Stuttering and auditory functions.

KUNNAMPALLIL GEJO JOHN,MASLP

KUNNAMPALLIL GEJO JOHN,MASLP

Content :
(1) Introduction. (2) Auditory processing. (3) Dichotic listening. (4) Phase disparity. (5) Acoustic reflex. (6) Theoretical explanation of the auditory effects. (7) Types, tools, applications & effect of auditory feedback. (8) Tests results of auditory processing in stuttering.

KUNNAMPALLIL GEJO JOHN,MASLP

INTRODUCTION :

Stuttering is the involuntary disruption of a continuing attempt to produce a spoken utterance.

Perkins, 1990
KUNNAMPALLIL GEJO JOHN,MASLP

Auditory processing :
Term used to describe the recognition & interpretation of a sound by the brain. Ear acoustic to electrical Learning to speak involves

interpreted by brain.

motor process. sensory process.

Self hearing helps to -- monitor ones own speech.

KUNNAMPALLIL GEJO JOHN,MASLP

Threshold for pure tones

Relative phase angle of air & bone conducted sounds

Effect of aud fn on oral activity not involving sp.

Aspects of auditory functions

Reflex response of ME msls to sd.

Central aud fng at level of brainstem.

Dichotic listening.

KUNNAMPALLIL GEJO JOHN,MASLP

Auditory processing in stutters :

Stuttering may be the result of errors of stutterers self hearing aspect.

In exploring this hypothesis , researchers have measured how stutterers CNS process different sounds including speech.

The resulting hypothesis was that stuttering may have its origin because of malfunctioning of the hearing mechanism in its role as rural monitor.
KUNNAMPALLIL GEJO JOHN,MASLP

Findings of all aspects of physiological functioning in stutterers :

(1) central auditory function in stutterers
Hall and Jerger assessed auditory function in 10 stutterers and 10 non-stutterers. Performance for the 2 groups was compared for 7 audiometric procedures including -- auditory reflex threshold, acoustic reflex amplitude function, performance intensity, function for monosyllabic phonetically balanced (PB word) performance intensity for SSI, SSI-ICM, SSI-CCM and SSW.

KUNNAMPALLIL GEJO JOHN,MASLP

Acoustic reflex amplitude function, synthetic identification with ICM and SSW test

As a group stutterers presented evidence of a central auditory deficiency.

The pattern of the test result suggested in brainstem level. The subjectivity of the deficiency is emphasized. In 1959, Rousey, Goetzinger and Dirks observed that stuttering children perform less well than non stutterers in localizing sounds in space.
KUNNAMPALLIL GEJO JOHN,MASLP

(2) Central processing in stuttering :

Hemispheric properties of stuttering --

Brain waves of stutterers have been examined & compared those with non stutterers.
Manifestations of cortical dominance were studied .CNS investigation suggested that stutters lack cerebral dominance for speech. Lindshy &Freestone (1942) suggested that stutters demonstrate right hemisphere dominance for language. Wilkins EEG studies shown that final neural dysfunction rather than hemispheric differences in stutterers. KUNNAMPALLIL GEJO
JOHN,MASLP

Right hemisphere activity -Difficulty in

- Central auditory processing, - Language development, - Speech motor reaction time & - Delay in tracing auditory stimuli
(may all be related to organization of speech, language & auditory functions in brain).

People with stuttering may be using less effective part of brain for processing speech functions.
KUNNAMPALLIL GEJO JOHN,MASLP

Fox (1996,2000) - decreased activity in auditory area during increased stuttering ,so reduces the left brain communication of this sensory information to frontal speech & language areas.

The abnormal right brain activity may be alternative pathology for brain sensory information to travel to the front of the brain .

People who stutter use Right hemisphere which leads to intermittent break down ,because Right hemisphere is not as adopt as the left for processing rapid transmission that characterizes spoken language. Right hemisphere is also associated with emotional expression.
KUNNAMPALLIL GEJO JOHN,MASLP

This suggestion has implication for the onset of stuttering in childhood when many functions appear to have bilateral representations. Fluency may be vulnerable to emotional disturbances & caused by excessive amounts of neurotransmitter dopamine in the left caudate nucleus. (This is the area that translates speech into muscle movements).
There is no conscious awareness of central auditory processing in left caudate nucleus (This explains why stuttering that relay in consciously controlling speech best only temporarily). Inability to integrate what stutterers hear with the muscle movements that he feels.
KUNNAMPALLIL GEJO JOHN,MASLP

 Left auditory cortex activity in stuttering Many brain imaging studies of stuttering have shown a lack of activity in the left superior temporal lobe, including auditory association areas & Wernickes area (FOX et al ,2000&DE NIL et al,2003).
These findings suggest the possibility that when individual stutter they are not using auditory feedback to monitor & control their speech. Another imaging study (SALMELIN et al ,1998) found that stutters have a reversal of the normal pattern of activation of the left & right auditory cortices during stuttering .

