Common features of fluency-evoking conditions studied in stuttering subjects and controls: an H2O PET study

We used H₂¹⁵O PET to characterize the common features of two successful but markedly different fluency-evoking conditions — paced speech and singing — in order to identify brain mechanisms that enable fluent speech in people who stutter. To do so, we compared responses under fluency-evoking conditions with responses elicited by tasks that typically elicit dysfluent speech (quantifying the degree of stuttering and using this measure as a confounding covariate in our analyses). We evaluated task-related activations in both stuttering subjects and age- and gender-matched controls.

Areas that were either uniquely activated during fluency-evoking conditions, or in which the magnitude of activation was significantly greater during fluency-evoking than dysfluency-evoking tasks included auditory association areas that process speech and voice and motor regions related to control of the larynx and oral articulators. This suggests that a common fluency-evoking mechanism might relate to more effective coupling of auditory and motor systems — that is, more efficient self-monitoring, allowing motor areas to more effectively modify speech.

These effects were seen in both PWS and controls, suggesting that they are due to the sensorimotor or cognitive demands of the fluency-evoking tasks themselves. While responses seen in both groups were bilateral, however, the fluency-evoking tasks elicited more robust activation of auditory and motor regions within the left hemisphere of stuttering subjects, suggesting a role for the left hemisphere in compensatory processes that enable fluency.

Educational objectives: The reader will learn about and be able to: (1) compare brain activation patterns under fluency- and dysfluency-evoking conditions in stuttering and control subjects; (2) appraise the common features, both central and peripheral, of fluency-evoking conditions; and (3) discuss ways in which neuroimaging methods can be used to understand the pathophysiology of stuttering.     

Is overt stuttered speech a prerequisite for the neural activations associated with chronic developmental stuttering?

Four adult right-handed chronic stutterers and four age-matched controls completed H(2)(15)O PET scans involving overt and imagined oral reading tasks. During overt stuttered speech prominent activations occurred in SMA (medial), BA 46 (right), anterior insula (bilateral), and cerebellum (bilateral) plus deactivations in right A2 (BA 21/22). These activations and deactivations also occurred when the same stutterers imagined they were stuttering. Some parietal regions were significantly activated during imagined stuttering, but not during overt stuttering. Most regional activations changed in the same direction when overt stuttering ceased (during chorus reading) and when subjects imagined that they were not stuttering (also during chorus reading). Controls displayed fewer similarities between regional activations and deactivations during actual and imagined oral reading. Thus overt stuttering appears not to be a prerequisite for the prominent regional activations and deactivations associated with stuttering.     

The effects of simulated stuttering and prolonged speech on the neural activation patterns of stuttering and nonstuttering adults

Functional magnetic resonance imaging was used to investigate the neural correlates of passive listening, habitual speech and two modified speech patterns (simulated stuttering and prolonged speech) in stuttering and nonstuttering adults. Within-group comparisons revealed increased right hemisphere biased activation of speech-related regions during the simulated stuttered and prolonged speech tasks, relative to the habitual speech task, in the stuttering group. No significant activation differences were observed within the nonstuttering participants during these speech conditions. Between-group comparisons revealed less left superior temporal gyrus activation in stutterers during habitual speech and increased right inferior frontal gyrus activation during simulated stuttering relative to nonstutterers. Stutterers were also found to have increased activation in the left middle and superior temporal gyri and right insula, primary motor cortex and supplementary motor cortex during the passive listening condition relative to nonstutterers. The results provide further evidence for the presence of functional deficiencies underlying auditory processing, motor planning and execution in people who stutter, with these differences being affected by speech manner.     

A positron emission tomography study of short- and long-term treatment effects on functional brain activation in adults who stutter

Previous studies have shown that fluency-inducing techniques, such as choral speech, result in changes in neural activation as measured by functional neuroimaging. In the present study, positron emission tomography was used to investigate the effects of intensive behavioural treatment, followed by a 1-year maintenance program, on the pattern of cortical and subcortical activation in stuttering adults during silent and oral reading of single words. The results indicate changes in activation lateralisation, as well as a general reduction in overactivation, especially in the motor cortex, following treatment. The results are discussed in light of previous functional imaging studies with stuttering adults.

Educational objectives: The reader will learn about and be able to describe the: (1) use of functional neuroimaging PET in the study of stuttering; (2) differences in neural activation between stuttering and non-stuttering adults; and (3) effects of behavioural fluency treatment on cortical and subcortical activations in stuttering speakers.     

