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.

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 http://jerryhalvorson.com/, 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 jerryhalvorson.com
Jerry

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?
Tom

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,
Tom

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

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.
Tom

-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.

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.

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.

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.

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!

Vivian Sheehan

I got this email from a reader Jack Brooks on Vivian Sheehan, a well-known speech therapist, working together with her husband Joseph Sheehan: see this page for some audios. (Also check out a documentary on the Sheehans.

I came across your blog and wanted to share my experience as a stutterer in therapy with Vivian (and Joseph) Sheehan:
Unfortunately, I learned of Vivian Sheehan's passing only recently and had been out of touch with her for several years due to relocating. My own experience with Vivian and Joseph Sheehan was as a severe stutterer who participated in the UCLA Group Speech Therapy Program in the mid 70's after fatefully seeing the Sheehans with Mel Tellis on a daytime talk show and thence contacting Vivian. She interviewed me thereafter at their house in Santa Monica and I saw immediately her deep understanding and empathy of the challenges faced by a stutterer.
After "passing muster" as a willing stutterer with Vivian, I participated in 3 rounds of the eight-week group sessions at the UCLA Clinic Speech Therapy Clinic with her, Joseph, and other therapist/trainees. This, unlike my prior years of well-meant but ineffective private therapy by highly respected speech therapists, was to be the life-changing help that enabled me to "earn the fluency" that came as a by-product of the real treasure that the Sheehan therapeutic process gave us participants, which was learning to become a stutterer "easily and openly."
Joseph and Vivian's radical but utterly logical therapy led this fearful, shamed recluse into becoming an excited, gregarious stutterer, who'd talk your ear off about "my stuttering," while looking deeply into your eyes, on fire about the new passion of communicating with the rest of humanity after so many years of self-confinement in a prison of fear to speak.
After Joseph passed, I went on to attend Vivan's Clinic at St. Joseph Hospital in Santa Monica periodically for "tune-ups" and to maintain contact with her. Visiting her at home once, when I expressed my interest in how "it all started," she freely shared copies of some of Joseph's groundbreaking early papers and writings that were the foundation of their therapeutic model. In early 2000, I had the privilege of attending a pre-retirement gathering at her house with of some of the stutterers who'd continued working with her and was able to share my deep gratitude and continuing inspiration for speech that she and Joseph so lovingly fostered.
My mother, also a stutterer, had said, "it takes a stutterer to know one!" Joseph Sheehan, a stutterer himself, knew this full well. I firmly believe Vivian did as well. She will live in my heart always.

What's in the crystal ball?

I got an email from Ora from New York who, instead of just speculating like I always do (remember I am a theoretical physicist! :-), has actually called up Indevus, the owner of Pagoclone, again and asked whether the trials will move to Phase III stage: see his first call. Not sure I learned anything new, but here is his summary:

She reported, there really isn’t much of an update since we last spoke [in December]: We’re still in partnership discussions and we’re still optimistic. The last time we spoke, I expected that we’d have something finished by end-of-year, but of course the problem with offering a timeline is that things always take longer than you hope, never shorter.
She said: We’ve been talking with more than one company. I said, this apparently means that the discussions are not as far along as I had previously optimistically assumed. She said: Well, it’s actually possible to have discussions with multiple companies simultaneously which are in a late stage; it’s not uncommon to do so, because there can be snags with one company and you don’t want to start over. All along we’ve been in discussions with multiple companies. We still consider this an important asset for our company and we want to get it into good hands to maximize its value to our shareholders. As previously reported, we don’t want to develop it ourselves because it’s outside of the core competency for our company.
I asked, what’s the status of the Phase II trials? She said, Phase II has ended, except for the open label phase; participants were given the option to continue; we’re still continuing to monitor. Anecdotal reports continue to be favorable.
I said, I keep looking for a scientific article. She said, actually we’ve submitted to a couple of different journals. But publication is not up to us, it’s up to the journal and their sense of the importance of the results. We’d like to have it published because it’s good publicity for us...The journals tend to be more interested in Phase III results because it’s closer to becoming a reality.

Research from Iran

I am happy to see that there are also Iranian researchers working on stuttering. As with the Chinese, I have always been impressed by the Iranians I have met. They were highly educated and very civilized. The Iranian news agency talks about research on a computer model to simulate human speech processes and thereby showing that basal ganglia malfunction could be at the core of stuttering: see here. I am impressed by how scientific and clear thinking the article is, unlike 90% of articles from Western authors. If anyone knows who the researcher is, please let me know! Here is a shortcut of the press release.

Iranian researcher in medical engineering has worked out a project examining impacts of medical treatment on patients suffering from expression difficulty, stuttering. He managed to design a computer model upon the brain function to monitor the impacts of the medical treatment.
The mechanisms behind the stuttering are still not clear and scientists have introduced variety of reasons for it but a major line of research over at least three decades has investigated the possibility of a speech motor control disorder as at least one component that this is influenced by emotional stats and environmental factors.
There are strong indications that the basal ganglia-thalamo cortical motor circuit, through the putamen to the supplementary motor area, plays an important role in the pathophysiology of stuttering. Also the influence of emotional states on stuttering is well compatible with the suggestion of stuttering as a basal ganglia disorder.
Hence, the core dysfunction in stuttering is the impaired ability of the basal ganglia to produce timing signals because of the unregulated value of dopamine receptor density in it.
Although scientists showed the relation between the basal gang and stuttering, but yet there is not appropriate computational model to show this relation quantitatively. In this study, we propose a computational model that explains the role of basal ganglia in stuttering.
Different parts of the brain involved in stuttering are all considered in our model. Our computational model has considered the involved parts of the brain in a fairly accurate way, explaining the behavior and mechanism of the disorder according to physiological information.
Using this model, we can predict the effect of changes in dopamine and other basal ganglia neurotransmitters in different situation such as emotional states.
Also, we can predict the effects of different drugs on the stutterers.

