I am off to Oxford on Thursday

I am going to the Oxford conference which is held from Thursday to Sunday. I will present a poster on logical fallacies when trying to assign a cause to the onset of stuttering in children, and I will give a talk on viewing stuttering as a disorder coming in two phases and acting on two levels.



Other interesting (:-)) speakers will include: Per Alm who talks about Fluency disorders: a discussion of possible causes and mechanisms, from a neuroscience perspective (I hope he will tell us something new as I heard talks with similar titles before) and on Temperament and Stuttering (where he will hopefully debug the current obsession with temperament as a/the major factor) Jerry Maguire has a poster on the results from the Pagaclone study. He told me that he cannot attend due to his father's 80th birthday (Happy Birthday! I met his father in October in LA) but his colleague Dave Franklin will be there. Jerry gave a workshop at the NSA conference this week where he talked about the results. I will report on the poster after the Oxford conference.



The conference program feels an adulation for the Lidcombe program. There are at least 10 talks, and of course they all talk about the "evidence" which I still cannot see clearly. That's probably because my statistical and critical thinking pain threshold is much lower! So I am still uncomfortable with the adulations.Even with positive evidence (which would be good news for kids) they of course forget that possibly any other treatment might very well give similar results, because only Lidcombe was tested. But the key sucess factor of Lidcombe is in my view that there are well-defined rituals for therapy; have you ever seen a religion without rituals? Humans need guidance and are habit aninals, and so do therapists. They love rituals even if the reasons behind the rituals are not so clear or well proven.



Here are a list of talks I will probably go to either because I like the topic, like the speaker, or have a low opinion of the topic or the speaker and see whether I can resist asking a critical question. Remember this is therapist land, the land of consensus, so everyone is nice to everyone else even if they have another opinion or the research "findings" are obviously flawed! Actually, to be fair, most don't realize that the methodology is flawed. So here they are (see program here):



Angela Morgan & Sheena Reilly, Murdoch Childrens Research Institute Functional brain activation differences for motor versus language regions in adults with and without stuttering: An fMRI study



Lesley Kuhn, University of Western Sydney & Ann Packman, The University of Sydney Looking at Stuttering Through the Lens of Complexity Theory Nicole Spindler, University of Goettingen Altered lateralization of cortical control of movement timing in persons who stutter



Sharon Millard,The Michael Palin Centre for Stammering Children & The University of Reading, Susan Edwards, The University of Reading & Frances Cook, The Michael Palin Centre for Stammering Children PCIT: Adding to the evidence Rosalee Shenker, Montreal Fluency Centre The Lidcombe Program 10 years later; what have we learned - One clinic's experience



Ann Smith, Purdue University New Windows on the Onset of Stuttering in Young Children Hans Månsson, University College Copenhagen Early Childhood Stuttering: A Systematic Framework of Predictive Factors for Persistence and Recovery



Naomi Sakai, Mejiro University, Japan Brain activation in adults who stutter under delayed auditory feedback: a fMRI study



Gerald A. Maguire, University of California, Irvine Medical Center Pagoclone, A Novel Nonbenzodiazepine, GABA-A Partial Agonist, Reduces Objective and subjective symptoms of stuttering



Tricia Zebrowski, University of Iowa Why Stuttering Therapy Works: The “Common Factors” Susan Block, La Trobe University, Melbourne Significant issues in stuttering: Managing stuttering in the next decade



Mark Onslow, Australian Stuttering Research Centre, The University of Sydney Treatment of Early Stuttering in the Real World: Lidcombe population research unveiled



Per Alm, Danish Information Centre for Stuttering & Uppsala University, Sweden Stuttering and Temperament, a review

New features

I have added two new features to my blog. First, you can now easily subscribe to a RSS feed. If you will want a button in your browser tool bar which gives you a drop-down list for all my recent posts. Click on posts or comments, and click on Atom, and then subscribe and select in Create in Bookmark Tool bar. Second, I have included a blog list, so you can read the latest posts from other stuttering blogs. I have so far only included three which seem to be most active or relevant. But please do tell me if you are of a different opinion.

