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right hemisphere are activated instead of those of the left hemisphere However, these explanations probably apply to only a minority of stutterers (Hecaen and de Ajuriaguerra) It is of interest that stutterers activate the motor cortex prematurely when reading words aloud and, as noted by Sandak and Fiez, affected individuals seem to initiate motor programs before the articulatory code is prepared Recently, several groups have reported subtle structural anomalies in the gray matter of the perisylvian region, but no common theme has emerged, and others are skeptical of these ndings (see editorial by Packman and Onslow) It has been commented in the literature on this subject that speech production is a highly distributed system and that compensatory mechanisms used by stutterers may confound interpretation of functional imaging studies The disappearance of mild stuttering with maturation has been attributed incorrectly to all manner of treatment (hypnosis, progressive relaxation, speaking in rhythms, etc) and used to bolster particular theories of causation Since stuttering may reappear at times of emotional strain, a psychogenesis has been proposed, but as pointed out by Orton and by Baker and colleagues if there are any psychologic abnormalities in the stutterer, they are secondary rather than primary We have observed that many stutterers, probably as a result of this impediment to free social interaction, do become increasingly fearful of talking and develop feelings of inferiority By the time adolescence and adulthood are reached, emotional factors are so prominent that many physicians have mistaken stuttering for neurosis Usually there is little or no evidence of any personality deviation before the onset of stuttering, and psychotherapy has not in our experience had a signi cant effect on the underlying defect A strong family history in many cases and male dominance point to a genetic origin, but the inheritance does not follow a readily discernible pattern Stuttering is not associated with any detectable weakness or ataxia of the speech musculature The muscles of speech go into spasm only when called upon to perform the speci c act of speaking The spasms are not invoked by other actions (which may not be as complex or voluntary as speaking), differing in this way from an apraxia and the intention spasm of athetosis Also, palilalia is a different condition in which a word or phrase, usually the last one in a sentence, is repeated many times with decreasing volume Perhaps stuttering represents a special category of extrapyramidal dystonic movement disorder, much like writer s cramp (page 94) Rarely, in adults as well as in children, stuttering may be acquired as a result of a lesion in the motor speech areas A distinction has been drawn between developmental and acquired stuttering The latter is said to interfere with the enunciation of any syllable of a word (not just the rst), to favor involvement of grammatical and substantive words, and to be unaccompanied by anxiety and facial grimacing Such distinctions are probably illusory The reported lesion sites in acquired stuttering are so variable (right frontal, corpus striatum, left temporal, left parietal) as to be dif cult to reconcile with proposed theories of developmental stuttering (Fleet and Heilman) Another form of acquired stuttering is manifestly an expression of an extrapyramidal disorder Here there occurs a prolonged repetition of syllables (vowel and consonant), which the patient cannot easily interrupt The abnormality involves throat-clearing and other vocalizations, similar to what is seen in tic disorders Treatment The therapy of stuttering is dif cult to evaluate and, on the whole, the therapy of speech- uency disorders has been a frustrating effort As remarked above, all speech- uency distur-
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bances are modi able by environmental circumstances Thus a certain proportion of stutterers will become more uent under certain conditions, such as reading aloud; others will stutter more severely at this time Again, a majority of stutterers will be adversely affected by talking on the telephone; a minority are helped by this device Some stutterers are more uent under conditions of mild alcohol intoxication Nearly every stutterer is uent while singing Schemes such as the encouragement of associated muscular movements ( penciling, etc) and the adoption of a theatrical approach to speaking have been advocated Common to all such efforts has been the dif culty of achieving carryover into the natural speaking environment Progressive relaxation, hypnosis, delayed auditory feedback, loud noise that masks speech sounds, and many other ancillary measures may help, but only temporarily Canevini and colleagues have made the interesting observation that stuttering improved in an epileptic treated with levetiracetam, and Rosenberger has commented on other drug therapies Cluttering, or Cluttered Speech This is another special developmental disorder It is characterized by uncontrollable speed of speech, which results in truncated, dysrhythmic, and often incoherent utterances Omissions of consonants, elisions, improper phrasing, and inadequate intonation occur It is as though the child were too hurried to take the trouble to pronounce each word carefully and to compose sentences Cluttering is frequently associated with other motor speech impediments Speech therapy (elocutionary) and maturation may be attended by a restoration of more normal rhythms Other Articulatory Defects These are most common in preschool children, having an incidence of up to 15 percent There are several varieties One is lisping, in which the s sound is replaced by th, eg, thimple for simple Another common condition, lallation, or dyslalia, is characterized by multiple substitutions or omissions of consonants Milder degrees consist of dif culty in pronouncing one or two consonants For example, the letter r may be incorrectly pronounced, so that it sounds like w or y; running a race becomes wunning a wace or yunning a yace In severe forms, speech may be almost unintelligible The child seems to be unaware that his or her speech differs from that of others and is distressed at not being understood These and similar abnormalities of speech are often present in otherwise normal children and are referred to as infantilisms Why they persist in some individuals is not understood More important is the fact that in more than 90 percent of cases, these articulatory abnormalities disappear by the age of 8 years, either spontaneously or in response to speech therapy The latter is best started if these conditions persist into the fth year Presumably the natural cycle of motor speech acquisition has only been delayed, not arrested Such abnormalities, however, are more frequent among the mentally retarded than in normal children; with mental defect, many consonants are persistently mispronounced Another type is a congenital form of spastic bulbar speech described by Worster-Drought in which words are spoken slowly, with stiff labial and lingual movements, hyperactive jaw and facial re exes, and sometimes mild dysphagia and dysphonia The limbs may be unaffected, in contrast to those of most children with cerebral palsy The speech disorder resulting from cleft palate is easily recognized Many of these patients also have a harelip; the two abnormalities together interfere with sucking and later in life with the enunciation of labial and guttural consonants The voice has an
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