What many therapists really think!

Have you ever wanted to know what your therapist really thinks? Here it is. I got an email from a therapist who shared his private views. I find that his views are quite similar to what other therapists tell me privately:

I am from Australia and currently work as a speech pathologist (as we are known here). I do not specialise in stuttering, but have seen around 15 cases of stuttering in children aged 4-14 since graduating 7 years ago. I read some of your blog early last year, and was reminded of it when I found an old email that I'd sent to a friend, who used to be a speech pathologist, regarding your "Do therapists believe in their therapy?" post. I thought what you wrote in this post was very accurate, and can be applied to other areas of speech pathology besides just stuttering. Currently, high-level scientific evidence (from meta-analysis of several independent randomised controlled trials) is lacking in virtually all areas of the profession. Your blog has many valid points regarding therapists and therapy for stuttering. I commend you for taking a sceptical approach to stuttering therapies, and am writing to tell you of some of my experiences. When I was a student, I took a semester subject on stuttering in the 3rd year of the degree course (of 4 years). The subject differed to other speech therapy-specific subjects in the course, in that it only had one lecture given by somebody other than the subject examiner. Nearly all of what was taught in the subject was 'smooth speech' (a variant of prolonged speech) for adults, and the Lidcombe Programme for children. I felt very much that the therapy techniques our lecturer used/preferred were emphasised, rather than giving equal time to other techniques. Much lecture time was also spent on practising 'rating' videos of stutterers - where we would count the number of syllables spoken, syllables stuttered, etc. We had a few 'recovered' adult stutterers who had gone through the university's intensive fluency clinic (learning smooth speech) speak to us of their experiences. We got to observe our lecturer taking a case history with an adult, and deliver a therapy session to a pre-school child.

In the final year of my degree, there was the option of undertaking an intensive fluency ('smooth speech') clinic with adults, but not everybody undertook this placement as it was part of an elective clinical subject, and not a core one. I did not do this placement, and the only stuttering clients I saw as a student were 2 adults, for 2 sessions each, in another placement at a rehabilitation hospital. I never directly worked with a child who stuttered until my first employment upon graduation. This level of exposure to stuttering would not have been uncommon amongst the students in my course. From my experience of working with children who stutter, the 'success' stories have all been with students aged under 7 (mostly under 6), and using similar techniques to the Lidcombe Programme and environmental modification (i.e. counselling parents and teachers on how to maximise their child's fluency/modify their own speech/what to do when the child stutters). I don't feel as though I have directly 'cured' the stutter in these cases, even though the students have gone on to have fluent speech. Rather, I may have helped assist/speed up the natural recovery process, and minimised the risk of the stutter becoming worse. It's possible that these children may have recovered on their own without my input. I must say that I do feel less competent when working with older students who stutter, because I feel that the expectation is that speech therapy should be able to 'cure' the stutter, but so far I've not been able to do this with the handful of older students I have seen. The stutter is usually also more advanced, and the student has passed the period of likely spontaneous recovery.

I agree with you on thinking that therapists' focus on the other, non-speech stuff may be because deep down they know (or soon realise) that fluent speech maintained over time isn't likely to occur due to their therapy; and that it's too easy to blame it on the patient when the therapy doesn't work. One of the greatest barriers to developing 'expertise' in stuttering for the typical speech therapist is that it isn't something that most of us commonly see. I might see 2 students who stutter a year, but 100 or so students for other speech/language disorders. Frequency and duration of therapy is also another issue, as currently I am typically able to see a student once a fortnight maximum during the school year. Also, there are also always new referrals/assessments, etc. to be done. One of the most frustrating things I think I would find with speech therapy, if I stuttered, is the therapist believing that *they* are the 'expert' in stuttering, when they haven't stuttered a day in their life. By the way, the lack of male speech therapists isn't just specific to Europe - in Australia it's around 3% male, and I believe something like 6% of ASHA members are male in the USA.

The Stutter Blog

Here is a new blog called TheStutterBlog. Most posts talk about stuttering research. Here is one I found interesting:

A study released by the University of Canterbury, Department of Communications and Development, suggests that stuttering in young children may not be linked to any kind of personal anxiety.

By measuring the cortisol (a hormone linked to anxiety & stress) levels in the saliva of children ages 3 and 4 years old, researchers found no higher levels in the children who stuttered versus those who do not.

According to Bianca Phaal, the masters student who recently completed the study, “Results of this study suggested that generalised anxiety and communication apprehension are not associated with early childhood stuttering, therefore it is unlikely anxiety is the root cause of stuttering”.

A Challenge to Lidcombe

I have been criticizing the Lidcombe random control trials in many posts (see for example here or search for Lidcombe in search bar) as not very convincing evidence due to methodological weaknesses and their uses as evidence to spread the message. It has been three years since the trials and the kids should now be at least 6 years old. I challenge them to publish data from those 50 or so kids that underwent treatment. How many are still stuttering? At ISA in Croatia, I or someone else asked Mark Onslow this question, and his answer was not very clear, but I recall something like "There are about 70%-80% fluent. So maybe Tom is somewhat right..." I didn't follow up as I should have.

So again: What has happened to those 50 kids? What the Lidcombe people should do is the following: Ask an INDEPENDENT researcher to look at those 50 kids and evaluate their speech, and then make the results public. If all or nearly all kids are fluent, I will been more convinced about the efficacy. So if any of you hears someone cite the random control trial, ask the speaker whether three years later an independent person has confirmed that nearly all are now fluent!

Richard Curlee died

Prof Ingham has informed me that

we lost one of the major players in stuttering research. Richard Curlee passed away in Tucson AZ. He had been hospitalized for some time with reoccurrence of conditions likely related to his polio when he was a child.

