 Stammering affects around 70 million people worldwide, cutting across all boundaries. Every language has a word for it: begaiement (French), tartamudez (Spanish), hakalaanaa (Hindi), hau hick (Cantonese), domori (Japanese), nsu (Nigerian Ibo).Many illstrious people from King George VI to Winston Churchil have been its sufferer. Stuttering has been an excuse for mockery, prejudice and misguided 'cures'. At last lot of research are on to find its exact reason and treatment.

1. by
Col Mukteshwar Prasad(Retd),
MTech(IIT Delhi) ,CE(I),FIE(I),FIETE,FISLE,FInstOD,AMCSI
Contact -+919007224278,
e-mail -muktesh_prasad@yahoo.co.in
for book ”Decoding Services Selection Board” and
SSB guidance and training at
Shivnandani Edu and Defence Academy,Kolkata,India
Stammering/Stuttering
Based on paper of
Norman Miller | 12.04.2016

2.  Stammering affects around 70 million people
worldwide, cutting across all boundaries.
 Every language has a word for it:
 begaiement (French),
 tartamudez (Spanish),
 hakalaanaa (Hindi),
 hau hick (Cantonese),
 domori (Japanese),
 nsu (Nigerian Ibo).

3. Famous people who
stammered
 Some illustrious folk have stammered throughout
history.
 The Roman Emperor Claudius and
 Britain's King George VI
 Above were just two of the famous rulers,
 Isaac Newton, Charles Darwin and Alan Turing all
stammered to varying degrees
 Hence those who can not be prejudiced with lack of
intelligence.
 Despite his renown as an orator, Winston Churchill
was another who battled to deal with a stammer, and
a phrase he used to describe Russia - “a riddle
wrapped in a mystery inside an enigma” - was
borrowed to describe stuttering by Charles Van
Riper, a 1930s American researcher who pioneered
an early form of treatment based on speech

4. stuttering has been an excuse for mockery, prejudice and
misguided 'cures‘.
 Stuttering has been an excuse for mockery, prejudice and misguided
'cures'.
 One old belief blamed it on abnormalities of the tongue, leading to
cauterisation or cutting the 'offending' body part.
 The Greek philosopher Demosthenes, meanwhile, worked on his fluency
by shouting at the sea with pebbles in his mouth.
 Some more modern ideas weren't much sounder.
 In the 1950s, US researcher Wendell Johnson blamed stuttering on
negative reactions by over-anxious parents to children's normal
speech hesitancies – an idea still trotted out despite any real supporting
evidence.
 Psycho-babblers blamed things like 'unresolved pregenital oral sadistic
conflict' (no, I haven't a clue either).
 Matters weren't helped by the genuine riddles and enigmas
stammering presents.
 For example, while around 5% of children between ages two and five
stutter at some point, most just 'grow out of it' - with no discernible
pattern as to who or how.

5. Understanding stammering
 Three forms of stammering are
 Developmental stuttering is the commonest - and the most widely
researched - appearing in young children and for the unlucky 1% of the global
population for whom it remains into adulthood.
 Neurogenic stuttering, by contrast, develops as a result of strokes or other
brain traumas.
 Psychogenic stuttering is a rare form that arises after severe emotional
trauma.
 Normal speech is produced via a series of precisely coordinated muscle
movements involving
 breathing,
 phonation (voice production) and
 articulation (movement of the throat, palate, tongue, and lips).
 This all requires several areas of the brain to co-ordinate things in neat
sequence.
 A region in the frontal cortex controls muscle movement planning and
execution, while
 regions in the temporoparietal cortex handle auditory feedback mechanisms.
 Parts of the basal ganglia (notably the striatum), thalamus and cerebellum
chip in with internal timing and sequencing cues.
 So the fluency most people take for granted actually depends on a lot of
things combining perfectly.

6. Understanding stammering
 The fluency most people take for granted actually depends
on a lot of things combining perfectly.

7. Looking at the brain
 “There is something fundamentally different about the brains of people who
stutter,” says Scott Grafton, a neuroscientist at the University of California
Santa Barbara.
 Used diffusion spectrum imaging (DSI) in an MRI scanner to map the
complex tangle of neural intersections used during speech
production by stammerers of various ages and both genders.
 What appeared was an abnormality in a region known as the arcuate
fasciculus.
 This bundle of nerve fibres provides a communication conduit for signals
between parts of the rear brain to parts of the front brain known to be
involved in speech production.
 And normally, the neural 'wiring' in the arcuate fasciculus splits into
several branches at the rear of the brain.
 “What’s interesting is the back half”, says Grafton. “In the vast majority of
the stutterers we scanned, there seems to be a missing branch of neural
connections,” says Grafton.
 One brain region linked into a speech production network by the arcuate
fasciculus is Broca's area, which is involved in directing muscle movement
of the mouth when you form words.
 The fact that children who stammer also show disorganised neural
connections in Broca's area suggests this may be another key player in
the stammering equation.