KUNNAMPALLIL GEJO JOHN,MASLP

Stutters may have difficulty performing auditory processing tasks (BARASCH et al ,2000) and that fluency can be induced by changing the way stutters hear their own speech (BRAYTON & CONTURE ,1978;POWELL ,1987).
Auditory self monitoring may provide a stimulus to time or integrate the sequence of activities that run in parallel when a speaker decides what she will say, selects the linguistic elements for it, and executes the utterance. Thus the dyssynchrony or timing disturbance are the basis of stuttering (Perkins,Kent,&Curlee,1991;Van Riper 1982) may be caused by a paucity of signals that synchronize the sequence for speech output.
KUNNAMPALLIL GEJO JOHN,MASLP

Therapies that focus on the use of slow speech, gentle onset, and light articulatory contacts may develop the clients auditory as well as proprioceptive monitoring of speech. Craver & Faber1982, Moore1986 found that stutterers have poor recognition & recall of words on auditory presentations.
Carpenter & Sommers1987 found stutterers & nonstutterers have equal auditory memory.

Dichotic listening : In the dichotic listening paradigm, different sound are presented simultaneously to the two ears.
KUNNAMPALLIL GEJO JOHN,MASLP

The listener must report everything he hears from both ears.

Since the sounds are simultaneous it is presumed that the listener must alternate attention between the two ears, placing one percept in short term memory while attending to the other and vise versa. When normal adults are tested in the dichotic paradigm, there is a slight advantage for certain sounds delivered to the right ear and for other sounds delivers to the left ears. Kimura was the first to demonstrate that verbal signals such as words and digits are more accurately reported from the right ear (ie, left hemisphere) than from the left ear (ie, right hemisphere).

KUNNAMPALLIL GEJO JOHN,MASLP

After simultaneous dichotic presentation (Kimura, 1961,1967) the reverse is true for melodies (Kimura 1967). If stutterers are, indeed, lacking in suitable hemispheric dominance for language, this fact should be readily revealed by a dichotic test. Variables in dichotic testing. : (1) It is important, for example, to ascertain the handedness of the subjects being tested stating that subjects are right or left handed is not as meaningful from laterality standpoint as the administration of a detailed handedness questionnaire (Oldfield, 1971).

KUNNAMPALLIL GEJO JOHN,MASLP

(2) Another variable is the order in which subjects are instructed to report sounds (ie, right ear first, left ear first, or either ear first). Most investigators who have controlled this variable have noted that there is a greater index of cerebral laterality when subjects are instructed to report first from left ear and then from the right ear. (3) Another variables is the stability of the dichotic ear advantage over time. Blumstein, Good glass and Tarter (1975), employing a test retest experiment, contend that 85% of normal right handed males have a right ear advantage in dichotic listening and that any such test sample contains 15% misclassified subjects. They observed that as many as 30% change ear dominance when retested. Thus consistency between test and retest is an important dimension in studies of cerebral laterality.
KUNNAMPALLIL GEJO JOHN,MASLP

Dichotic listening paradigms test a response to a sound input. The test evaluates cerebral laterality in a steady state, it does not evaluate laterality in the dynamic state of speech production. This may be very important in the investigation of stuttering. Suppose, for example that stutterers have a disturbance in cerebral laterality that causes a compromise in their speech output. This abnormality may not be static, that is, it may only appear during speech or perhaps only at certain times during speech production.

KUNNAMPALLIL GEJO JOHN,MASLP

Dichotic listening in stutterers :

Curry and Geogory (1969) used a dichotic listening paradigm with 20 adult stutterers (19 males, 1 female) and 20 appropriate controls. All were stated to be right handed. The author employed several dichotic tasks, one of which was the dichotic word test. The test involves the recognition of pairs of consonant vowel consonant (CVC) words of high familiarity presented in groups of 6 pairs with 0.5 sec separating each pair. After each group of 6 word pairs had been presented, the subjects attempted to recall the 12 different words, in any order and without concern for which words KUNNAMPALLIL had been presented to any particular ear. GEJO
JOHN,MASLP

The anticipated right ear superiority was significantly less for stutterers than for non stutterers. 75% of the non stutterers had right ear scores that were higher than their left, this was true for only 45% of the stutterers. Dorman and Porter (1975) evaluated 16 right handed adult stuttereres (12 males, 4 females) and compared them to 20 controls (10 males, 10 females) subjects had to write down responses to synthetically generated consonant vowel dichotic stimuli. There was no significant difference between stutterers and non stutterers.

KUNNAMPALLIL GEJO JOHN,MASLP

Pinsky and Mc Adam (1980) tested 5 adult stutterers and 5 fluent speakers in a dichotic listening paradigm. All individuals were right handed except one who was stated to be weakly right handed. The authors failed to find a significant difference between the stutterers and non stutterers.
Rosenfield and Goodglass (1980) queried whether the above study had failed to take into account a number of variables that might affect the results. Children stutterers, for example, might be different from adult stutterers. In an effort to control all relevant variables. Rosenfield and Goodglass (1980) evaluated a group of adult male, strongly right handed, stuttereres.
KUNNAMPALLIL GEJO JOHN,MASLP

They evaluated left cerebral dominance for language using consonant vowel stimuli and tested right hemisphere laterality for melodies by testing melody input. Right ear advantages were obtained for consonant vowel stimuli and left ear advantages were noted for melodies output significant disturbance between the groups of stutterers and controls. However, there were significantly greater number of stutterers than controls who consistently failed to show the expected ear laterality for either type of material. As pointed out by Moore (1976) stutterers seem to differ from nonstutterers when investigators employ meaningful verbal stimuli. Of the dichotic studies that employs words or digits, rather than meaningless consonant vowel or other stimuli, most find difference KUNNAMPALLIL between stutterers and non stutterers.GEJO
JOHN,MASLP

Sussman and Mac Neilage (1975) employed a dichotic paradigm and other paradigm, that of pursuit auditory traking.

