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.     

Subfactors of DSM-IV Conduct Disorder: Evidence and Connections with Syndromes from the Child Behavior Checklist

Is conduct disorder (CD) as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) a unitary entity, or do variants of CD exist? We addressed this question, using data collected from the parents of 1,669 Australian boys, aged 6–17. Parents were interviewed to assess DSM-IV Conduct Disorder (DSM-IV CD) criteria. Results revealed 2 subfactors of DSM-IV CD symptoms, made up of overt behaviors (e.g., initiating physical fights) and covert behaviors (e.g., stealing without confrontation). Ordinary least squares regressions showed the 2 CD subfactors to be significantly and uniquely predicted by Child Behavior Checklist (CBCL; T. M. Achenbach, 1991a, 1991b) syndromes labeled Aggressive Behavior and Delinquent Behavior, respectively. The results are discussed in terms of the utility of differentiating these 2 variants of CD in future editions of the DSM.     

Listening comprehension and working memory are impaired in attention-deficit hyperactivity disorder irrespective of language impairment

This study investigated listening comprehension and working memory abilities in children with attention-deficit hyperactivity disorder (ADHD), presenting with and without language impairments (LI). A 4-group design classified a community sample (n = 77) of boys aged 9–12 into ADHD, ADHD + LI, LI, and Normal groups. Children completed tests of basic language and cognitive skills, verbal and spatial working memory, and passage-level listening comprehension. Multivariate analyses and post hoc comparisons indicated that ADHD children who did not have co-occurring LI comprehended factual information from spoken passages as well as normal children, but were poorer at comprehending inferences and monitoring comprehension of instructions. ADHD children did not differ from normal children in verbal span, but showed significantly poorer verbal working memory, spatial span, and spatial working memory. The ADHD + LI and LI groups were most impaired in listening comprehension and working memory performance, but did not differ from each other. Listening comprehension skills were significantly correlated with both verbal and spatial working memory, and parent–teacher ratings of inattention and hyperactivity/impulsivity. Findings that children with ADHD but no LI showed subtle higher-level listening comprehension deficits have implications for both current diagnostic practices and conceptualizations of ADHD.     

Demographic characteristics,social competence,and behavior problems in children with gender identity disorder: a cross-national,cross-clinic comparative analysis

This study examined demographic characteristics, social competence, and behavior problems in clinic-referred children with gender identity problems in Toronto, Canada (N = 358), and Utrecht, The Netherlands (N = 130). The Toronto sample was, on average, about a year younger than the Utrecht sample at referral, had a higher percentage of boys, had a higher mean IQ, and was less likely to be living with both parents. On the Child Behavior Checklist (CBCL), both groups showed, on average, clinical range scores in both social competence and behavior problems. A CBCL-derived measure of poor peer relations showed that boys in both clinics had worse ratings than did the girls. A multiple regression analysis showed that poor peer relations were the strongest predictor of behavior problems in both samples. This study—the first cross-national, cross-clinic comparative analysis of children with gender identity disorder—found far more similarities than differences in both social competence and behavior problems. The most salient demographic difference was age at referral. Cross-national differences in factors that might influence referral patterns are discussed.     

Treatment of Prostitution Using Integrative Therapy Techniques: A Case Study

This case study examines a pattern we believe to be common among female prostitutes: a woman (Bonnie) who, like most prostitutes, is a survivor of childhood sexual abuse. Bonnie's prostitution is part of the unconscious repetition compulsion common in trauma victims; by prostituting herself, Bonnie re-creates the scenario of sexual abuse that occurred during her childhood, while maintaining an illusion of control over the situation. We maintain that an effective approach to treatment for Bonnie is integrative therapy, a type of psychological counseling designed to address the major aftereffects of sexual abuse: dissociation from the body and sexuality in general; a profound sense of powerlessness; critically low valuation of the self; and mistrust and fear of intimacy. Bonnie's story shows the dynamics of both prostitute behavior and integrative therapy, providing an example we believe to be applicable far beyond this case study.     

From I: A/M to “Who am I?”—Aggregation/Massification and Trauma-Based Affects and Object Relations in Groups: A Response to Earl Hopper

Hopper's portrayal of the fourth basic assumption of Incohesion: Aggregation/Massification has two components: (1) a revision of Turquet's theory of BA Oneness to incorporate the polarity of aggregation and massification stemming from annihilation anxiety; and (2) a conception of the difficult patient as having an encapsulated psychosis. Hopper's theory of the encapsulated psychosis offers an important but incomplete perspective in explaining borderline and narcissistic pathology, as well as psychological trauma. In this response to Hopper, I suggest that the fourth assumption is in fact a still more primitive state of boundary opening and closing. I also see a need to differentiate trauma as such from borderline pathology, and further hold that the relationship between Hopper's British Independent theory and trauma theories based on dissociation needs to be clarified.     