8. Looking at the brain(2)
 Another area now implicated in stammering is the striatum, a part of the brain
located in the basal ganglia which plays a key role in facilitating voluntary
movement.
 The basal ganglia receives information about a desired goal – such as
producing speech - from the cerebral cortex, and helps to achieve that
goal by selecting the appropriate physiological actions and initiating
movement of relevant bodily parts to produce a smooth, fluid result.
 Various studies suggest malfunctions in the striatum may be yet another
element in stuttering.
 At Oxford University's Department of Experimental Psychology, Kate Watkins
and Jen Chesters found further neural abnormalities in both adult and child
stutterers, using diffusion tensor imaging (DTI) and functional MRI.
 “We found differences in the white matter underneath the ventral premotor
cortex, which is connected to the arcuate fasciculus,” says Watkins. “But
we found differences in the arcuate fasciculus too.”
 Soo-Eun Chang at the University of Michigan, meanwhile, has carried out
brain scans of stuttering children as young as three (no easy task due to
youthful fidgetiness).
 She found reduced grey matter volumes in speech relevant regions, as
well as stunted white matter connectivity in regions associated with
auditory-motor activity.
 Chang's suggestion is that these regions develop differently in
stuttering children, affecting their ability to plan and execute fluent

9. Broca's area (in red). Image: CC-BY-SA-2.1-jp

10. Striatum (in purple)

11.  These studies increasingly hint that people who stammer
do so because of connection faults in the speech-
producing networks of their brain.
 However, the elephant in the room is whether these
anomalies in the brain cause the stutter or whether 'natural'
dysfluencies in early childhood create the anomalies in the
developing brains of children who go on to stammer.
 Kate Watkins admits that, at present, scientists simply
cannot yet answer this chicken-and-egg conundrum.
 “The differences are there in young children close to the
time that stammering starts, but most of the data acquired
has been from adults who have stammered all their
lives. So it is absolutely the case that stammering could
cause the brain anomalies.”
 The only way to solve this mystery would be longitudinal
studies over years or decades.

12. Recovered stammerers
 Scans of stammerers who have overcome the condition has led the way in
comparing the brain function of persistent stammerers compared to so-
called 'recovered stammerers'.
 Among fluent speakers it is areas in the left hemisphere of the brain that take
the dominant role in speech production.
 In persistent stammerers, however, their right hemispheres activate more
strongly when speaking, even when they are fluent.
 For Kell, this suggests their brains are attempting to find some way to
compensate for malfunctions in the relevant left hemisphere speech areas.
“To some degree, this could reduce symptoms - but only partly,
because the right hemisphere usually is not specialised in speaking,”
he says.
 Unlike fluent speakers, in persistent stammerers their right hemispheres
activate more strongly when speaking, even when they are fluent.
 Among recovered stammerers, however, Kell found left hemisphere networks
were brought back into play.
 He identified one particular neural fix in an area known as Brodmann Area
47, or BA47, that is known to be linked to various speech mechanisms
including phonological processing.
 In persistent stutterers, scans show BA47 as one of the areas failing to
activate properly - but among recovered stammerers it appears to be
working again.

13. Recovered stammerers
 This kind of plasticity could also help explain the
fact that four times as many boys as girls
seem to stutter.
Soo-Eun Chang at the University of Michigan
who studies stammering in children suggests
that girls’ brains may have a greater plasticity
which allows them to adapt better.
 “There is some evidence that girls who stutter
may have better connectivity in certain brain
networks that help coordinate between
auditory and motor areas of the brain, which
may help them more able to recover.”
 But if stuttering is caused by anomalies in brain
structure, what causes those anomalies in the
first place?

14. Gene genie?
 In the hunt for specific ‘stammering genes’, Dennis
Drayna at the National Institute of Health in the US is
focusing on families with multiple stammerers - including
one extended Cameroonian family with over 40
stammerers and several families in Pakistan, where the
tradition of marriages between cousins would amplify the
impact of such genes.
 In one analysis of the DNA of nearly 400 people who
stammer, matched with a similar sized fluent control
group, he found three gene mutations that appeared
repeatedly among the stutterers.
 These genes encode an enzyme that breaks down and
recycles cellular components.
 Drayna believes that the gene mutations he identified in
stammerers could cause a breakdown in the healthy recycling
of cells in areas of the brain related to speech processing,
resulting in the sort of anomalies – such as missing neural
connections – observed in areas like the arcuate fasciculus.
 Drayna envisions a future where those found to have these gene