They reasoned that dichotic listening tested elements of laterality pertaining to speech perception, where as the tracking paradigm test speech production.

Their experiment involved matching the frequency of the variable tone in one ear to the to the frequency of the externally varied tone in the other ear.

The former tone was altered by a transducer attached to the tongue or jaw. KUNNAMPALLIL GEJO
JOHN,MASLP

The subject varied the frequency of this tone by approximately moving tone or the jaw, subjects were required to match the frequency of this transducer related tone to the frequency of the externally varied tone.

The authors tested the right handed male and female stutterers and nonstutterers for laterality pertaining to speech perception (dichotic listening) and speech production (tracking paradigm).

They noted a right ear advantage for both nonstutterers and stutterers on the dichotic studies, stutterers did not differ from nonstutterers in laterality on the speech perception task.
KUNNAMPALLIL GEJO JOHN,MASLP

On the tracking paradigm, however normals had right ear advantage whereas stutterers did not (i.e. nonstutterers best altered the transducers tone when they heard it in the right ear and had to match it against the externally varied tone in the left as opposed to having a transducer tone in the left and the extremely varied tone in the right).

This indicated left hemisphere dominance for nonverbal output. Stutterers failed to demonstrate such laterality for non verbal output.

KUNNAMPALLIL GEJO JOHN,MASLP

Phase disparity : In order to study intrinsic abnormality in the stutterers auditory monitoring system, phase disparity between air and bone conducted tones was studied. In 1957, stromosta exploited the fact that two pure tones. 180 degree out of phase but equal infrequency and amplitude, will cancel each other out. Stutterers and normal speakers listened to an air conducted tone introduced to the ear and to a bone conducted tone of the same frequency simultaneously introduced at the teeth.

KUNNAMPALLIL GEJO JOHN,MASLP

Subjects were asked to vary the phase and amplitude of air conducted tone until a critical adjusted was achieved at which no sound was audible to them.

There was a significant difference between stutterers and nonstutterers in the relative phase angle of the air and bone conducted sounds at 2000 Hz.

Using a similar method, Stromsta (1972) noted an unusual phase disparity between stutterers left and right ears.

KUNNAMPALLIL GEJO JOHN,MASLP

The acoustic reflex : One component of the total auditory monitoring system, the acoustic reflex has come under particular scrutiny because of its intimate relation to vocalization. The stapedius muscle contracts during vocalization, Brog and Zakrisson (1975) visually and electromyographically evaluated stapedius muscle activity that accompanied vocalization in fluent speaker who had a perforated tympanic membrane. EMG activity in the stapedius muscle accompanied speech, even at low levels of phonation.

KUNNAMPALLIL GEJO JOHN,MASLP

Stapedius EMG activity occurred before the onset of vocalization in 55% of their cases and after vocalization in 45 % (Borg and Zakrisson, 1975) in the former instance the time difference between reflex onset and phonation onset was less than 75 msec.

The authors concluded that EMG activity in the spapedius muscle is not caused by feedback of the voice signal but, rather is centrally mediated as a component of the vocalization process.

KUNNAMPALLIL GEJO JOHN,MASLP

Shearer and Simmons (1965) investigated stapedius muscle activity in stutterers and non stutterers in ongoing speech. They observed that stapedius muscle activity tended to parallel vocalization in non stutterers. In stutterers, however, parallelism was less consistent. At time, the onset of stapedius activity seemed to be delayed relative to the onset to the vocalization.

Hall and Jerger (1978) compared the acoustic reflex to external sound in stutterers and controls. Reflex threshold was equivalent in the two groups but reflex amplitude was smaller in the stuttering KUNNAMPALLIL GEJO group.
JOHN,MASLP

Theoretical explanation of the auditory effects : Feedback control theory has provided the main framework for explaining the relation between stuttering and the processing of auditory feedback. Under feedback control theory, (1)Feedback from sensory system plays a direct role in controlling ongoing speech action. (2)Delaying feedback results in speech control errors such as stuttering. (3)Feedback control theory has never achieved a detailed KUNNAMPALLIL GEJO explanation of instances of stuttering (Garber and Seigel, 1982).
JOHN,MASLP

Evidence supported by theory : (1) Errors under DAF decrease with slower rates of speech since slower rates enable temporal summation to augment top down priming of nodes for an intended output. (2) Some subjects speak slower/ louder at the most disruptive feedback delay despite instructions to speak always at maximum rate. By speaking slower/ louder they can overcome the effects of the returning feedback and gain better control over the output.

KUNNAMPALLIL GEJO JOHN,MASLP

Auditory feedback : As we talk, the information is feedback to the brain by the way of numerous circuits. These are called closed circuits or cycles ,which have all components completely contained within speakers mechanism . They provide the information to the speakers about what he said & how he said it by the way of auditory, tactile & kinesthetic modes. The return flow of information provided by these circuits helps to monitor our own speech. Errors are normally identified & corrected automatically .This KUNNAMPALLIL GEJO process is important for all learning behaviours
JOHN,MASLP

Closed loop system

System organizes in closely connected special & temporal units.

There will not be any time normal course for the speaker to pause & check the adequacy of the utterance after each word, phrase or even after sentence uttered.