Fixed-time schedule effects as a function of baseline reinforcement rate

Using an arbitrary response, we evaluated fixed-time (FT) schedules that were either similar or dissimilar to a baseline (response-dependent) reinforcement schedule and extinction. Results suggested that both FT schedules and extinction resulted in decreased responding. However, FT schedules were more effective in reducing response rates if the FT reinforcer rate was dissimilar to baseline reinforcer rates. Possible reasons for this difference were evaluated with data analysis methods designed to identify adventitious response-reinforcer relations.     

Depression and Self-Esteem in Boys with Attention-Deficit/Hyperactivity Disorder: Associations with Comorbid Aggression and Explanatory Attributional Mechanisms

It was tested whether boys with attention-deficit/hyperactivity disorder (ADHD), subgrouped by aggressive status, would show higher rates of depressive symptomatology and lower levels of self-esteem than would comparison boys and, in a subsample, explored attributional mechanisms that may be related to such internalizing features. Study 1 utilized 114 boys with ADHD (all prior recipients of stimulant medication) and 87 comparison boys, aged 7–12 years. Aggressive boys with ADHD reported more symptoms of depression than did nonaggressive boys with ADHD, who, in turn, reported more depression than did comparison boys. Effect sizes were moderate to large and did not vary with a depression rating scale uncontaminated by ADHD-related items. For self-esteem, the most pronounced effect was that aggressive boys with ADHD showed lower levels than did nonaggressive ADHD or comparison boys; effects were again moderate to large. Study 2 participants were a subsample of boys with ADHD from Study 1 (N = 27). We probed causal attributions in ADHD-related domains through responses to hypothetical vignettes, in which the protagonist's medication status (medicated, not medicated) was crossed with type of outcome (good, bad). Medication-related attributions were frequent. In describing the protagonist's success in relation to medication treatment, the sample showed significant associations between (a) medication-related attributions and (b) increased depressive symptomatology as well as decreased self-esteem. We discuss attributional processes that may help to explain the variation in internalizing symptoms among children with ADHD.     

Childhood Peer Relationship Problems and Young People's Involvement with Deviant Peers in Adolescence

Using prospective longitudinal data from the Christchurch Health and Development Study, this article examined the relationship between children's peer relationship problems in middle childhood and their subsequent risk of forming deviant peer affiliations in adolescence. The analysis proceeded in three steps. First, a structural equation model demonstrated a moderate association between early peer relationship problems and later deviant peer affiliations (r = .27). Second, the model was extended to include a latent variable measure of early conduct problems. This analysis revealed that when the confounding effects of concurrently measured conduct problems were taken into account, peer relationship problems in middle childhood were no longer significantly related to young people's choice of deviant peers in adolescence. Third, the model was further extended to include lagged variables, permitting an examination of possible reciprocal relationships between early conduct problems and peer relationship problems. Results suggested that both early peer relationship problems and adolescent deviant peer involvement are symptomatic of early child behavioral adjustment. The implications of these findings for explanations of deviant peer selection are discussed.     

Neuropsychological Characteristics of Adolescents With Conduct Disorder: Association With Attention-Deficit–Hyperactivity and Aggression

The purpose of this study was to determine whether an association exists between neuropsychological deficits and conduct disorder (CD) with and without concurrent attention-deficit–hyperactivity disorder (ADHD). In addition, we explored the differential neuropsychological performance of aggressive and nonaggressive CD adolescents and the combined effect of this behavioral status and ADHD on performance. Fifty-nine adolescents (mean age of 15.4 years) who met the criteria for CD were compared with 29 controls comparable in age, gender, and socioeconomic status. A neuropsychological battery of current tests measuring executive functions and a battery of language tests were used in the study. Multivariate analyses showed that, compared with controls, CD adolescents had significantly lower verbal skills but did not differ on executive function measures. However, the lower verbal performance of CD adolescents is not explained by the existence of a CD subgroup with concomitant ADHD or aggressiveness. The study confirms with a sample of CD adolescents the association between verbal deficits and antisocial behavior when socioeconomic status is controlled. Our results also demonstrate that CD per se can be a sufficient condition for such deficits.