited the article and actually realised that the interpretation possible are rather limited due to their design.

They have randomly chosen two groups of stuttering kids, and only treated one group. And they found that the treatment group is more fluent; and therefore claiming success. However, the standard random control trial setup has a different purpose: see whether there are above-placebo benefits. You administer a pill to BOTH groups, and therefore BOTH groups do not know whether they receive treatment or not. In the Lidcombe study, the treatment group and their parents knew that they received treatment. The extra fluency in the treatment group could mean three things:

1) Success due to the placebo effect: believing heals. (Admittedly, even placebo effect is good if it is permanent!)

2) Success due to additional-to-placebo effect: the Lidcombe study has a treatment component that is successful. This leaves open the possibility that all other known treatments like demand & capacity would be as successful. For example, the treatment component might be ANY extra attention given by parents to their stuttering child. A study by Franken et al. compared Lidcombe to demand & capacity and find no difference in outcome. (However, I think their sample size is rather small.)

3) Success due to unique-to-Lidcombe effect. Lidcombe is more successful than other treatment approaches because of treatment component X, Y, and Z.

As you can see the study leaves all three options open, but the mainstream talk is virtually exclusively about option 3 even though this is not the only possible interpretation of the data!!!!

More fluent without hearing

Sometimes I speak with Per Alm over Skype. I asked him whether people with PDS stutter less when they do not hear their voice. And he confirmed my suspicion. He also mentioned that van Ripper reports on two case studies where people with PDS became fluent after having become deaf. Of course, these are anecdotal findings.

And, we need to be careful not to read too much into this correlation between fluency and hearing. This type of findings does not imply that a bad hearing system is to blame for stuttering. I would rather guess that the person now needs to concentrate more on his speech, and this makes him more fluent. This would put the no-hearing-more-fluency findings into the category of fluency inducing tasks like singing, shouting, acting, speaking with a foreign accent, and more.

Stuttering after accident.

Here is a Mirror article on a UK singer Marc Almond who after a car accident started stuttering again. He stuttered as a child. Would be interesting to put him in a brain scanner!

PhD scholarship

Here is an advertisement for PhD scholarships, which could be linked to stuttering. Contact Robin Lickley, the younger Scottish generation's answer to Sean Connery. :-)

PhD positions funded by the European Commission under the Marie Curie Early Stage Research Training (EST) scheme are available on the Edinburgh Speech Science and Technology (EdSST) project. This is an interdisciplinary training programme in speech science and technology featuring a strong interaction between the two disciplines. Two of the available topics are applications relevant to stuttering:

Speech recognition applications for stuttered speech Dialogue training for people who stutter

Alternative topics which fit within the remit of EdSST are possible.

See http://www.cstr.ed.ac.uk/edsst/opportunities.html for further details.

Battle of the profs

They are still smiling, but soon they will be battling for truth: may the best win! The BSA magazine Speaking Out wants to run a debate between Scott Yaruss and Mark Onslow. Together with Speaking Out editor Andrew Harding, I will edit the debate for the BSA research committee. Should be interesting. I keep you updated and tell you when it's online. Most likely here where many past Speaking Out articles are. Thanks to the good work by Andrew Harding, and Allan Tyrer the BSA webmaster.

BSA Vacation Scholarship

Today is the deadline for the BSA Vacation Scholarship applications; I should have talked about the scheme a long time ago. :-( It is an initiative of the BSA research committee of which I am vice-chair and that I started in 2001 when I was a BSA trustee. We give students funding to do research work in stuttering over the summer to get them addicted to stuttering research. :-)

Read more here:

This year the Research Committee of the British Stammering Association is again running its Vacation Scholarship scheme to provide students with the opportunity to propose and execute a research project related to stammering. The project may take the form of original research or a review of existing research. Whichever approach is chosen the project should help the BSA to fulfil its vision of a world that understands stammering. Reviews should therefore also include a well developed proposal for future research for which the BSA could seek funding. The immediate aim of the scheme is to assist those who wish to conduct research into stammering, or related areas, in their future careers. The long-term aim is to increase awareness of the importance of research amongst professionals working with people wanting to improve their fluency.

Applications are invited from departments of speech language, psychology, medicine, social science or any allied disciplines, for students to work on a research project during the summer vacation. All applications should be submitted by the sponsoring departments on the students' behalf. Joint applications where two students share the work, and the bursary, are permissible.

Functional and structural abnormalities

Several research groups have now found functional and structural abnormalities in the brain of people with PDS.

Structural abnormalities:
Sommer et al
Jaenke et al
Watkins et al
Foundas et al

Functional abnormalities:
de Nil et al
Ingham et al
Fox et al
Neuman et al
Watkins et al
Salmelin et al
Mori et al
Blomgren et al
Stager et al

Lost student

I am a bit stressed. And no time for longer posts.