Hence, speech once learned become self regulatory with satisfactory monitoring depends up on the proper functioning & integration of the of the all feedback circuits .
KUNNAMPALLIL GEJO JOHN,MASLP

Types of auditory feedback : (1) Altered Auditory Feedback -Changing how stutterers hear their voices improves fluency. This can be done in many ways: Speaking in chorus with another person. Hearing voice in headphones distorted. Hearing a synthesized sound in headphones mimicking phonation (masking auditory feedback, or MAF). Hearing voice in headphones delayed a fraction of a second (delayed auditory feedback, or DAF).

KUNNAMPALLIL GEJO JOHN,MASLP

These phenomena are called altered auditory feedback.

No brain scans have looked at stutterers' auditory processing while speaking with altered auditory feedback.

Hypothetically, introducing errors targeted at the area that integrates auditory and somatic processing increases blood flow to that area, increasing activity level to normal.
Nonstutterers can't tolerate altered auditory feedback. Altered auditory feedback increases blood flow to non-stutterers' auditory/somatic integration area, raising activity to an abnormally high level. Too much activity is as bad as not enough activity.
KUNNAMPALLIL GEJO JOHN,MASLP

Interestingly, the effects of too much activity in this area are somewhat like stutteringrepeating words and unexpected silent pauses. Stuttering is reduced in many subjects by delayed, masked, frequency altered feedback. Even amplified feedback may have some of the same power. The proportion of stuttering events prescribed telephone conversations were significantly reduced in the AAF conditions relative to the non-altered auditory feedback condition.

KUNNAMPALLIL GEJO JOHN,MASLP

(2) Delayed auditory feedback -It refers to a delay in the return of the air conducted speech signal to the central auditory system. As an electronic or mechanical phenomenon ,it was reported by LEE(1950)who coined the term artificial stutter and commend on its fluency disruption effects. The most disruptive interval was found to be in the 180-200 msec (Fairbanks & Guttman 1958:Ham &Steer1967).

KUNNAMPALLIL GEJO JOHN,MASLP

The basic observation with which we are concerned is that when normal speakers air conducted auditory feedback is retarded by a time interval of the order of 0.2secs. amplified sufficiently to complete with their normal bone conducted feedback ,there tends to be a disintegrative effect on their verbal output .

Delayed auditory feedback (DAF) apparently degrades the individuals ability to self-monitor his or her ongoing speech.

In the normal speaker, the introduction of DAF via headphones breaks down the speakers fluency, often producing prolongation of vowels and slurring of articulation.
KUNNAMPALLIL GEJO JOHN,MASLP

Under conditions of DAF, most normal speakers will show a marked interruption of normal prosodic speaking patterns.

Conversely, in the stutterer, speech may become more fluent under DAF, probably related to the prolongation of vowels which results in a general slowing down of speaking rate.
Slowing down the stutterers rate of speech is often facilitative for improving overall speech fluency.

KUNNAMPALLIL GEJO JOHN,MASLP

Procedures for DAF :

1. The selector mode on the Facilitator is set to DAF (the letters DAF appear on the instrument window). The loudness level of amplification-DAF is determined by the relative setting of the VOLUME switch. 2. The relative time-delay on the Facilitator ranges from .05 to 0.5 secs, with the clinician able to control the delay-time by increments of approximately 10 msecs (timing changes in msecs are achieved by adjusting the delay time to the value appearing in the instrument window).

KUNNAMPALLIL GEJO JOHN,MASLP

3. Explain to the patient something like this, "I want you to wear these headphones as you read (or repeat) aloud. What you say will be fed back to you on the phones a bit delayed. You wont be able to hear yourself as you usually do when you speak. Just keep speaking. I will record on another recorder how you sound. 4. After the initial testing on the effects of DAF on speech and voice, play the recorded output back to the patient. Depending on the effects of DAF, either go forward with more DAF practice or stop using it. 5. For those patients who profit from using DAF, it is recommended that the patient wear a portable Facilitator in the provided waist-pack. The DAF mode should be used whenever it appears to facilitate better speech or better oral reading.
KUNNAMPALLIL GEJO JOHN,MASLP

Tools used in auditory feedback - Metronomic Pacing. Delayed Auditory Feedback (DAF). Looping. Time-Warping. Masking.

KUNNAMPALLIL GEJO JOHN,MASLP

(1) Pacer The pacer provides metronomic pacing in the form of an audible click to help assist patients with the timing/rhythm aspects of speech production. Among these are stutterers and patients with motor speech disorders such as cerebellar ataxia and Parkinsons disease. The pacer rate is adjustable from 50 to 150 beats per minute adjustable in 5 beat increments. (2)Delayed Auditory Feedback The AFT program provides DAF, as a form of disruptive feedback, which has proven to be effective in fluency therapy. The DAF in AFT has a range of feedback from 150-500 milliseconds, adjustable in 10-millisecond increments.
KUNNAMPALLIL GEJO JOHN,MASLP

(3)Looping Playback
Looping records the patients (or clinicians) speech and then plays the digitally recorded speech back immediately. This is used to develop critical self-listening skills. Patients can hear their own speech just as an outside listener would hear it. The clinician or the patient can record the target production. The absence of a visual display helps the patient focus strictly on the auditory aspects of speech. The duration of the recorded speech is from 5 to 30 seconds, adjustable in one-second increments KUNNAMPALLIL GEJO
JOHN,MASLP

(4)Time-Warping Time-warping provides the ability to record a patients speech and immediately play the speech back at different rates without changing the frequency content of the speech. This is very useful for allowing patients to hear their articulation clearly by slowing, or increasing, the rate of playback. (5)Masking In masking mode, a speech-band noise signal is played through headphones so that patients cannot hear their own speech production. This deliberately degraded feedback has been shown, in some cases, to improve speech. In many patients, it can enhance the proprioception of speech/voice behaviors (e.g., easy onset, eliminating hard glottal attack, etc.).
KUNNAMPALLIL GEJO JOHN,MASLP

Applications of DAF : The AFT program has a wide range of applications in speechlanguage pathology including voice, articulation, motor speech disorders, fluency, aphasia, professional voice, accent reduction, and learning disabilities.