15. Treatments
 One old school treatment developed in the 1960s involves 'masking devices'
which feed white noise into the ears of stammerers as they try to speak,
based on the idea that stammerers often become more fluent when they
can't hear themselves clearly.
 A classic example of this was cited by Charles Van Riper in his 1982
book The Nature Of Stuttering when he described a persistent stammerer who
became fluent almost immediately after an accident that made him completely
deaf.
 “The cessation of stuttering occurred within three hours of the trauma,” wrote
Van Riper.
 During speech production, activity in the motor and auditory areas of the
brains of people who stutter was out of sync, but devices that blocked
auditory feedback as stutterers spoke seemed to make the relevant neural
activity get more in sync.
 The Oxford research builds on research in 2010 by Oren Civier at The Leslie
and Susan Gonda Multidisciplinary Brain Research Center in Israel which
also pointed to a malfunction in the how the brains of stammerers handle
auditory feedback as they try to speak.
 (Webmaster’s note: a related approach is altered auditory feedback, where
speech is played back with a small delay and/or at a different pitch.
Seewww.stammering.org/electronic )
 Activity in the motor and auditory areas of the brains of people who stutter
was out of sync

16. Treatments
 At UCSB, they have enjoyed some success with a technique called MPI
(Modifying Phonation Intervals).
 Phonation intervals are the periods of time vocal folds vibrate to produce
vowels and voiced consonants, delineated by voiceless consonants and
pauses.
 Roger Ingham found that intensive training in modifying PIs gave stammerers
fluency.
 There are inspiring before/after videos on this Youtube link.
 To compare MPI to other treatments, the UCSB team assigned 17 adult
stammerers to MPI therapy, and 10 others to another method called
prolonged speech (fluency shaping) therapy, where speech is slowed down
to almost a drawl.
 While 11 of the 17 MPI participants became fluent, just three of the prolonged
speech group did.
 Brain imaging studies showed MPI to be associated with decreased activity in
the putamen area of the brain for those who became fluent – a neural region
associated with phonation, motor learning and control.

17. Drug therapies
 Others have sought a magic pill to treat stammering - often looking at drugs
already used to treat other conditions.
 Early results were mixed.
 Anti-anxiety drugs like alprazolam (aka Xanax) and citalopram (Celexa)
reduced stuttering in some patients – but had no effect on most.
 Haloperidol – a drug used to treat conditions like Tourette's that often
include speech problems - also showed some promise in inducing fluency,
but came with severe side effects.
 Another avenue focused on drugs that block the brain chemical dopamine,
inspired by the discovery that some fluent speakers treated with dopamine
boosters for other conditions then acquired a stutter.
 The dopamine blocker risperidone - more commonly used to treat bipolar
conditions – was one drug that produced improved fluency in many
stammerers, with PET brain scans showing raised activity in speech-
associated areas like the striatum in the basal ganglia.
 Between 2008-2011, meanwhile, neuroscientist Gerald Maguire conducted
studies of pagoclone – an anti-anxiety drug that targets a brain chemical
known as GABA – which suggested it brought on significantly improved
fluency in around 55% of stutterers, with minimal side effects.
 However, funding issues led to research on the drug grinding to a
halt. (Webmaster’s note: see also Pagoclone – disappointing news.)

18. Drug therapies(2)
 Maguire holds a specially endowed chair in
stuttering research at University of California
Riverside School of Medicine, and as a lifelong
stammerer has chosen to try various potential
drug treatments on himself.
 He believes dopamine blockers are the
likeliest candidates as anti-stuttering
medication.
“Every study completed of a dopamine
antagonist has shown positive benefit,” says
Maguire. “Dopamine medications result in a
more natural speech by improving the function
of the striatum. We become fluent when we
sing because we bypass the defective
striatum.”

19. Drug therapies(3)
 Gerald Maguire’s money is now on asenapine
 His money, though, is now on asenapine - a drug already
approved to treat people with bipolar disorder and
schizophrenia.
 After taking it for nearly a year, Maguire put a figure of 80% on the
reduction in his own stutter, and he is now helping conduct Phase
IV US trials.
 Kate Watkins is holding fire on prospects for anti-stammering
drug treatments. "I think the scientific theories that implicate
dopamine are persuasive - but the evidence from brain imaging
studies is not particularly clear with respect to either dopamine
or GABA."
 USCB's Roger Ingham is also wary.
 He concedes that several studies found dopamine levels in the
brains of stammerers 50-200% higher than fluent controls, but
criticises the number of subjects used – just three stutterers in one
paper - as being too low to draw firm conclusions.
 But at least stammering is finally getting the serious research it
deserves.