Talk on Stuttering

3) BRAIN-COMPUTER INTERFACE MAY HELP PEOPLE TO SPEAK UP
Functional Magnetic Resonance Imaging (fMRI) is allowing scientists to identify the brain regions responsible for correcting auditory errors -- the differences between how we hear our own speech and what we expect it to sound like. Researchers are now feeding this information into refining what they call the "DIVA Model", a way of modeling neural networks that could enable the design of neural implants and brain-computer interfaces for people with damage to their speech motor output.

Collaborating with Philip Kennedy at Neural Signals Inc. in Georgia, Boston University's Frank Guenther is developing a brain-computer interface that records brain signals from a person's speech motor cortex and transmits them across the scalp to a computer. This computer then decodes these signals into commands for a speech synthesizer, allowing that person to hear what he/she was trying to say in real-time. With practice, using the synthesizer should help someone to improve their sound output.

The long-term goal of the brain-computer interface is to enable almost conversational speech for individuals with locked-in syndromes or diseases that affect speech motor output, such as Amyotrophic Lateral Sclerosis (ALS, or Lou Gehrig's Disease). Other applications of the model include stuttering, apraxia of speech, and other related disorders.

Dr. Frank H. Guenther will speak on Thursday, July 3 at 8:40 a.m. "Involvement of Auditory Cortex in Speech Production" (Talk 4aSCb1) in Room 250B

Neurology is not all

My posts often focus on neurology and genetics of stuttering. I just want to clarify my stance: Neurology is a necessary but not sufficient part of the story. Beyond any doubt, we cannot explain the whole spectrum of stuttering with neurological and genetic concepts alone. The vast majority of stuttering symptoms from stuttered speech, secondary symptoms, psychological and social effects are not directly due to a neurological problem, but in my view the reaction of a normally functioning human brain to an underlying neurological problem in speech production. Moreover, I am loosing hope that a breakthrough in treating stuttering will come from focusing on the underlying neurological problems. Maybe in the distant future, but not in my lifetime. Medication might alleviate but not fix. At the end of the day, rather ironically I predict that after understanding the neurology better, we will realize that the best treatment approach are the old and current ways of treating stuttering namely changing our ill-adapted behaviour and training our normally functioning brain to better cope with the underlying neurological problems in speech production.

You need to pray

“I can’t remember any prayer that I have prayed that has not been answered,” said Helen Catchings, 62, of Vienna, Va. God cured her of stuttering and gave her the resources for her home-care business, she said. And she said she has seen members of her church cured of cancer, brain tumors and other illnesses through prayer, baffling doctors. “I give Him all the credit,” Catchings said.

MTV True Life

Have a look at the True Life Series from MTV on the life of young people who stutter. I like the documentaries; they are well done.

• MTV
• Music Videos
• MTV Shows
• Entertainment News

Another example of confused thinking?

Everyone (including myself) repeat the mantra that it is much more difficult for adult stutterers to recover from stuttering, because they have been stuttering for so long and the stuttering has imprinted itself on the brain. I just realised that this statement is a good example of misleading and confused thinking: not completely wrong but also not 100% correct.

Imagine you are a driving instructor who has 100 novice drivers in your class to start with. Over time you sent them to the driving examination according to the level of skills learned. After a few months, you still have a few "resilient" ones that you either haven't sent to the exams yet or that have failed them. Now, surely you wouldn't say that it is difficult to make good drivers out of them because they have been driving badly for so long? You rather say that they have no talent for driving and are the worst talents left from a pool of 100 average novices.

Let's get back to stuttering. How about this simple explanation: Adult stutterers have trouble recovering because they are simply the worst talents left from the pool of kids who stuttered in childhood! They are the ones with the worst underlying issues and/or a brain with low brain plasticity! So they have trouble recovering not because of the long time stuttering but because they are a biased sample, namely the once who were unable to recover in more than 15 years?? Doesn't this make perfect sense?

OK. I am not saying that the "long term" in stuttering does not make it more difficult, but now I strongly believe that the main reason is that we are the worst of the pool!

Uncertainty kills us

Everyone knows the phrase:

People who stutter know exactly what they want to say but are just unable to say it.

In fact, it is much worse, because we also do not know when this temporary inability ends and the motor command is sent to our muscles. It could be a half second or 2 seconds later. I do not remember anyone mentioning this specifically. It's like your head being forcefully held under water and not knowing when your torturer is letting you breathe again.