KUNNAMPALLIL GEJO JOHN,MASLP

(1) Planum Temporale Abnormality and DAF -The planum temporale (PT) is an anatomical feature in the auditory temporal brain region. Typically people have a larger PT on the left side of their brains, and smaller PT on the right side (leftward asymmetry).

A brain scan study found that stutterers have the opposite: their right PT is larger than their left PT (rightward asymmetry).
A second study found that stutterers with this abnormal rightward asymmetry had significantly improved fluency with DAF, but stutterers with the normal leftward asymmetry didn't improve with DAF.
KUNNAMPALLIL GEJO JOHN,MASLP

The study also found that stutterers with this abnormal rightward asymmetry stuttered more severely than stutterers with the normal leftward asymmetry. In adults with persistent developmental stuttering and atypical PT anatomy, fluency is improved with DAF.(Neurology 2004 Nov 9;63(9):1640-6.) (2) Delayed Auditory Feedback Most Helpful for Those Who Stutter with Atypical Auditory Anatomy -(American Academy of Neurology-) Researchers in New Orleans have identified a subset of stutterers that may benefit most from delayed auditory feedback (a technique by which the original acoustic speech signal is artificially modified KUNNAMPALLIL GEJO and then fed back via headphones).
JOHN,MASLP

Findings of their study were Delayed auditory feedback (DAF) has been shown to induce fluency in many individuals who stutter, though not all stutterers experience enhanced fluency by this technique.

The primary aim of this study was to learn if there is a relationship between the anatomy of the auditory association cortex (planum temporale) and fluency induced with DAF in adults with persistent developmental stuttering.

The planum temporale is a brain structure important in processing auditory information.

KUNNAMPALLIL GEJO JOHN,MASLP

A study group of 14 adults with this type of stuttering disorder and 14 control subjects read prose passages three times: at baseline, with non-altered feedback, and with DAF. Three measures of fluency were evaluated: stuttering event frequency, severity, and reading time. " a subgroup of adults with atypical rightward planum temporale asymmetry, who were more disfluent at baseline and had fluency induced with DAF," (Anne Foundas, MD,) "However, deficits in auditory processing cannot account for stuttering in all people who stutter, because we identified another subgroup of adults who had typical leftward planum temporale asymmetry and who did not become more fluent with DAF."
KUNNAMPALLIL GEJO JOHN,MASLP

Effect of auditory feedback on Non speech Oral activity : Both stutterers and nonstutterers the delayed feedback conditions produced disturbances in the pattern such as errors ,prolonged lip closures , and prolongation of the pattern. However the effect of DAF was about the same for both group of subjects. It was only under DAF that any difference appeared stutterers tend to have longer lip closures.

KUNNAMPALLIL GEJO JOHN,MASLP

Effect of DAF in normal speakers :

It is possible by means of magnetic tape recording &recording device suitably designed to return a subjects vocal output via earphones with a brief delay in transmission.

KUNNAMPALLIL GEJO JOHN,MASLP

Two explanations are given about the effects of DAF in normal subjects : (1) Normal speakers air conducted auditory feedback is by the interval of the order 0.2sec& amplified sufficiently to complete with their bone conduction feedback ,there tends to be a disintegrative effect on their verbal output. This disintegration takes the form of a slow speaking rate, articulatory inaccuracy ,disturbances of fluency including blocks &repetitions of the syllables like in stutters. In addition there is an increase in loudness & pitch ,which Fairbanks inferred to result from the subjects struggle to resist the interference with their response
KUNNAMPALLIL GEJO JOHN,MASLP

(2) Following activation ,the nodes responsible for speech are self inhibited & & then undergo a normal cycle of recovery .
This recovery cycle includes a period of hyper excitability during which nodes have greater than normal sensitivity, with a peak occurring approximately 200msec following onset of activation & return to a resting level by 300msec following onset of activation.

This explains why the delay of 0.2 sec produces maximum disruption of speech .
When feedback arrives 0.2sec after onset of activations ,it provides additional priming of just activated nodes ,that produced it at precise times
KUNNAMPALLIL GEJO JOHN,MASLP

When three sources of additional priming (amplification, hyper excitability & normal bottom up priming) combine to exceed the top down priming of appropriate nodes, these just activated nodes will be reactivated under most primed principle, with an effect resembling the repetition errors of stutterers. Errors under DAF decrease with slower speech rates ,since lower speech rates enables temporal summation to augment top down priming of nodes for an intented output. This may explain why some subjects speak slower at the most disruptive feedback delay (0.2sec )despite instruction to speak always at a maximum rate. By speaking slower they can overcome the effects of returning auditory feedback &gain better control over the output.
KUNNAMPALLIL GEJO JOHN,MASLP

Effect of DAF on stutterers : Under the theory stuttering occurs whenever the just activated nodes receive greater priming than nodes to be activated next. There are 2 hypothesis to account for this theory. One hypothesis is that returning feedback is delayed by about 0.2 sec with in the sensory analysis nodes of stutterers & aquires greater than normal amplitude due to mal functioning of the stapedial reflex. As a result the normal auditory feedback of these stutterers will achieve the conditions, which disrupt the speech of normal speakers receiving delayed & amplified auditory feedback .
KUNNAMPALLIL GEJO JOHN,MASLP

Like wise shadowing & choral rehearsal prevents stuttering by augmenting the priming of the appropriate or next to be activated nodes. The other hypothesis is that nodes of stutterers, evidence an abnormal recovery cycle . Both hypotheses predict that masking & returning auditory feedback will reduce the probability of stuttering &amplifying it will have the opposite effect. Both hypotheses predict release from auditory input guides speech production.