I have never met him, but I found two books on stuttering. Here is a biography:

Richard F. Curlee was a professor and head of the Department of Speech and Hearing Sciences. He is a graduate of Wake Forest College, and earned master's and Ph.D. degrees in communicative disorders from the University of Southern California. He has been on the faculty at the University of Arizona since 1975 and teaches graduate courses on stuttering, counseling and research design, as well as an introductory undergraduate course. He is a speech-language pathologist with clinical and research interests in the study and management of people with communication disabilities, especially those who stutter. He has authored or co-authored several dozen articles and book chapters on stuttering and co-edited two texts on its nature and treatment. He has been an Associate Editor in the area of stuttering for both the Journal of Speech and Hearing Disorders and the Journal of Speech and Hearing Research. At present, he is an Associate Editor of the Journal of Fluency Disorders and the Editor of Seminars in Speech and Language. He is a member of Phi Beta Kappa, Phi Kappa Phi and Sigma Xi, and a member and Fellow of the American Speech-Language-Hearing Association.

New book by Prof Ingham

Roger Ingham has edited an interesting new book on neuro-imaging in communication sciences and disorders, which is very much in the same spirit as this blog, namely that neuroscience (and genetics) have given scientists new tools to explore and better understand stuttering. Here is the book cover text:

There can be little doubt that the huge developments in brain imaging technology over the past 15 years have opened up a whole new vista of possibilities for the assessment and treatment of human communication disorders. At issue of course is whether those possibilities are being realized and what form of influence this will have on the field speech-language pathology and hearing disorders in the immediate future. The rate of development in neuroimaging is so rapid that it is almost impossible to predict very far into the future in trying to understand this influence. Nonetheless, it is now becoming clear that the availability of technologies that make it possible to investigate, even in real time, the neural regions and systems that are functionally related disorders is having a transforming impact on the discipline. In this series we have brought together some of the principal researchers in our discipline and who are working at the "cutting edge" in applying neuroimaging to communication disorders.

China pushes into stuttering

I am pleased to see that Chinese scientists are also pushing into stuttering research. I have always been impressed by their drive, patience and cleverness. It is an open secret that the outstanding success of US science has often been driven by foreign (including Asian) scientists at US universities, and not by the more commercial and evolution-denying US Americans, but who have provided the financial and political safe haven needed for science to prosper. China is changing and more Chinese scientists see a good future at home. Check out their abstract here. They found structural differences in stuttering brains using MRI. I need to look at their article to know more.

Song LP, Peng DL, Jin Z, Yao L, Ning N, Guo XJ, Zhang T.

Rehabilitation College, Capital Medical University, Beijing 100068, China.

OBJECTIVE: To investigate the differences of regional grey matter volume between adults with persistent developmental stuttering and fluent speaking adults, and to determine whether stutterers have anomalous anatomy of speech-relevant brain areas that possibly affect speech fluency. METHODS: High-resolution magnetic resonance imaging (MRI) scanning was performed on 10 adults with developmental stuttering, aged 26 (21 - 35) with the onset age of 4 (3 - 7) and 12 age, sex, hand preference, and education-matched controls. The customized brain templates were created in order to improve spatial normalization and segmentation. Then automated preprocessing of MRI data was conducted using an optimized version of VBM, a fully automated unbiased and objective whole-brain MRI analysis technique. RESULTS: VBM analysis revealed that compared with the controls, the stuttering adults had significant clusters of locally gray matter volume increased in the superior temporal, middle temporal, precentral and postcentral gyrus, and inferior parietal lobule of the bilateral hemisphere (P <>

Starting to stutter at 18

I want to share with you the story of someone who started stuttering at age 18! It is a very unusual case which might tell us about stuttering itself.

I am 26 years old and study civil engineering. My therapist and people who stutter (PWS) say that my story is a bit unusual, since I’ve started to stutter at age 18. No stressful situation occurred at the onset of my stuttering. If this was the case, I’m sure I would remember, because it was only a few years ago. I’m sure that I have never stuttered as child. I have an older sister who stutters, and my whole family and our close friends know the differences between fluent and stuttered speech.

My story as a PWS starts when I was 18, attending 10th grade. I started to notice some difficulties when I had to say words starting with /r/. I would have to stop for a moment, before I would be able to say the word. At the beginning no one else noticed my difficulties, but I was very much confused. As time passed by, I talked worse and worse. Words starting with /r/ were not as much of a problem any more, but words starting with other syllables started to be a problem. My speech was still fluent most of the time, but after some 6 months people started to notice my problem. At this time, they thought that I’m kidding, but I couldn’t explain to them that I wasn’t jocking. Others asked me if I started to stutter, but I didn’t feel I was stuttering, since it wasn’t the same as other people who stutter whom I know. I felt angry at myself for having a problem that I have never had before, and I was already grown-up. That’s when I started to talk very bad and feel very bad about it.

Heavy stuttering started some 2 years after the onset, at the time when I started university. In addition to my disfluencies, I had repetitions, blocks, voice prolongations and facial muscles spasms (grimaces), as well as spasms of muscles all over body - I would move my arms as a orchestra conductor, kick my feet on the floor, and so on. That is when I started to intentionally use synonyms in order to avoid difficult words and I started to avoid almost all speech situations that I possibly could. It frustrated me a lot. Interestingly for me, at the beginning of a hard stuttering period, I didn’t stutter when speaking under influence of alcohol, nor when I spoke in English, a language that I have never knew perfectly.