发展性口吃的脑机制

口吃是一种常见的言语障碍,对此曾提出过大脑半球言语功能偏侧化异常假设。近期,发展性口吃的神经成像研究在支持这一经典假设的同时,还发现负责言语监控的颞叶系统和负责言语运动控制的额叶系统与皮层下脑结构存在功能失调,这可能损害言语产生时的精确时间控制。据此,研究者开始用神经网络的观点来解释发展性口吃产生的脑机制,认为患者可能存在由多个言语产生相关脑区构成的“双通路”网络的功能障碍     

Perceptual evaluation of the speech before and after fluency shaping stuttering therapy

An often-cited criterion for assessing the effect of a stuttering therapy is the ability of the stutterers to produce normally fluent speech. Many modern stuttering therapies use special techniques that may produce stutter-free speech that does not sound completely normal. The present study investigates this problem in the framework of the Dutch adaptation of the Precision Fluency Shaping Program.

Pre-, post-, and -year follow-up therapy speech samples of 32 severe stutterers who were treated in a four-week intensive therapy are compared with comparable samples of 20 nonstutterers. For that aim the samples were rated on 14 bipolar scales by groups of about 20 listeners. The results show that the speech of the stutterers in all three conditions differs significantly from the speech of the nonstutterers. The pretherapy speech takes an extreme position on a Distorted Speech dimension, due to the large proportion of disfluencies. The posttherapy speech has extremely low scores on a Dynamics/Prosody dimension, a‘1 while the follow-up therapy speech differs from the normal speech on both dimensions, but now the distances are smaller. These results are discussed in relation to the severity of the stuttering problem in the group of treated stutterers. Finally, implications for future research on therapy evaluation are discussed.     

Stuttering: a dynamic motor control disorder

The purpose of this review is to determine what neural mechanisms may be dysfunctional in stuttering. Three sources of evidence are reviewed. First, studies of dynamic inter-relationships among brain regions during normal speech and in persons who stutter (PWS) suggest that the timing of neural activity in different regions may be abnormal in PWS. Second, the brain lesions associated with acquired stuttering are reviewed. These indicate that in a high percentage of cases, the primary speech and language regions are not affected but lesions involve other structures, such as the basal ganglia, which may modulate the primary speech and language regions. Third, to characterize the motor control disorder in stuttering, similarities and differences from focal dystonias such as spasmodic dysphonia (SD) and Tourette’s syndrome (TS) are reviewed. This review indicates that 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.

Educational objectives: The reader will be able to describe: (1) the similarities and differences between stuttering and other speech motor control disorders, (2) which brain lesions are most likely to produce acquired stuttering in adults, and (3) what type of brain abnormality most likely underlies stuttering.     

Reprint of: stuttering treatment control using P300 event-related potentials

Positron emission tomography studies during speech have indicated a failure to show the normal activation of auditory cortical areas in stuttering individuals. In the present study, P300 event-related potentials were used to investigate possible effects of behavioral treatment on the pattern of signal amplitude and latency between waves. In order to compare variations in P300 measurements, a control group paired by age and gender to the group of stutterers, was included in the study. Findings suggest that the group of stutterers presented a significant decrease in stuttering severity after the fluency treatment program. Regarding P300 measurements, stutterers and their controls presented results within normal limits in all testing situations and no significant statistical variations between pre and post treatment testing. When comparing individual results between the testing situations, stutterers presented a higher average decrease in wave latency for the right ear following treatment. The results are discussed in light of previous P300 event-related potentials and functional imaging studies with stuttering adults.Educational objectives: The reader will learn about and be able to describe the: (1) use of P300 event-related potentials in the study of stuttering; (2) differences between stuttering and non-stuttering adults; and (3) effects of behavioral fluency treatment on cerebral activity in stuttering speakers.     

Stuttering treatment control using P300 event-related potentials

Positron emission tomography studies during speech have indicated a failure to show the normal activation of auditory cortical areas in stuttering individuals. In the present study, P300 event-related potentials were used to investigate possible effects of behavioral treatment on the pattern of signal amplitude and latency between waves. In order to compare variations in P300 measurements, a control group paired by age and gender to the group of stutterers, was included in the study. Findings suggest that the group of stutterers presented a significant decrease in stuttering severity after the fluency treatment program. Regarding P300 measurements, stutterers and their controls presented results within normal limits in all testing situations and no significant statistical variations between pre and post treatment testing. When comparing individual results between the testing situations, stutterers presented a higher average decrease in wave latency for the right ear following treatment. The results are discussed in light of previous P300 event-related potentials and functional imaging studies with stuttering adults.Educational objectives: The reader will learn about and be able to describe the: (1) use of P300 event-related potentials in the study of stuttering; (2) differences between stuttering and non-stuttering adults; and (3) effects of behavioral fluency treatment on cerebral activity in stuttering speakers.     