KUNNAMPALLIL GEJO JOHN,MASLP

Thus stuttering is overcome when others utter the words when stutter is blocking since the input helps prime the appropriate nodes to the level required for activation . Finally both hypotheses predict that delay producing maximal interference with speech will be shorter stutters than non stutterers Brandt & Wilde (1977)found that like stuttering, the dysfluencies of normal speakers under DAF was reduced when the subject read in unison with another voice & they timed their speech to the beat of a metronome. Borden et al (1977) observed both similarities &differences between normal speakers under DAF &stutterers in electromyographic recordings from laryngeal & articulatory KUNNAMPALLIL GEJO muscles .
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Venkatagiri(1982) found that like stutterers the DAF dysfluencies of normal speakers showed a distinct adaptation , effect over successive recordings occurred more often in content words than on functional words , on long words than on short words .

Although the consistency effect was present,it was smaller when compared to stutters .

KUNNAMPALLIL GEJO JOHN,MASLP

Practice & effect of DAF : Practice with a sentence reduces the effect of DAF because practice strengths internal trace of the expected feedback &successive movements are driven by discrepancy between ongoing feedback &expected feedback or feedback trace. This means practice should increase rather than decrease the probability of errors for sentences produced under DAF. These observations suggest that articulation is not under the direct feedback control.(Adams1985). Many more explanations are need to understand the relation between stuttering &processing of auditory input.
KUNNAMPALLIL GEJO JOHN,MASLP

(3) Frequency shifted Auditory Feedback (FAF) :

FAF downshift makes hear voice sounding like a gravel-voiced radio announcer saying his station's call letters. A quarter-octave pitch shift reduces stuttering about 35%. A half-octave pitch shift reduces stuttering about 65-70%. A full-octave pitch shift reduces stuttering about 70-75%. Combining DAF and FAF reduces stuttering about 80%.

KUNNAMPALLIL GEJO JOHN,MASLP

Shifting pitch up or down is equally effective in short-term studies. But there may be long-term differences between up- and downshifts. FAF causes non-stutterers to speak at a higher or lower vocal pitch, depending on whether the device is set for an up or down frequency shift. This higher or lower pitch vocal pitch results from changing vocal fold tension. In other words, FAF induces changes in vocal fold tension in nonstutterers. Speech clinics have reported that FAF devices induce vocal fold relaxation in stutterers. KUNNAMPALLIL GEJO
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Usually, stutterers need a greater pitch shift, between one-half and one octave down.
Also, the study used older headphones which lacked the bass response of today's headphones. FAF downshifts induce a slower speaking rate, similar to DAF.

If this effect is consistent, then a FAF downshift should produce long-term carryover fluency.
Conversely, a FAF up shift (the Mickey Mouse voice) appears to induce vocal fold tension. FAF up shifts induce faster speaking rates. If this effect is consistent, then a FAF up shift should result in poor long-term performance (e.g., no carryover KUNNAMPALLIL GEJO fluency, and possibly JOHN,MASLP "wearing off).

Tests results of auditory processing in stuttering :

(1) Auditory threshold :

Early report by Harms& Malone(1939)that each of 62 stutterers examined by pure tone audiometry had a impairment of hearing, but a succession of further studies failed to disclose any significant lose.
Tomatis (cited by Van Riper,1982)stated that 90 % of his stutterers had a hearing loss in one ear and related it to a theory involving both auditory feedback and cerebral dominance. Hugo,Aimard,Plantier & Wittling (1966) could find any difference in sensitivity between the left & right ears of stutterers.
KUNNAMPALLIL GEJO JOHN,MASLP

MacCulloch & Eaton (1971) reported a lowered auditory pain threshold for Puretones in a comparison of 44 stuttereres with a group of controls . Phase disparities
Stromsta (1957) in his study he used 2 pure tones of equal frequency and amplitude and diametrically (180 degrees ) out of phase cancel each other out. Stutterers and normal speaker listened to an air conducted tone and to bone conducted tone of same frequency simultaneously introduced. The subject then varied the phase and amplitude of air conducted tone until a critical adjustment was at which no sound was audible KUNNAMPALLIL GEJO JOHN,MASLP to them .

Using this procedure at frequencies of 500,1000,2000Hz,Stromsta found that at 2000Hz there was differenc between stutterers and nonstutterers in the average relative phase angle of air and bone conducted sounds as indicated by the amount of adjustment they made.

Later by the same method, Stromsta found an unusual phase disparity between stutterers left & right ears.

His subjects adjusted amplitude and phase of two air conducted tones heard at either ear until they cancelled an identical bone conducted tone.
KUNNAMPALLIL GEJO JOHN,MASLP

At the point of cancellation the air conducted tones at the two ears had a phase disparity at several frequencies about twice as wide , on the average, for the stutterers as for the nonstutterers.