I recently chatted to a speech and language therapist, and she complained about the futile nature of studying for an exam on stuttering. What is the point of studying stuttering if everyone gives conflicting answers and not clear advice for treatment?

Are computers better?

I am wondering whether therapists can predict whether a child recovers or not more accurately than a simple computer algorithm... I could feed the algorithm with information on the age of onset, gender, and possibly family history, and then it would make a guess. I need to think about this more carefully.

Move your thumb

I heard that if you move your thumb while speaking, you stutter less! I am wondering that this effect has to do with the fact that the finger regions are close to the speech and language areas?

In a whim of a moment

Have you seen the recent movie Match Point directed by Woody Allan? Great movie: subtle and unpredictable yet realistic plot. The story plays in London featuring Upper Middle Class life, an ex-professional tennis player from a poor background climbs up the social ladder during his work as a tennis coach at the posh local tennis club. The theme is a common one: A small event can have a huge impact on your life. Remember the cliche: You miss the woman of your dreams by seconds. You get out of the bus seconds before the explosion. You miss the plane that crashes by seconds. And so on. I might have such a story, related to stuttering but not about my life.

In the neighbourhood next to my neighbourhood, a kid who stuttered lived. We never spoke but I knew he stuttered and I think he also knew that I stuttered interpreting from his facial expressions. During the summer holidays, the town council organised day summer camps, and he was there, too. One day I witnessed how he tried to explain something to a supervisor while we visited a mine museum. I thought to myself: My God, good lord I don't stutter that badly. Only later did I find out that I often stuttered as badly! You could sense that he really suffered also socially from his stuttering, more so than I did. At some point I lost sight of him. He was not at my high school, and then I left for England and the US to study and do a PhD.

Last year, I saw him again. He was also a spectator at the Open Beach Volley Ball tournament of my home town. (Over-)Loaded with years of self-help groups, therapies and involvement in the BSA and research, an evangelical fever came over me telling me: "You need to talk to him. Clear up your past. Ask him whether he also knew that you stuttered. And maybe give advise if he needs help." So I slowly approached him but then my courage disappeared. I felt a mental and stuttering block. He also looked a bit fearsome to me. He had gained quite a bit of weight, and really had a look of sufferance on his face. He looked uneasy with his life. So I told myself "leave him alone, you just shock him" and passed him, but we exchanged looks: he did recognise me, and might even have identified me as the kid from the neighbourhood next to his that stuttered, too.

Three weeks later, I read his death announcement in the local newspaper headed by "Life wasn't always very kind to you."! You can imagine that I was a bit shocked. It was clear to me that he committed suicide, though I don't know for sure, of course. My educated guess is that his severe stuttering had a major impact on his decision. He probably felt helpless, no means of communicating and expressing himself, and no good job perspective, maybe he was unemployed. God knows. I am wondering whether I could have made a difference? By chance, in a whim of a moment, I changed my plan not to talk to him. I don't feel guilty, as I did not make him stutter. But still, maybe I could have given him hope... A small difference might have made a huge impact on his life, or maybe not?

Only a sampling bias?

Scientific research is full of traps, especially regarding the use of biased samples. For example, the first polls in the US started in the early 1900, I think. And they got the prediction completely wrong, because they took voters out of the phone directory. But in early 1900, only wealthy people had phones and so they completely missed the non-phone population's political views which not surprisingly happen to be the opposite. And the candidate low in the polls won with a landslide. This post is about a possible sampling bias that creates an effect that looks intriguing and surprising, but is probably not.


Have a look at this paragraph:

"In the group of stuttering preschool children in the study summarized above (Yairi&Ambrose, 1999) their expressive language abilities were measured. The group with early onset stuttering, who entered the study at age 2-3, showed syntactic abilities and length of utterances well above what was expected for... In fact, in some aspects the language abilities in this group were on a level with the norms for 2 years older children. This was true both for children who recovered and for children who persisted to stutter. Children who entered the study at a later age showed language abilities at about age expectations, except for the group of children with persistent stuttering in the oldest age group (entering the study at age 4?5), whose abilities were somewhat below the norm. These results indicate that children with early onset stuttering tend to show precocious learning of language."

So does early language development causes stuttering? This is also what I was asking myself, but it didnt make too much sense to me. I heard many people quoting this study and another one by Rommel et al. (In Montreal, I went to see a Radiohead concert with Rommel.) But now I believe that this finding might be nothing else than a sampling bias effect. On the STUTT-L mailing list, Don Luke made an interesting observation: "This would make sense. All these children began stuttering upon reaching the same point in their development of language skills."

Here is my argument:

1) Let us assume that stuttering starts at a certain stage in the development (of language and speech skills). This is a very reasonable assumption to make.

2) Children naturally fluctuate in their development; some are earlier than others, but starting early does not mean having superior abilities later.

