Speech problems

Recently while evaluating a child with speech problems, the parents mentioned whether the child had apraxia or not. What ensued was a discussion in which neither the parents nor myself knew what we were talking about. To add to the confusion, my hippocampus had thrown out several associations to apraxia of speech, like dysarthria, phonological disorder and aphasias. Doing an internet search compounded the difficulty just as asking various people did. Everyone answered something that they were not sure about and soon my head was swimming about their differences. Luckily I found an article in Neurocase (2005) 11, 427-432 by Ogar et al.

APRAXIA OF SPEECH: Impaired ability to coordinate the sequential, articulatory movements neccessary to produce speech sounds is called apraxia. Articulatroy erros and prosodic abnormalities are hallmarks. Signs include effortful trial and error grouping with attempts at self correction, persistent dysprosody, articulatory inconistency on repeated productions of the same utterance and/or obvious difficulty initiating utterances. Vacular lesions, trauma, tumors can cause this. Apraxia of speech is also the first symptom in neurodegenerative diseases such as corticobasal degeneration or non-fluent progressive aphasia.

CONDUCTION APHASIA: Result of damage to communication between Wernicke and Broca. This communication is through extreme capsule and/or arcuate fasiculus. Speech is fluent, comprehension is good but oral reading is poor and major impairment in repitiion. Many paraphasias occur and transpositions of sounds within a word also occurs (television -> velitision).

BROCA'S APHASIA: In this the speech is understood, and the all the levels of speech planning are intact except for motor execution which is not intact.

(Apraxic speakers are believed to select the correct phonemes, only to have trouble with their motor execution; People with conduction aphasia typically speak with near normal prosody, whereas halting effortful speech with abnormal prosody. They may also lack awareness of their speech errors and therefore may not always make attempts at self correction while the opposite is true in cases of apraxia of speech)

DYSARTHRIA: Dysarthria is caused by impairment of muscle strength, tone, range of motion and/or coordination. It can be caused by UMN or LMN lesions of the cranial nerves.

(Errors heard in dysarthric speech are typically consistent and predictable, while the speech errors heard in apraxia of speech tend to be highly irregular. Sound distortions, prolonged segment durations (e.g prolonged vowels or consonants) and prolonged inter segment durations (e.g. abnormal pauses within sounds, syllables or words) are characteristic for apraxia of speech.

PATHOPHYSIOLOGY OF APRAXIA: Van der Merwe's model of speecch planning and programming says that initially, basic linguistic units or phonemes are selected. During a second motor planning phase these phonemes are organized into temperospatial codes for speech production. In the third, motor programming phase, muscle specific motor programs are selected and sequenced before moving forward to fourth phase when these sequences are carried out by the speech musculature. Apraxia of speech is caused by problem with second phase.

TREATMENTS: For mildly apraxic patients, poor prosody may be the primary speech deficit and therefore, goals designed to improve intonation and stress. For the moderately or severely apraxic patient, therapy might focus on relearning oral postures for individual speech sounds.
-PROMPT uses rate and rhythm control strategies
-Wambaugh and colleagues use remediation of misarticulated consonants through modeling repetition of minimally contrastive words, graphic cues and phonetic placement cueing.

Dreams

Shani says:
"I say dreams are a mechanism of the mind to test any changes it makes to the model of the world (in our head), while we sleep.Say i watch a documentary on snakes. I already have a section on snakes in my head (part of the model of the world around me) that has all the 'relevant' information i have collected on snakes so far. Owing to what happend during the day, while i lay in bed and sleep, my mind goes to work to extract the new data (or extent of emphasis on old data/rules), and then wants to suppliment the old notion of snakes with the new data ... as it does that it needs to verify whether that change is good, i.e. wouldn't lead to me say getting bit by a snake cuz i stepped on it. So to verify, the mind creates a drama and lets my updated model react to it, i might see myself in a jungle and then a snake and the mind carefully monitors my reaction to it ... if everythign goes smooth, good, if not then maybe the changes weren't quite right ... "

I say:
"I think there is the biological and then there is the psychological function of dreams. It is not clear whether the dreams play a homeostatic role in our lives, meaning that they create the balance, re orient us and bring us to the center of our biological or our psychological lives.

I think you are right about dream being the censor for the change that occurs in our minds. I would though want to extend it by saying that introducing snake as a data in the mind means introducing various things in the mind. I would liken it to the mind going over the translation of the world that it did in the day time. I would think that is what you mean by going over the data.
The translation though would be a tricky thing because that would mean what is the data that the mind sees.
If I were wearing red spectacles I would interpret all data about colors as various shades of red. So it is interesting how the mind interprets the new data. In gross terms new data is interpreted, associated and then stored.
In the example of the snake. You dreamed about the snake. Your interpretation of the snake, i would think is a very biological phenomenon which involves integration of the lines and the colors and then naming it by comparing it to past experiences. The comparing part starts to spill over in to the psychological realm. Now when you compare it, the emotional significance of the snake will be brought forth. Freud felt that unconscious mind or the dreaming mind is involved with primary thinking. Thinking that would use primitive patterns of reaching conclusions. (See level I and level II defences). There are some bizarre explanations for a snake incidentally. Snake has been interpreted as a phallic symbol and the explanation is that the mind while associating it might recall a similar emotion (the one that the person might have felt on seeing a snake) associated with a similar form. Ofcourse there is a lot of "static" also going on in terms of defences and the resulting situation is bizarre dreams which need to be interpreted.

Dyslexia

Dyslexia: A specific reading disability due to a defect in the brain's processing of graphic symbols.