Mangan (1982)replicated Stromastas earlier study and failed to find a difference between stutterers and nonstutterers in phase and amplitude adjustments of air and bone conducted sound .

KUNNAMPALLIL GEJO JOHN,MASLP

(2) Central auditory processing test :

Research has assessed how well individuals who stutter can process auditory signals in various parts of the brain. Rouse ygoetzinger & Dirks (1959)reported that stuttering children did not perform as well as non stutterers in making mediane plane sound location response. Sound localization findings by Kamiyama (1964)and Asp (1968) were in agreement with those of Gregory ,although Asp observed some differences on tests of loudness balance and Herndon (1967)found differences in the ability to discriminate between different durations of the tone .
KUNNAMPALLIL GEJO JOHN,MASLP

A number of studies used the Synthetic sentence identification / Ipsi lateral competing message test (SSI-ICM) to compare stutters &non stutters.

This test requires participants to identify words in a nonsense phrase (such as small boat with a picture has become ) when competing noise is presented in the same ears.

Three studies using this test found that stutters performed worse than normal participants (Hall &Jerger ,1978;Molt & Guilford ,1979;Toscher & Rupp,1978).

KUNNAMPALLIL GEJO JOHN,MASLP

The more fluent normal speakers performed significantly better than the less fluent normal speakers (Blood et al,1987).
Stuttering &normal dysfluencies may be associated with some difficulty in central auditory processing. In contrast to these studies Guitar (1987) found no differences between stutters &non stutters on the SSI-ICM,but stutters in their study had all recently completed a treatment program. This finding intriguing in light of evidence from brain imaging studies that individual who stutter who had demonstrated an absence of activity before treatment in the left auditory cortex showed normal levels of activity immediately after treatment (De Neil et al &Ingham ,2003).
KUNNAMPALLIL GEJO JOHN,MASLP

In Staggered spondaic word test, the stimuli used are series of 2 bisyllabic words having equal stress on each syllable.
The syllables are then overlapped in time The overlapping syllables a dichotic input to the listner. Hall & Jerger(1962)stated that stutterers &nonstutterers significantly differed in their total correct responses to the competing portion of the test. Stutterers performed poorly on this test when compared to non stutteres. Another tool for assessing central auditory processing is the masking level difference test(MLD) ,which requires listeners to detect the onset &offset of a tone in the KUNNAMPALLIL GEJOpresence of masking noise.
JOHN,MASLP

When masking noise is played in the same ear as the tone ,there are fewer cues for listeners to use in filtering the tone from the masking tone.
Listeners must use very subtle temporal cues to detect the tone ; under these conditions ,persons who stutter perform more poorly than groups of nonstutters(Guitar 1987).

These results may be interpreted to support to support the outcome of the SSI studies because both tests require the participants to use temporal information in one case (SSI),rapidly changing formant frequencies in identifying words , and in the other case (MLD), detection of the onset & offset of a tone in masking . KUNNAMPALLIL GEJO
JOHN,MASLP

Two other studies of central auditory processing tested the hypothesis that people who stutter have difficulty resolving temporal differences.

Herndon (1966) found that stutters were poorer than nonstutters at distinguishing Which of two brief tones was longer.

Barasch et al (2000) administered the duration pattern sequence (DPS) test ,which involves judging the relative lengths of three tones , and another measure in which subjects estimated durations of tones & silent intervals .

KUNNAMPALLIL GEJO JOHN,MASLP

These tests failed to distinguish between the stuttering & nonstuttering participants as groups, but they showed that less fluent participants in each group scored worse on the DPS than more fluent participants.

In addition ,more disfluent subjects in both groups judged temporal intervals to be longer than less disfluent subjects.

It has been suggested that fear &anxiety affect temporal processing (Fraisse, 1963) and that anomalies in temporal processing may be an underlying cause of both stuttering (Kent 1984 ) and high levels of normal disfluency(Wynne1982).
KUNNAMPALLIL GEJO JOHN,MASLP

Therefore, the researchers conclude that stutterers performance is poor on all these central auditory function tests. Stutterers as a group performed poorly than nonstutters on task requiring fine discrimination of the small time difference in signals

KUNNAMPALLIL GEJO JOHN,MASLP

(3) Dichotic listening tests : In the early studies, a procedure was developed to assess hemispheric dominance for speech &language by testing which ear was more accurate at hearing speech sounds. Kimura 1961 invented the dichotic listening test , which simultaneously presented two different syllables dichotically. Listeners reported which syllable they heard. Auditory nerves connecting the ears to the cerebral hemisphere carry more information to the hemisphere on the opposite side than to the hemisphere on the same side .
KUNNAMPALLIL GEJO JOHN,MASLP

Results with normal speakers indicated that syllables presented to the R ear were most frequently reported as heard ,which was called a R ear advantage for speech. This procedure has been used to assess laterality differences between stuttering &nonstuttering groups.
A number of experiments found that many persons who stutter do not show the typical R ear advantage that nonstutters do, which is evidence that people who stutter do not have Lt hemisphere dominance for language (Blood 1985;&Moore 1975). Some dichotic studies found no difference between stutters &nonstutters (Dorman 1975&Pinksy &McAdams ,1980).
KUNNAMPALLIL GEJO JOHN,MASLP