For three years I couldn’t find a clinic or therapist, because people told me that no one works with PWS older than 18. In July 2003, I found out an Institute in Belgrade that works with adult PWS too. I immediately started a treatment with an experienced therapist. The first few treatments felt a bit silly, but soon I realised that if I want to improve my speech I will have to adapt to the treatment requirements. After only 6 months I have achieved big improvement, and I was extremely happy. Therapy consisted of individual and group treatment and included direct fluency shaping techniques with a lot of psychological counseling and some elements of cognitive-behavioural therapy. Therapy required a lot of work by myself, and for the first three months I was doing fluency techniques excercises 2h/day, 6days/week. I was attending ambulance treatment twice per week. Soon, I started to feel more self confidence and I could control my speech even in some everyday situations. I stopped to avoid speech situations. Stuttering was still there, but in smaller extent than before. I practiced direct techniques less than before, but used it in everyday speech situations more and more. In July 2004 I underwent intensive 14-days group stationary treatment led by my therapist. Not much I achieved in fluency, because I already spoke fluently most of the time; I felt a lot more self confident and free from fear of speaking in all situations. Afterwards, bad periods with more disfluent speech occurred only during very stressful situations, such as exams on faculty. Those ‘bad’ periods were characterised by low level of stuttering. Today, I still have some disfluences (light blocks), but I don’t pay attention to them and don’t find them disturbing to me. Since my intensive course, I stopped going to treatments. I continue working on improving myself as a person and a speaker. I occasionally attend self-help group and have participated in a live TV show talking about me and stuttering in general. After that show, I received many calls and messages from my friends and colleagues teasing me that I am a fake member of self-help group since I spoke fantastically.

I consider myself lucky not to have started stuttering early in childhood. I speculate that this absence of bad and cruel experiences connected with stuttering during childhood and growing-up actually contributed in great extent that I solve my problem with stuttering in such short time. On the other hand, I think I would never achieve this good results if I haven’t continuously practiced and followed therapy tasks and demands.

When I started with the treatment, my therapist asked me what I would consider as my goal in this therapy. My answer was “I would consider myself ‘cured’ if I were able to say anything that I want to, at any time in every situation”. Today, I can say that I reached this goal.

Therapy that doesn't work often works

That's the conclusion I have drawn some time ago. It is the paradox of many treatments be it behavioural therapy or medication. Science tells us that the vast majority of alternative medicine does not work, except acupuncture. Nevertheless, many patients claim that such treatments worked for them. How is this apparent paradox possible? One word: placebo! If you give someone pill that contains no active compound like sugar, called a placebo (pill), and say that it works, it will actually work. OK. Maybe not cure the person but definitely show an improvement though often not very long lived. The key to understand this paradox is in the way that science defines how a treatment "does not work". Scientists ask the question: Is the treatment advocated better than no treatment or a placebo pill? If not, it does not work. It is a relative statement: it doesn't work better than a placebo pill. However, a person taking the treatment will experience an absolute improvement. He or she doesn't split into two: his clone A taking the treatment and clone B taking the placebo. So he will witness an improvement not knowing that he would have witnessed the same with a placebo. Of course, if you tell him that the pill doesn't work, it will not work!! So telling him it will work even though it does not work better works. I look at alternative medicine as a way to induce the placebo effect in humans.

This lesson is also very important for stuttering. Any therapy will work for us to some degree, but because it is often placebo it will be short-lived.

You can read about the placebo effect and alternative medicine in an article that Ora has forwarded to me: here.

Dying a silent death?

Indevus, the owner of Pagoclone, has just disclosed their financial results without any mention of Pagoclone. It is now getting more likely that Pagoclone is dying a silent death rather than being sold to someone else to cover the expenses of a Phase III trial.

Here is the CNN article. You notice that Indevus talks a lot about other drugs but no mention of Pagoclone.

News on Pagaclone soon?

Indevus, the owner of Pagaclone, is announcing its financial results on Thursday. Hopefully an analyst will nail them down on what they will do with Pagaclone: (see my last posts here and here)

Indevus To Announce First Quarter Fiscal 2008 Financial Results On Thursday, February 7, 2008

LEXINGTON, Mass., Jan. 31 /PRNewswire-FirstCall/ -- Indevus Pharmaceuticals, Inc. (Nasdaq: IDEV) will announce its first quarter fiscal 2008 financial results in a press release to be issued before market open on Thursday, February 7, 2008. The Company will host a conference call and webcast to discuss these results at 9:00 AM eastern time on Thursday, February 7, 2008.

Where is the measurement error?

In physics, we insist to include the measurement error into all our calculations. For example, lets drop a ball from five meters above the ground and measure the time it takes to hit the ground. Our time measurement will include an error, because we stop the clock ourselves. So the error might be of the order of 1/10 of a second. Let me repeat the measurement a few times in my head: 0.99s, 1.00s, 1.02s, 0.99s and so on. We can also measure the time with a laser, and the error might just be of the order of 1/100 of a second. But still you always have a measurement error. If we calculate the average speed of the ball, i.e. 5 meters divided by time needed, it will include an error because we need to include the time (and its error) in the computation. This procedure is very very important.

Is it done in stuttering research? NO. Let me repeat it again: NO RESEARCH HAS EVER INCLUDED MEASUREMENT ERROR!. What they should do is the following: For each measurement, they need to estimate the measurement error, and include in all the calculations like statistical tests the error range from the measured values. For example, if I measure the stuttering syllables a few times, I will get different values, e.g. 15%, 10%, 20%, and then I must conclude that the value is around 15% with an error range of 5%. And I need to carry this error range with me if I calculate statistical significance for example.

I discussed this issue once with Per, I think, and he said it is not done and anyway it is not physics and too much work. But, actually, because it is not physics, where measurements are much cleaner, quantifiable, and the error low, the argument to use measurement error analysis is even much greater! I think very few people are even aware of measurement error analysis.

If they had included it, I am convinced (and I bet my life) that ALL MARGINALLY SIGNIFICANT RESULTS WOULD GO AWAY, swamped away by the measurement error. If I am going to be cynical, I say that only those researchers who do not do measurement error analysis will be able to publish, and those who did perished because they have nothing to report on most of the time!