Imagine a world where people who stutter know that they can pronounce the syllable one second after they experience the inability to pronounce. Well, we would just wait the one second and then say it. No need for additional panic or counter-measures, as we know that we can say it one second later. We have perfect certainty about our temporary inability.

Unfortunately, we are unable to predict the length of our temporary inability. We could be a split second away from the word, or stand there for seconds looking like a complete fool. And at the start every inability could be one of those disastrously long blocks. My suspicion is that a lot of stuttering symptoms are triggered, because we succumb to the time pressure and want to do something. Most stuttering therapies say that "it is about controlling your speech" when in fact you could as well re-interpret by saying that "it is about resisting triggering your symptoms in the face of time pressures from the uncertain length of the temporary inability to pronounce."

More fluency versus side effects

Here are some quotes from someone who tried Zyprexa:

"I am glad that I am off the zyprexa......my weight has reduced and I feel more awake again......its funny how you can get used to feeling less awake/alert and for it to seem 'normal'....its only when you come off the drug that you realise how it affected you."

".....in hindsight when I was on the zyprexa I actually felt quite lousy....tired and probably lacking emotion to be honest, its only when I am off the drug that I can see how it really affected me."

"My speech did improve while I was on the drug, I cant get away from that fact, and thats not just a subjective view, my wife and others did notice the improvement, however the possible negative health benefits were too much......"

Stutterers "can" sing fluently

As a regular reader, you know how much I sacrifice myself for the cause of stuttering. And here is another example. Myself and Einar have undertaken a dangerous self-experiment last summer.

Here is the abstract that I want to send to the journal:

In this article, we show that people who stutter are able to sing fluently. To test our claim, we set up a Karaoke system in Tom Weidig's garage. Two male right-handed stutterers ("E" and "T") were used. They each were asked to sing Robin Williams' Love Supreme. Our findings show that both subjects were able to sing fluently, and did not deviate from the controls. One of them, "E", sang noticeably better, however the other subject ("T")'s dancing and entertaining abilities were clearly superior. We speculate that the difference in singing performance was due to either the higher level of alcoholic consumption in subject "E" or an inherent genetic predisposition. We have included two video recordings below.

Subject "T" video (the faces are darkened on purpose in order to adhere to restrictions imposed to us by the ethics committee.)



Subject "E" video (the faces are darkened on purpose in order to adhere to restrictions imposed to us by the ethics committee)

Riitta Salmelin at Paris

Let me continue my summaries of the Paris conference workshop talks. The next speaker is Riitta Salmelin from Helsinki University. She is a professor and leader of the Language Perception and Production group. Check out her web page. She is actually a physicist by training like myself. I only briefly spoke to her at Paris. She is mainly interested in language perception and production per se, and studies stuttering as an interesting example to understand the general language processes better. That's fair enough, as long as we get interesting results from her lab!

She is best known for her MEG work on the stuttering brain. In fact, I believe that she is the only scientist who used Magnetoencephalography to study stuttering. MEG is a very interesting imaging method because it opens up a different world to the experimentalists: the world of millisecond changes of electrical activity of neurons as opposed to the fMRI world of "slow and stretched over time" pysiological changes in blood flow enduced by neuronal activity. I asked her why no-one else has done MEG, and she said: It is difficult to do! In the last years, progress on MEG has been considerable mainly due to new hardware and algorithms. MEG is especially useful to create movies of neuronal activity unlike fMRI. So you can see how activity goes from one region into another. Such timing studies are very important to establish causal relationships between different brain regions. For example with fMRI, you can only say that there is a correlation between two regions, but due to the low time resolution you cannot easily say which one was first.

Her talk was divided in two parts: first she gave a summary of her work over the last years, and secondly, she presented a newly developed MEG method that allows to extract relative timing directly. In a 2000 MEG study (see their Brain article abstract), they found abnormal functional activation in people who stutter even during fluent speech: earlier activation in left motor and pre-motor cortex but delayed activation in left inferior frontal cortex when preparing an utterance, and stronger activation in right motor and pre-motor cortex during speech production. From studies that contrasted silent to overt reading (which allows them to see which additional regions are involved in overt speech production), they interpret their findings as pointing to abnormalities in processes specifically involved in overt speech production rather than core linguistic analysis by stutterers. Moreover, she spoke about abnormal auditory processing in people who stutter. I cannot remember what her interpretations of these findings are. Then, she also spoke about the interesting observation that hand regions are strongly involved in overt reading, and speculates that stutterers do not have the same motor cortical specialisation.