Motor Performance of Stutterers

A continuing program of research, which is concerned with identifying brain mechanisms underlying stuttering through an analysis of manual motor control, is described. Clear evidence has been found that the neural mechanisms associated with sequential responding (and, by implication, with speech) are lateralized in stutterers as they are in nonstutterers. Although no gross or general in-coordination has been found in motor performance by most stutterers, their left hemisphere mechanisms appear to be inefficient for organizing and initiating new sequences of responses and vulnerable to interference from other neural activities. Results of research on bimanual coordination in stutterers are consistent with a model that attributes the interference, in part, to interhemispheric processes, possibly involving the supplementary motor area. One implication of the research is that the disfluency of stuttering is onfy one manifestation of a more general disfunction in motor and cognitive organization and planning.     

Motor performance of stutterers: a search for mechanisms

A continuing program of research, which is concerned with identifying brain mechanisms underlying stuttering through an analysis of manual motor control, is described. Clear evidence has been found that the neural mechanisms associated with sequential responding (and, by implication, with speech) are lateralized in stutterers as they are in nonstutterers. Although no gross or general incoordination has been found in motor performance by most stutterers, their left hemisphere mechanisms appear to be inefficient for organizing and initiating new sequences of responses and vulnerable to interference from other neural activities. Results of research on bimanual coordination in stutterers are consistent with a model that attributes the interference, in part, to interhemispheric processes, possibly involving the supplementary motor area. One implication of the research is that the disfluency of stuttering is only one manifestation of a more general disfunction in motor and cognitive organization and planning.     

Some effects of the Edinburgh Masker on stuttering during oral reading and spontaneous speech

This study assessed the effect of a voice-activated masking unit, known as the Edinburgh Masker, on the speech of four stutterers during oral reading and spontaneous speech. The results show that one stutterer reduced stuttering almost completely whenever the masker was activated. Two subjects showed either marginal or temporary reductions of stuttering during one speaking condition but showed no change in the other condition. The other subject reduced stuttering only during spontaneous speech. No reduction in stuttering was associated with reduced speech rate. A perceptual analysis procedure conducted to assess for altered speech quality during masking conditions found changes in speech quality were evident in two subjects. The clinical implications of these findings are discussed.     

An acoustical analysis of stutterer''s speech prior to and at the termination of speech therapy

The speech of nine adult stutterers was analyzed acoustically prior to and at the termination of a modified Van Riperian procedure to determine if therapy produced discernable changes in their post-therapy fluent speech. The findings indicate that stuttering frequency decreased significantly and reading rate decreased by a statistically insignificant amount during the course of therapy. Vowel duration and the occurrence of voicing during the stop consonant production increased significantly. These findings support the hypothesis that stuttering therapy can affect more than the fluency and rate characteristics of the stutterer's posttherapy speech.     

Perceptual study of the speech of “successfully therapeutized” stutterers

The purpose of this investigation was to determine if the fluent speech of “successfully therapeutized” stutterers and a group of partially treated stutterers was perceptually different from the fluent speech of normal speaking subjects. Tape recorded speech samples of treated stutterers were obtained from leading exponents of (1) Van Riperian, (2) metronome-conditioned speech retraining, (3) delayed auditory feedback, (4) operant conditioning, (5) precision fluency shaping, and (6) “holistic” therapy programs. All forms of disfluency were edited out of these tapes. The remaining samples were then paired with matched fluent samples of normal talkers and presented to a group of 20 sophisticated judges. The judges were instructed to select from each paired speech sample presented to them the one produced by the stuttering subject. The results of the analyses of variance for correct identification of the stutterers showed that the partially treated stutterers, as well as each group of therapeutized stutterers, were identified at levels significantly above chance. This meant that the fluent speech of the partially and successfully treated stutterers was perceptibly different from the utterances of the normal speakers sampled. In addition, the analyses of variance also revealed that all stuttering groups had a significant severity factor. This finding indicated there was a significant difference between the severity subgroup in all the samples investigated. These results were discussed in terms of their clinical implications.     