Let's try deep brain stimulation

A reader c sent me this article on deep brain stimulation. It's an interesting tool which leads to clear improvements in many LaTourette and Parkinson sufferers. Its main effect is inhibition of electric activity of neurons locally. Maybe we should try it with stuttering, though I am not sure which region to stab!

Clear conflict of interest in therapy evaluation!

After academic research in theoretical physics, I worked in risk management for an American investment bank. Core principles of any good risk management is independence of the evaluator and avoidance of conflict of interests. Virtually all outcome studies violate these principles. The studies are done by the therapists themselves, which is a very clear conflict of interest. The therapists have a great interest in getting good results, and are not focused on finding loopholes as independent evaluators would do. I have never heard of any therapists that published a study that showed that his or her therapy approach is not or less beneficial.

The most well-known example is of course the Lidcombe approach to treat children. The group around Prof Onslow are heavily promoting Lidcombe and at the same time have evaluated it! But, there is a bit of hope: an independent Dutch study is underway and looks at the Lidcombe approach versus a demand & capacities approach.

TheStutteringBrain is skiing this week!

A warning on drug trials!

Ora sent me this article (you need to be registered to access but it's free!) from the New York Times on how drug trials are misleading:

Researchers Find a Bias Toward Upbeat Findings on Antidepressants
By BENEDICT CAREY
The makers of antidepressants like Prozac and Paxil never published the results of about a third of the drug trials that they conducted to win government approval, misleading doctors and consumers about the drugs true effectiveness, a new analysis has found. In published trials, about 60 percent of people taking the drugs report significant relief from depression, compared with roughly 40 percent of those on placebo pills. But when the less positive, unpublished trials are included, the advantage shrinks: the drugs outperform placebos, but by a modest margin, concludes the new report, which appears Thursday in The New England Journal of Medicine.

My conclusion is two-fold. First, I am convinced that virtually all studies suffer from this publication bias effect (i.e. null or negative trials are conveniently not published or non-publishable) including stuttering research (not just on medication though). Second, I am always amazed at how strong the placebo effect is, and one can certainly argue that even the placebo is a significant improvement which the patient wouldn't have gotten if s/he hadn't taken the worthless or minimal-effect medication!!! Strange world...

Lack of motivation a convenient excuse?

When I talk to therapists and ask why many (most?) patients are not succeeding in therapy over the long-term. I often here things like "you are not motivated enough" or "the moment is just not right" or "there are no cures" or "we just don't know enough about stuttering" or "you need to practise more". Could I not turn this around and blame relapse on the therapist because s/he was not able to motivate the patient hard enough or made practising unnecessary difficult due to bad advice?? Have you ever heard a therapist at a conference talking about their mistakes? I haven't to this day. I only heard talks about success, enriching personal development experiences for the patient, and so on. And they also revel in showing just how sensitive, caring, bonding, holistic, intelligent, hard working, smiling, and most importantly professional (what ever that term may mean?) therapist they are; attributes that, to put it mildly, people who stutter are not that interested in, all they want are results for them!

Here is my analysis. Yes, it is true that motivation plays an important role in long-term success. You do need extraordinary motivation. For example, I was absolutely motivated at each of my therapies, though not obsessively. Even a good therapist might not be able to motivate some patients. However, this argument even though it is correct to some degree is also a very dangerous argument, because mediocre therapists can use it as an excuse for their own failure. They can hide behind it. This is also true for non-professional therapists like the crackpot award winners that I nominated. A healthy advice would be: if you are a patient and you fail, look at yourself to find points of improvements; if you are therapist and your patient failed, look at yourself to find points of improvements!

And here is a challenge to all therapists: I will buy that therapist a drink who gives a talk with the topic "The mistakes I made and why they were mistakes"! I would even offer a meal, but a meal with me might be too much punishment for the winner! :-)

The Valsalva hypothesis

Virtually all theories on stuttering from amateur (and many professional) researchers that I have seen are just wrong and void of empirical evidence. However, there is one theory where I just cannot make up my mind on whether it is a piece of the stuttering puzzle or just complete non-sense! It's Malcom Perry's Valsalva mechanism hypothesis. Claire Walker nicely summarises the hypothesis here:

So, stuttering has been linked to differing neural patterns, but why does stuttering cause different parts of the brain to be more active? One idea is called the Valsalva Mechanism, which is a natural bodily function, but it may turn the extra effort put into speech into the block that stutterers fight with everyday (3). The Valsalva Maneuver was named after an Italian anatomist, Anton Maria Valsalva and its purpose is to bring more air pressure into the lungs to help a person exert more force on an object, such as weight lifters who hold their breath when lifting large masses. (3). To create more air pressure in the lungs, the abdomen muscles contract and press against the diaphragm, which in turn presses up on the chest cavity. For this mechanism to increase the air pressure in the lungs, the larynx has to tighten around the airway so that the air cannot escape and this is called the effort closure (3). All of the muscles involved in the Valsalva mechanism are connected neurologically, so that they can all contract at the same time and with the same force (3).

The reason that this mechanism is thought to be tied to stuttering is because stutterers put a lot of force and effort into the words that they stumble over. This force causes the lips and tongue of the stutterer to press harder together, thus creating more air pressure in the lungs, but also causing speech difficulties (3). Fluent speech actually requires very little effort, so when a stutter puts a lot of effort into speaking the Valsalva Mechanism does what it is supposed to do, it is an instinctive reaction when we are trying to force something out of the body (3). This confusion between the Valsalva mechanism and the neurological components of speech can happen because there is neurological tuning involved in the motor neurons that control all the muscles involved in a movement, this includes speech (3).