Finally, she explicitly spoke about a new method of analysis called Dynamic Imaging of Coherent Sources (DICS) that they have spent years to develop, and which is now ready to go. Check out the abstracts here and here. The papers are quite mathematical, and I doubt any biologist or neuroligist will completely understand them. During her talk, she showed some graphs of real-time neural connectivity during reading, I think. They will apply (are applying?) their new method to stuttering, and I am very keen to see the results. We would hopefully be able to see what is really going on during stuttering and fluent speech in people who stutter.

In fact, I am getting more and more enthousiastic about MEG as opposed to fMRI and MRI which feels more and more like getting at the crime scene just after the murder or watching the crime far away rather than during the murder and close up, which is of couse much more fun! So be prepared to hear more about MEG in the future on this blog, and I will bet my money on this new approach to move the field forward.

50% late recovery rate!!!!

You should check out the article Late childhood stuttering by Howell et al from University College London. They write that nearly 50% of all stuttering children at age 8 recover! This result is a real surprise to me. I thought that the recovery is very low after age 7. (Actually, they all had treatement, so it is not really natural recovery...) You can read the full article here. Here is the abstract, but I suggest you read the real manuscript as the abstract is a bit vague.

PURPOSE:
A study was conducted that examined factors that lead children who stutter at around age 8 years to persist in the disorder when they reach age 12 years.

METHOD:
Seventy-six children were verified to be stuttering at initial assessment. When they reached 12 years of age, they were classified as persistent or recovered. A range of measures was taken at the 2 age points, and measures were examined by recovery group.

RESULTS:
Although the tendency for more males than females to stutter was confirmed, the reasons for this tendency are not apparent for these speakers. Different patterns in speech were observed: Severity ratings of the recovered speakers dropped by age 12+. The severity ratings for the persistent speakers remained high at 12+, and dysfluency types tended to change from whole words to part words. Persistent and recovered speakers differed on temperamental performance at around age 8 years and performed differently on sensory and motor tasks at age 12+ years.

CONCLUSIONS:
Stuttering in late childhood affects mainly males. The later a child attends clinic, the longer he or she will stutter. Speech patterns of children who persist diverge from those who recover or who are fluent. As speakers persist, there are temperamental, sensory, and motor changes.

Off to study

I am off this week to study for an exam. I have read 2500 pages in the last weeks, and therefore suffering from an information overload...

Intro to imaging

If you want to learn more about brain imaging, here is an introductory article. (Thanks to Dave for the link)

Christy Ludlow's talk at Paris

Christy Ludlow is heading a research team at NIH: see here. She is quite a dynamic multi-area scientist not only working on stuttering but also for example on swallow disorders. She has published an interesting article A Dynamic Motor Control Disorder where she and Loucks puts forward the idea that stuttering is a system disorder and that no single area is defect as such:

...the central control abnormalities in stuttering are not due to disturbance in one particular brain region but rather a system dysfunction that interferes with rapid and dynamic speech processing for production.

Admittedly, the article is very vague on details of an underlying mechanism, and does not provide proofs as such. They rather draw their conclusions on what makes most sense given all the observations on stuttering and related disorder. And, I completely share the system disorder idea and have written about similar ideas like the traffic-jam prone transport system of a city: see here. Actually, I have a hard time to see how stuttering could not be a system disorder given our current knowledge and the considerable variability of effects, and unfortunately also how you would actually prove this with the current data!

During her talk, she made a few interesting observations. First, 37% of people with acquired stuttering after brain injury reported that they stuttered as kids! Second, none seem to have lesions in speech and language areas but connecting areas. She also said that about 50% of the kids who stuttered after age 6 recover. (I have never come across this observation, but I do remember that my professor at Imperial College in London said that he stuttered as a teenager and then it went away...) And 50% of stuttering kids have concomitant (or in plain English "also other"!) disorders. She also spent time talking about possible models of a neural basis of stuttering and mentioned possible starting points like delayed or abnormal development of fiber tracts, genetic predisposition, and cell migration and neural pruning. A brain with such a starting deficit would then be modulated both neurologically and behaviourally by reaction to stuttering. But she did not commit to any specific direction. To be honest, I did not remember most, but I see her efforts as a clear attempt to put some meat on the bones of her system dysfunction idea from the above article.