Brain stem electrical responses of stutterers and normals by sex,ears, and recovery

Auditory brainstem electrical responses (BSER) of right and left ears of active stutterers, recovered stutterers, and nonstutterers, both male and female adults, were obtained at click rates of 11.1 and 71.1/sec. Latency intervals of waves I, III, and V were measured. The auditory systems of subjects were stressed using a rapid rate of 71.1 clicks/sec. The latency of wave V was used as the measure of the stress condition.Analysis of variance was used to determine statistical significances of main effects and interactions of mean BSER (waves I, III, V, and wave V in stress condition) of left and right ears of male stutterers (active and recovered), female stutterers (active and recovered), and male and female nonstutterers.With one exception, all main effects and all higher order interactions were nonsignificant. The one main effect that was significant was gender. Females have significantly faster rates of neural transmission than do males. The question was raised, does this finding contribute toward an explanation of the sex ratio in stuttering?     

Perceptual analyses of stuttering and nonstuttering children's fluent speech productions

Several investigators have reported a significant perceptual difference between adult stutterers' and nonstutterers' fluent speech productions. However, there is only limited information concerning the perceptual evaluation of stuttering and nonstuttering children's fluent speech. Therefore, in this study identical fluent sentences from nine stuttering children (mean age = 6 yrs, 8 mos) and nine nonstuttering children matched individually for sex and age (within 6 mos) were analyzed perceptually in both a paired- and single-stimulus paradigm by 12 sophisticated listeners. Individual subject analyses revealed that only one-half or fewer of the stutterers could be discerned in either paradigm. In the remaining cases, either no discrimination could be made or a nonstutterer was incorrectly identified as a stutterer. When averaged for subject group comparison, these findings indicated that listeners could not discriminate between the two groups. Possible explanations for this discrepancy in results between child and adult stutterers are proposed.     

The nature and treatment of stuttering as revealed by fMRI A within- and between-group comparison

This article reviews some of our recent functional magnetic resonance imaging (fMRI) studies of stuttering. Using event-related fMRI experiments, we investigated brain activation during speech production. Results of three studies comparing persons who stutter (PWS) and persons who do not stutter (PWNS) are outlined. Their findings point to a region in the right frontal operculum (RFO) that was consistently implicated in stuttering. During overt reading and before fluency shaping therapy, PWS showed higher and more distributed neuronal activation than PWNS. Immediately after therapy differential activations were even more distributed and left sided. They extended to frontal, temporal, and parietal regions, anterior cingulate, insula, and putamen. These over-activations were slightly reduced and again more right sided two years after therapy. Left frontal deactivations remained stable over two years of observation, and therefore possibly indicate a dysfunction. After therapy, we noted higher activations in persons who stutter moderately than in those who stutter severely. These activations might reflect patterns of compensation. We discuss why these findings suggest that fluency-inducing techniques might synchronize a disturbed signal transmission between auditory, speech motor planning, and motor areas.

Educational objectives: The reader will learn about and be able to: (1) identify regions of brain activations and deactivations specific for PWS; (2) describe brain activation changes induced by fluency shaping therapy; and (3) discuss the correlation between stuttering severity and brain activation.     

Word-by-word analysis of observer agreement utilizing audio and audiovisual techniques

The purpose of this study was to compare audio and audiovisual techniques of analyzing stuttering behavior using a recently developed index of agreement (Young, 1975). Twenty speech pathologists identified moments of stuttering for ten adult stutterers using both audio and audiovisual methods. Although no statistically significant differences existed between the two conditions, the listeners had more difficulty identifying moments of stuttering during the audio condition when mild stutterers were used.     

Teacher perceptions of stuttering

The attitudes of 521 teachers in the Tuscaloosa, Alabama City School (82% of the teacher population) toward stuttering were assessed using the Teachers' Perceptions of Stuttering Inventory (TPSI). The TPSI consists of five teacher identification questions and 10 attitudinal statements about which teachers are asked to indicate their strength of agreement. Results indicated that a significant number of teachers hold unsubstantiated beliefs concerning the etiology of stuttering and the personality characteristics of stutterers. Teachers having experience with stutterers or having had course work in speech disorders indicated more realistic attitudes toward stutterers and expressed more demanding attitudes toward stutterers in the classroom situation. In view of the potential positive role teachers can play in assisting stutterers, the results were interpreted as suggesting a need for teachers to receive either preservice or inservice instruction with respect to the problem of stuttering.