What really happens during a stutterers speech is not wholly known, but if we take an example of someone stuttering on a word starting with p, say plane, then the brain remembers that p-words were difficult to say. Thus the brain ‘thinks’ that more effort has to be put into saying p-words, so the Valsalva mechanism kicks into gear and the stutterer is left squeezing their lips and trying to get any p-word to come out of their mouth (3). What makes p-words difficult for many stutterers is the fact that you have to close your lips, momentarily, to build up a little air pressure to say p-words. However if the nervous system is too excitable the brain may misinterpret this signal to mean that a Valsalva maneuver is being started and thus try and shut the air in the lungs, making speech very difficult (3).

Here is William Parry's own summary from his website:

The Valsalva Hypothesis postulates that excessively forceful closures of the mouth or larynx associated with certain types of stuttering, as well as difficulty in phonation, may involve a neurological confusion between speech and the human body's Valsalva mechanism.

Persons who stutter may have learned to activate the Valsalva mechanism in an effort to produce words, as if they were things to be forced out of the body. Such activation is most likely to occur when the stutterer anticipates difficulty or feels the need to use extra effort to speak properly. While this might instinctively feel like the right thing to do, it actually makes fluent speech impossible.

When a person who stutters prepares to exert effort in speaking, excessive neuromotor tuning of the Valsalva mechanism may occur. Such tuning may:

	render the Valsalva mechanism over-excitable to triggering stimuli, such as the increase in subglottal pressure that accompanies the start of articulation;
	interfere with normal prephonatory tuning of the vocal folds (because the larynx is instead being neurologically tuned for effort closure), thereby causing delays and difficulty in phonation; and
	contribute to abnormal laryngeal behavior, either by increasing the strength of laryngeal reflexes (the Valsalva maneuver is known to strengthen reflexes), or by interfering with the suppression of reflexes, which normally occurs during speech.

The Valsalva Hypothesis views the Valsalva mechanism as only one of many factors involved in stuttering. For example, a stutterer's anticipation of difficulty might be affected, to varying degrees, by attitudes, expectations, neurological impairments, or emotional factors.

Furthermore, a child's original disfluencies may be caused by a variety of neurological, psychological, or developmental factors not involving the Valsalva mechanism. These original causes may be different for various individuals, but their commonality is that they create the perception that speech is difficult and will require extra physical effort. The child — already accustomed to using the Valsalva maneuver when exerting effort or expelling bowel movements — may instinctively assume that words can be forced out in the same way. Continuation of this behavior during certain critical years of childhood may influence the development of nerve pathways in the brain. Over time, these behaviors become deeply rooted in the nerve pathways of the brain, making them extremely difficult to change.

For further discussion of the Valsalva Hypothesis, see Stuttering and the Valsalva Mechanism: A Key to Understanding and Controlling Stuttering.

Stuttering is cool - blog

My blog seem to become more and more popular. I receive 5 emails this week! Here is a new blog with audio comments, in case you are interested:

Hi Tom,
I'm a life long stutterer and also a regular reader of your blog. I never quite read up on the science of stuttering (you think I would have!) but your posts are fascinating. Anyway, just thought I'd send you a quick email in case you'd be interested to know that I've recently launched a podcast for stutterers. It's called "Stuttering is Cool" and it's focused around audio comments submitted by my fellow stutterers. For me, hearing other people stutter really helps me feel that I am not the only one. And it's great to meet other stutterers!

Feel free to send in your audio comments, too. The address is http://www.stutteringiscool.com

It's fun to know - blog

I discovered a new blog called It's Fun To Know. He also talks about stuttering: see here. He seems quite witty.

Twins: Little shared environmental effect

I have just re-read the 13000-twin study by Katherina Dworzynski et al and she clearly empirically confirms what I have been saying in my last posts:

Stuttering appears to be a disorder that has high heritability and little shared environment effect in early childhood and for recovered and persistent group of children by age 7.

And further,

With respect to the genetic effects throughout, it also needs to be emphasized that, even though substantial estimates of heritability were obtained, many monozygotic twin pairs were discordant for stuttering. This is further evidence for the importance of the child's unique environmental influences, in that specific stressors have unique effects when a genetic liability is present.

Again, the nature vs nurture fallacy is revealed. It is simply wrong to divide the world into nature and nurture. There are three categories: the genes (nature), unique environmental stressors (more or less random events), and shared environment effects (nurture). Think about being the CEO of a small start-up company. Unique events like you having a car accident or a virus infection, sheer bad luck, pregnancy of your most important employee, and so on can completely change the outcome of your company's success because you only have a few months of financing to hit a certain target before your bank or venture capitalist cuts financing (window of development for child). I have seen this many times. Of course, you are especially vulnerable to such events if you have a bad or weak business plan (think of this as the genes - the instructions on what to do). General market conditions are also important but not that crucial, and can increase or decrease vulnerability. I never thought that venture capital, the topic of a book I have written (see here), is relevant to stuttering! :-)

The Genain quadruplets

The Genain quadruplets are a "beautiful" experiment of nature that can teach us a lot about genetic and environmental factors. All four girls share exactly the same genes, and lived in the same family environment. Unfortunately for them but fortunately for science, they share exactly the same genetic predisposition to schizophrenia. In exchange for free treatment, the quadruplets were and still are monitored; they are now about 50 years old. Interestingly, the expression of schizophrenia was very different between the quadruplets: Myra after an initial episode was never hospitalized and is married, Nora was hospitalized repeatedly but had marginal adjustment while outside the hospital, Iris experienced more-chronic hospitalization and her symptoms range from severe catatonic withdrawal to times of marginal adjustment when she was able to leave hospital, and Hester further deteriorated and remains hospitalized! Check out this review: here.

The case study shows that the same genes for schizophrenia (and many other brain disorders like stuttering) can lead to very diverse outcomes, though all quadruplets did develop schizophrenia. The family environment including parenting skills (nurture) were the same for all four, though parents might have treated them differently. However, a difference in treatment is mostly due to the kids being different. So the parents react to the difference of the child.