3) So the early-starters hit the critical stage first where they are vulnerable to stuttering!

4) So early-onset stuttering kids have early development and therefore superior-than-peers language skills at that age (but not necessarily in adulthood)


So I hope you can see that this is a pure statistical effect that has nothing to do with a direct casual link to stuttering. There is only a correlation. It might also be that late-starters go through that stage too late to start stuttering for whatever reason.

DISCLAIMER: I have actually not read the articles in detail, so I might start from a wrong premise, but the stats argument must be correct as it is maths.

More intelligent?

I am virtually convinced that a well-designed experiment will NOT show any link between stuttering and intelligence.

The only arguments I could come up with that there should be a link are

1) IQ is partially due to the environment, and a person who stutters reacts different to an environment. But this could go both ways. For example, as a teenager he withdraws and reads a lot of book or works with computers. Or, for example, his stuttering hinders him from participating in class and he is turned off by learning.

2) Stuttering is sometimes part of serious development problems in kids which lead to mental retardment. This would drag the average IQ down. But they are not typical stutterers.

I think the two effects are negligible. And one can also argue that 2) should not be included anyway in the sample.

Why would there be a connection anyway? What has speech to do with intelligence? Also brain imaging studies mostly show abnormality in structure and function in speech and language related areas. IQ is mostly associated with the frontal cortex.

Discrimination against men

Let me play devil's advocate.

I constantly hear that women are discriminated against based on the argument that "Women are underrepresented in X, so they must be discriminated against, because they are equally able and any lack of interest is pure social conditioning".

So lets turn this argument around.

Why are there so little male speech and language therapists? Are men being discriminated against? For example in the UK, I just know of one male SLP.

The other question one needs to ask is whether women SLP can truly understand the needs of male stutterers.

I have the impression that many (but certainly not all) fail to understand what works with men. Many (but not all) men don't want long talking sessions, they want targeted practise with specific goals and ideally in a competitive setting. They don't mind being told off from time to time.

Interesting biography

In my last post, I speculated that the main author Sarah Smits-Bandstra is Luc de Nil's PhD student. Actually I found her "interesting" biography at the end of the article. Such short biographies are typically intended to present the author's academic background and research interests. Here it is:

Sarah Smits-Bandstra is a registered Speech-Language Pathologist and a doctoral candidate at the University of Toronto. She is married and has a beautiful baby boy named Reid. Her research interests include the neural mechanisms of disfluent speech, and stuttering treatment effectiveness in preschool and school-aged children.

She is clearly in "a chemically enduced form of madness" (citation by Rita Carter from her book about the human brain when talking about human love). I am wondering whether my mother would go to lengths to claim that a) she is married and b) has a beautiful boy named Tom? But then again she is 60, off the hard drugs and much wiser. :-)

What does it mean?

I found this very interesting article on PubMed: here.

Luc de Nil has done a lot research in the past. I am aware of his brain imaging studies, and research on dual tasks. Webster was the first to show that people with PDS are less good at dual tasks. In their article they conclude that people with PDS take longer to automatise finger sequences. The first author is probably one of Luc's students or researchers.

"The present study compared the automaticity levels of persons who stutter (PWS) and persons who do not stutter (PNS) on a practiced finger sequencing task under dual task conditions. Automaticity was defined as the amount of attention required for task performance [Parasuraman, R. (1998). The attentive brain. Cambridge, MA: The MIT Press]. Twelve PWS and 12 control subjects practiced finger tapping sequences under single and then dual task conditions. Control subjects performed the sequencing task significantly faster and less variably under single versus dual task conditions while PWS' performance was consistently slow and variable (comparable to the dual task performance of control subjects) under both conditions. Control subjects were significantly more accurate on a colour recognition distracter task than PWS under dual task conditions. These results suggested that control subjects transitioned to quick, accurate and increasingly automatic performance on the sequencing task after practice, while PWS did not. Because most stuttering treatment programs for adults include practice and automatization of new motor speech skills, findings of this finger sequencing study and future studies of speech sequence learning may have important implications for how to maximize stuttering treatment effectiveness. Educational objectives: As a result of this activity, the participant will be able to: (1) Define automaticity and explain the importance of dual task paradigms to investigate automaticity; (2) Relate the proposed relationship between motor learning and automaticity as stated by the authors; (3) Summarize the reviewed literature concerning the performance of PWS on dual tasks; and (4) Explain why the ability to transition to automaticity during motor learning may have important clinical implications for stuttering treatment effectiveness."

I still don't understand how it can fit into my picture of PDS. Weak connections between speech and language areas cannot explain these findings. It is possible that both the weak connection and the lack of automaticity are both caused by something else.

From my experience, I certainly have trouble automatising sequences fast and loose such automatisms under stress quickly. I remember that I had especially trouble learning all the katas (a set of exercises, a bit like a dance) in Karate...