Other studies found no significant group differences but found that fewer stutteres than nonstutters showed the expected Rear advantage (Rosenfield &Goodglass 1980). The more linguistically complex the stimulus ,the more likely that the differences between stutters &nonstutters would be found .
Any auditory processing anomaly related to stuttering is likely to be on a continuum rather than simply present or absent. More severe or neurologically involved stutters may have more abnormal auditory processing . Researches view stuttering as disorder in the control of seqence & timing .
KUNNAMPALLIL GEJO JOHN,MASLP

There are 5 observations which point the connection between stuttering &processing of auditory input.
(1) Stuttering can be virtually eliminated in some with the flick of switch introducing white noise with in the frequency range of speech which is loud enough to mask the stutterers auditory feedback (1955)

(2) Stapedial reflex of the middle ear appears to differ between stutteres & nonstutterers.
The stapedial muscle normally contracts 100-165 msec prior to phonation ,there by reducing the amplitude of the ear drum vibration & alternates the hearing of ones own speech .
KUNNAMPALLIL GEJO JOHN,MASLP

Webster &Lukes(`1968)found that stapedial reflex is less stable in stutterers. Dhonovitz & Johnson et al (1978) found that under conditions of anxiety stutteres show less stapedial attenuation than nonstutters . Hall & Jerger (1978) compared the acoustic reflexes to the external sound in stutterers &controls. Reflex threshold was equivalent was in 2groups, but reflex amplitude was smaller in stuttering group. Hannley and Dorman (1982) observed no difference in the latency or amplitude of the reflex.
KUNNAMPALLIL GEJO JOHN,MASLP

March banks &El-Yaniv(1986) found no difference between stutterers and normal speakers in middle ear muscle activity during vocalization . (3)Auditory processing of an about to be produced word facilitates its correct production
Stutterers often release them from a block when someone else word on which they have difficulty (Bar &Carmel 1970) (4)stutterers become very fluent when their returning auditory feedback is delayed by means of a recording &reproducing device (Hutchinson& Burk1973)

KUNNAMPALLIL GEJO JOHN,MASLP

(5) Reception errors like in stutterers can be obtained in normals by amplifying as well as delaying their auditory feedback . Researchers have tried to link the timing deficit to stuttering by suggesting a single mechanism in brain may control both incoming and outgoing signals. Faulty timing of incoming signals would give rise to stutterers poor performance on central auditory processing tests. Faulty timing of outgoing signals would result in stuttering. (4) Brain electrical potentials : Studies of electrical brain activity in response to auditory stimuli have provided further evidence that auditory processing is KUNNAMPALLIL abnormal in individuals who stutter. GEJO
JOHN,MASLP

Molt and Luper(1983) found that stutterers had faster average peak latency than normal speakers.

Studies by Hood (1987) & Parker (1995) reflecting both subcortical &cortical activity have found group differences between stutters & nonstutters.

However the first study found stutters responses to be slower than nonstutters responses & the second study found them to be faster than non stutters responses .

A study of Molt(1997) is more relevant to the question raised by the brain imaging studies ofKUNNAMPALLIL whether person GEJO who stutter have a deficit in the left auditory cortex. JOHN,MASLP

Molt found that stutters have longer latencies & lower amplitudes of brain waves in the in the cortex when they where asked to make decisions about semantic incongruencies in sentences they listened to Early latency potential (ABR) -Blood &Blood (1984) recorder longer wave III and wave V latencies for stutterers and abnormal inter peak latency for five of eight stutterers. Smith,Blood and blood (1990) found no differences in latencies but greater amplitude of wave I for stutterers .

KUNNAMPALLIL GEJO JOHN,MASLP

Middle latency response in stutterers -Studies have shown that auditory middle latency response Wave Pb was prolonged in subjects who stutter as compared to normals . Hood (1987)conducted an investigation of the MLR s of males who stutter and found that the latency of the wave Pb was significantly longer for those who stuttered than controls. MLRs were recorded from 10 males who stutter &10 controls using a variety of filter bands in response to clicks presented binaurally at various rates. The latency of Pb was found to be significantly shorter in the group of subjects who stutter.
KUNNAMPALLIL GEJO JOHN,MASLP

Wave Pb of the MLR is generated by the thalamic portion of the reticular activating system. The thalamus is critical to speech and language production. Other researchers suggest that the metabolism of the thalamus is lower than normal(Rapoport1991)(JSHR,Vol.38,5-17,1995);
Significant difference in the delay of Wave Pb latencies in adult stutters as compare to the adult non stutters in both ears . This indicate the differences in the thalamocortical pathways &reticular formation as there are hypothesized to be the possible generators for the MLR waves. The difference may lead to poor temporal processing &programming in stutterers . KUNNAMPALLIL GEJO
JOHN,MASLP

P300 event related potentials in stutterers -Stutters exhibit different patterns of interhemispheric activity than nonstutters with a tonal P300 task. Insula and auditory cortical areas of the superior temporal lobe are major sites of generation of the P300 response (Rogers et al 1991) Blood (1991) tested stutterers using P300 and found no differences between stutterers and nonstutterers in the latency of p300. 16 young adult males aged 17 to 36 years with Rt handed compared with stutterers and found that stutterers exhibited relatively lower amplitude P300s in the right hemisphere. This may be interpreted as possibility that altered cerebral dominance plays an important role. GEJO KUNNAMPALLIL
JOHN,MASLP

KUNNAMPALLIL GEJO JOHN,MASLP