So why do the Genain quadruplets develop so differently? The answer lies most likely in environmental stressors unique to a child. I would split it in pre-natal and post-natal factors. Pre-natal factors include the position of the child in the womb in relationship to the others, differences in weight due to differences in nutritional supplies, injury, and so on. And post-natal factors include illness, injury, unique random events like a traumatic experience, reactions of parents to behavior proper to one child and so on.

What's environment?

In my last posts, I spoke about onset of stuttering and about triggers. I also said that I am very skeptical that environmental factors play a leading role, especially at onset. It's the eternal debate between nature and nurture. But the more I think about this issue, the more I am convinced that I and many others have been confused and it is the really the debate between nature, events and nurture. Anything that is not attributed to genes is often called environmental. This term is strictly speaking correct, but environment is not just nurture. Rather, environment is the general environment that the child (and his siblings and friends) lives in AND unique events that happen to the child within the environment: like virus infection, head injury, traumatic experience, and so on. I would argue that, relatively speaking, events are driving divergence between siblings because they cause a large difference between the one hit by the event and the sibling which is not, as opposed to the general environment with its similar impacts on siblings.

We are definitely the product of our genes, of our events, and of the immediate environment (of family and friends) and culture that you grew up. And, even nurture is not just nurture by parents, but also by other family members and most importantly by peers. So you can see that parents actually often do not have such a big role at all. In my next post, I will talk about the Genain quadruplets (mono zygotic) and their life with a genetic predisposition to schizophrenia in order to explain my ideas with a concrete example.

Finally, as a physicist, I cannot resist pointing out to all of you that the environment is not really well-defined. Where does it start and "you" begin? You are really nothing else than a bunch of atoms! Is the air you have in your lungs part of your environment or not? and your blood? The millions of bacterias in your stomach? The 90% of atoms especially water that are completely swap every so many years and you are not even the same person physically speaking than we were 10 years ago!

Uphill struggle for the environment

I discussed the danger of associating causes to the onset of stuttering. Formulating the wrong questions is also confusing the minds of nearly all parents, and many therapists and researchers, though not all.

First, it is misleading to ask or try to answer the question: What causes stuttering? It is important to disentangle onset of stuttering and lack of recovery from stuttering. The onset of stuttering does not mean onset of life-long stuttering. An adult stutterer needs to go through both onset of stuttering and lack of recovery. If someone asks you about what causes stuttering, you should say: We must ask two questions: first what causes the onset of stuttering, and second what causes some not to recover. The two questions very likely have very different answers.

Second, it is misleading to ask what factors are to be blamed for the non-recovery of some kids. This point might be a bit more subtle. Factors, that cause some not to recover, are not really to be blamed for the non-recovery, but they are just not strong enough to overcome onset of stuttering. Think about overcoming stuttering as climbing the Mount Everest. Are you going to blame the bodies and minds of 99% of the population to cause non-ascent to Mount Everest? No, you rather say that 99% are just not good enough to climb Mount Everest as compared to the Top 1%, and you would re-assure them that they have normal bodies and minds. A better but still not perfect way to formulate the question is what causes most to recover. The question should really by: Under which (exceptional) circumstances are kids able to recover from onset of stuttering?

Let me be a bit more concrete. I will give you my big-picture guess on what is happening, and you can hopefully see why these questions are misleading us. The onset of stuttering is the failure to develop certain standard neural pathways because the construction plans are non-standard due to abnormal genes or because the construction was hampered by a neurological incident like head injury, virus infection, low birth weight. The moment of onset is the moment the system gets its first real test in the same way that your brand new but defective car engine runs smoothly until you hit high speeds on the motorway. There is no or little environmental impact like parenting skills or endured stress, except for the out-of-the-ordinary events like injury or virus infection. The onset is entirely caused by internal factors that mostly happen long time before onset like the genes or like the head injury at age 2. Your car engine has a design fault or a manufacturing problem in the factory long time before you hit the high way. Environment and outside events might make stuttering appear a bit earlier or later, but it would have appeared anyway. You could have hit the highways a week later.

At the onset, stuttering children have abnormal neural pathways which cause them to have dysfluencies to which everyone reacts someone somewhat differently in terms of stuttering symptoms. The latest brain imaging results suggest that all children (even those that later recover) have structural abnormalities. Most kids are recovering but some are not. Why? Here is how I think about it, and I use the same escalator analogy for explaining why matter cannot escape black holes! :-) Think of a downward escalator that you want to walk up. You have to overcome the downwards speed by walking up faster. The downward speed is the difficulty to create a second compensatory pathway related to the magnitude of the neurological abnormality. In order to reach the top of the escalator i.e. to recover from stuttering, you need to have an upward walking speed greater than the escalator's downward speed. The upwards speed is determined by whether the kid does the right things, which depends again on genetics like its brain plasticity, semi-genetics like temperament and purely environmental factors like good parental feedback. The key point is that the kid needs ABOVE AVERAGE compensatory skills and environment, in the same way that you need above-average walking speed to climb up a escalator with a standard speed. So those kids that only have average skills and environment to learn compensation or those who have extreme downward speeds, will fail. The majority who recovers was lucky because either the escalator had a slow downward speed which was well compensated by their average skills and environment, or the escalator had a serious downward speed but they had exceptional compensatory skills. For example, girls are more likely to recover because they have a higher ability to compensate. So finally can you really blame their average skills and their environment for stuttering? No.

The fallacious mind.

I want to talk more about the onset of stuttering and how parents, therapists and researchers often draw fallacious conclusions. They often see the onset of stuttering being related to X (be it the birth of the younger sibling, the kid being attacked by a dog, high fever, below-average language & speech capabilities, and so on), and conclude that there is a direct causal relationship. However, this is fallacious, because there are other explanations for a relationship that are not causal. The human brain has evolved to automatically search for explanations. If an event happens, you scan your environment or immediate past for explanations, and stop when you found one. This effect is especially pronounced when the event occurs suddenly like the onset of stuttering often does. We need explanations. If you cant find them, we still find them: Blame the gods.