India stutters, too

Please check out the Indian Stuttering Association: here.

TheStutteringBrain found a rare species

In my last post about Anne Foundas' talk, I mentioned that she hasn't come across a female left-handed stutterer. And I wondered whether this is a true effect or just statistical fluctuation. Well they do seem to exist, here is a reply to my last post:

..Long story longer, I read your post and saw that there is a dearth of left-handed female stutterers. Well, I just so happen to be one of those. Maybe I'll contact her!

New brain imaging on kids

I found this call for participants to a new brain imaging study. I haven't heard of the group before. Their study would be good to replicate the finding of Soo-Eun et al. and Watkins et al.

Columbia University Neuroimaging Study
Seeking Participants Who Stutter

Conducted by Dr. Bradley Peterson, this on-going research study is focused on learning more about the causes of several disorders that develop in childhood and adolescence. One of the conditions of interest is stuttering.

The study requires participants to agree to one or two visits, and includes an MRI scan which lasts about one and a half hours. This study requires a total of 6-7 hours to complete.

Participants must be between the ages of 6-14, can be taking medications, and also may have other diagnosed conditions in addition to stuttering.

No expense will be incurred by eligible subjects, and a modest payment for participation is being offered. Participants will receive $120, in the form of a gift certificate or a check depending upon age, as a "thank you" for being in the study.

Study location: Columbia University, NY State Psychiatric Institute, New York, NY

Contact person: Kristin Klahr - 1-212-543-6072 <mristudy@childpsych.columbia.edu>

Note: Those contacting the study coordinator to learn more about the project are under no obligation to agree to participate.

A new blog called StutteringMike

Here is a new blog called StutteringMike.

Anne Foundas' talk at Paris

Anne Foundas, a professor of psychiatry and neurology at Tulane University, gave the first talk after the morning tea break (with free French patisserie) at Paris. I had never met her before, but she is well-known for her pioneering research on the anatomy of the stuttering brain. She was one of the first to report anatomical anomalies using MRI, though apparently the early MRI studies on brain anatomy were quite delicate to do. She is also quite interested in handedness. Check out her web page: here, and a recent article.

Her talk was different to the other talks in that she had a more systematic, top-down, and conceptual approach. She talked about the different types of possible models: anatomical, functional, and timing. She also mentioned a two-factor model of stuttering mentioned in (Buechel and Sommer 2004). This framework is a bit similar to what I had in mind when I wrote about stuttering being a two phase disorder: see here. She also made a distinction between local and global anomalies, and wondered which combination is leading to stuttering. Many people have abnormal brains but not automatically abnormal functionality, and many disorders show similar abnormalities. Interestingly, they are still looking for a left-handed female stutterer, and they just cannot find one. Is it a real effect (i.e. left-handed women are much less like to stutter?) or is it just statistics? Here is my calculation: of all stutterers, 20% are female (1 in 5), and 10% of the population is left-handed, so 2% of the stuttering population should be female and left-handed assuming no gender effect. Lets imagine they asked N stutterers, they should find 0.02*N. I guess they asked a few 100, so there should have been a couple of them. So if you are female and left-handed, post a comment! She also talked about their belief of possible sub-types with the main deficit in either 1) auditory processing-linguistic and sensory processing, 2) motor functions - speech motor planning & production, or 3) attention-arousal-emotion. She also talked about her latest brain imaging results, but again I got lost with too many brain regions. But she did say that the cerebellum in recovered stutterers is greater, (which would make sense if it helps with compensation), and she said that the typical female brains seem to be more variable.

At the end, Christian Kell made a very intriguing comment: Given some similarities in abnormalities across disorders, he was wondering whether stutterers should really be compared to controls as opposed to those with similar atypical brain anatomy? Do they have something in common? To me, this opens a fascinating possibility namely that all disorders have similar abnormalities because they share a common factor, namely abnormalities stand for the failure of brain plasticity: abnormal brains mean lower brain plasticity. Kids have deficiencies, and only the brains with low abnormalities can compensate well, and therefore the persistent ones (in all kinds of developmental disorders) are a biased sample.