Example: My kid starts stuttering. His brother was born a few weeks ago or I am heavily pregnant. Therefore, onset is caused by stuttering. Or, some kids that start stuttering have slower-than average language development. Therefore, slow language development causes stuttering. Or, I heard my kid stuttering the first time a day after a big dog scared her and she broke out in tears. Therefore, the dog causes stuttering. Or, my kid cried a lot and became more withdrawn, and then she started stuttering. Therefore, something cause it to be distressed which causes stuttering.

Lets be rigorous and systematic, if A is related to B, then many combinations are possible in order of likelihood:

A and B are not causally related but a pure coincidence i.e. related by chance.
A and B are not causally related because C caused A and B to happen.
A and B are not causally related (in the right order) because B caused A.
A and B are causally related.

Each of the four example can be explained by a non-causal explanations.

Example: My kid starts stuttering. His brother was born a few weeks ago or I am heavily pregnant. Therefore, onset is caused by stuttering.

Possible Non-Causal Explanation: Both onset and birth are indirectly related, i.e. they both often happen at roughly the same time due to the nature of human development and off-spring production.

Example: Some kids that start stuttering have slower-than average language development. Therefore, slow language development causes stuttering.

Possible Non-Causal Explanation: Kid had a neurological incident (head injury, virus infection, perinatal hypoxia, low birth weight) or genetic makeup that produced havoc in the developing brain leading to BOTH slow language development AND stuttering.

Example: I heard my kid stuttering the first time a day after a big dog scared her and she broke out in tears. Therefore, the dog causes stuttering.

Possible Non-Causal Explanation: Both event happen by chance at the same time. The kid like millions of others just got scared and cried, and that's it! You can always find a event to relate to onset. Kid started stuttering and something more dramatic ALWAYS happens like death of family member or friend, distressing situation like doctor's visit, thunderstorm, and so on.

Example: My kid cried a lot and became more withdrawn, and then she started stuttering. Therefore, something cause it to be distressed which caused stuttering.

Possible Non-Causal Explanation: This is a cool one. Actually stuttering caused the distress! The kid started to feel that it couldn't pronounce well in private, and it got distressed. The mother noticed this but not the dysfluency which she only noticed a few days later!!! The mother made the mistake in that she thought she had all informations on the events which she didn't have. She just saw one side of the story line!

I explicitly wrote possible non-causal explanation, because if such an explanation exists, it does not imply that it is the right one. There might be a causal explanation that is the correct one or that the effect is a combination of 2 or more explanations. It is only possible to find the right one from the many possible one by careful research. But my rule of thumb is: If there is a non-causal explanation, it will be the right one in 95% of the cases! (because most relationships in life are non-casual)

Gareth clueless on research

Gareth Gates, runner-up of Pop Idols and best-selling pop star, is definitely an inspiration for many of us on how you can really become more fluent when you work hard and are very very focused. The McGuire program is providing a good framework. However, in terms of him explaining why he stutters and why he is fluent while singing, I am sorry to say but Gareth is just a COMPLETE DISASTER. Unfortunately, he is very misinformed. So he (and the other participants) is a mixed blessing for people who stutter, because they re-enforce the message that it is just psychological or "I don't stutter when I sing because I act and I am not myself" (So who is singing, Gareth?) Success does not imply that their theory on stuttering is correct.

Gareth and McGuire people, read my blog on the latest stuttering research! Your methods are very helpful for many, but your theories are confused, fallacious and wrong.

Drayna talks on genetics at StutterTalk.com

StutterTalk.com is encroaching on my territory by content, interviewing Dennis Drayna on genetics research (download here), and overtaking me by design...

Dennis Drayna doesn't really say anything new. I think childhood stuttering is a key part of the genetics equation. It might very well be that there are genes for onset of childhood stuttering and genes for recovery of childhood stuttering, and they are not correlated!

Shut up or go to sleep!

This piece of research gives interesting insights into the learning process, which might be helpful for learning speech techniques more efficiently. Two conclusions I would draw. First, you should take a nap after an intense practise. Second, you should avoid at all costs performing conflicting behavior (like using "anti-speech techniques") after practise. For example, you practise hard and then take a break and do not focus on technique while speaking. It is probably much better to just shut up for a few hours (at least 1 hour, actually a nap would do the same thing), or practise in the evening and go to bed because then you don't speak for 9 hours!

This research shows nicely that we might be able to improve behavioural stuttering therapy not by learning about stuttering but by learning more about learning in general.

Lies, damn lies, and younger siblings

I have spoken about the danger of linking the birth of a younger sibling to the onset of stuttering before. I feel obliged to write about this again because I have read it in Barry Guitar's newly update book which is supposed to be a bible among speech therapists.

I have been looking at the empirical numbers. Unfortunately, I could only find the birth spacing of women in developing countries. The younger sibling is born

<2 years after birth of last child with a probability of 25%
2-3 years later with a probability of 25%
3-4 years later with a probability of 25%
>4 years with a probability of 25%.

Lets assume the older sibling starts to stutter at age 3, then in 50% of the cases his younger sibling is born within a year, and in 25% (50% divide by 2) within half a year.

So in 25% of the cases, parents can perceive a strong correlation between onset of stuttering and birth of younger sibling. And it's a complete illusion!!!! It is a beautiful example of the common logical fallacy of confusing correlation with causation.

Note: I am not saying that no relationship exists to exact time of onset (i.e. when it starts now or a few weeks later) or strength of onset (i.e. whether the frustration or general well-being level is higher resp lower). But the coincidence explains very well any observation... and if there is a relationship it is very weak.