Dyslexias are characterized by their characteristic hemishperic deficit.
Pirozzolo (1979) and Pirozzolo and Hess (1976) suggest that there are two fundamental types of dyslexia: auditory-linguistic dyslexia and visual-spatial dyslexia. Persons with the former exhibit difficulties in the verbal and language area, have naming problems, and are slow in carrying out any types of verbal tasks. The persons with the former struggle with visual perceptual difficulties. Bakker (1973; 1979; 1982; 1983) thinks about different approaches to reading. The linguistic-auditory group uses their left type hemishphere hence called L-type dyslexics. The visual dyslexics have a difficulty with perceptual requirements in word representation and use the disorder stems from right hemisphere, hence the term P-called dyslexics. The same kind of differentiation is meant by the the words dysphonetic(auditory problems) and dyeidetic dyslexics (visual problems). Hemishpheric EEGs also show preferential brain activation with the different types of dyslexics.

Prigogine: the end of certainty

In his book, the end of certainty, Prigogine talks about irreversibility as a possibility. This is something that people have neglected when putting forward laws that describe how nature operates. He calls many laws deterministic in nature, in that, they can be bidirectional with respect to time. He however says that this bidirectional time is a very narrow minded view. It only takes into consideration the isolated experimental subjects and considers them free of the multiple other factors that are impacting on them.

I was involved with a functional behavioral analysis of a child with disruptive behaviors. In a functional behavioral analysis one tries to determine the antecedents that cause the behaviors and the consequences that either enforce or extinguish the behaviors. A hypothesis of the whole situation is made and that hypothesis is tested out. The parents are then given strategies to manage the behaviors from the hypotheses. The proof that those strategies work has been shown to the parents during the testing phase. Hypothesis like "the child can go to a non preferred activity if he knows that it is time limited and if it is followed by a preferred activity", is an example.

This kind of analysis of behaviors is fine if a behavior is only considered to be present and influenced by a limited number of antecedents and consequences. But the truth of the matter is that the true antecedents to a behavior are multiple and have a propensity to be unknown. Freud believed the majority of the decisions that a person was making were unconscious. When dealing with these many possibilities of environmental and psychological variability, it is essential not to "over simplify" or "over complicate"things to the point that incredulous demands be made of patients in "treatment".

Prigogine talks about phase space which would be very applicable to the scenario of the disruptive child. All the different possible behaviors of the child are represented in that phase space. Prigogine also talks about stable (determinism) and unstable (chaotic) equilibrium and details characteristics of those systems.

A beautiful example he uses is of Poincare who proved that dynamical systems are non integrable. An integrable system would be a static deterministic world without the possibility of freedom. Non integrability results from existence of resonances between degrees of freedom. What we have done with behavioral analysis is to put on deterministic glasses and translated the multi factorial world into a lesser dimension. The city of Oz was not really green.

Prigogine also talks about prevalent energies in a system. How potential energy is maximum in a state of equilibrium and free energy is at minimum in a state of equilibrium. Increasing energy in a system also increased the areas of randomness in it. He describes creativity as an irreversible phenomenon which has been associated with complexity. Any system in non equilibrium can spontaneously evolve in to increased complexity and any system in non equilibrium can lead to irreversible phenomenon, hence creation.

With this he comes full circle to creation as an irreversible process which creates a system of equilibrium for itself till of course it is pushed into non equilibrium again. It will get pushed into non equilibrium.

From this we glimpse a view of a world which is constantly oscillating in between equilibrium and non equilibrium. A world which is constantly changing due to chaos, organizing and disorganizing itself. And caught in the center is man who attempts to act like the universe, organizing and then disorganizing whatever it comes across. Creating and then uncreating. Cooking and then digesting. Being born and then dying.

Jungian archetypes in media

In a conversation today, I realized how the theory of Jungian archetypes has an association with the recent trend of going behind the mask of the superhero. In Hollywood movies the trend has turned from the behaviors of the superheroes to the motivations behind them. In all past cultures this has come at a certain point in their respective civilizations. The stories attributed to the gods are present in greek, roman, egyptian, hindu and virtually any civilizations. When religion clamped down on the muslim culture the stories about the life of mystics and pirs was born. It almost points to an innate need of a civilization to have stories about the ideals. As if the masses are trying to express their conflicts in the idealized figures that they try to emulate. This primordial need is manifesting itself in the the movies of the present also.
Batman from the times of George Clooney and Kilmer has suddenly a different mood now. Superman was explored in more detail in Smallville. Spiderman has definitely become more introspective. Star wars had to explore the origins of the dark side.
The point to notice is that the creators of all these characters had invented their past when they were brought to life initially. Spiderman's conflicts about being Parker and avenging the death of his grandfather are not new. Neither is Clark's search for his home land and the isolation that he feels new. But they were limited by the spread of the comic media. Now it is as if the whole world is re discovering these archetypes as the media reaches out to them.
There is ofcourse a finite amount of media or the interpretation of media that can be incorporated in an individual's mind. That amount of finite data, has a comprehensible number if we apply the bell curve to the human population. Neuropsychology shows us that all new information has to be interpreted, associated and then remembered. Hence within that bell curve there is all sorts of different combinations that exist. Some person might comprise his "moral good" as an expression of batman and superman, another might have a different combination. The result is a pallette of different colors that portray the internal unconscious life of an individual. Twinship to different archetypes as well as parental/environmental mirroring might also play an important part in selection of the colors that go to make a pallette.
A point to note is that people who do not watch movies are not necessarily bereft of this archetypal life. They just reach out and grab onto the archetypes that have been passed down from other sources like religion or ancestary.
Retelling stories and understanding them from different perspectives an important part of the human dillemma. Something that will continue in its myriad variations.

Psychic trauma in children: review of an article

AM J Psychiatry 138:1 January 1981 by Lenore C. Terr, M.D.

Background:
This article discusses the response to psychic trauma in children who were exposed to the kidnapping in Chowchilla.
The story of the kidnapping goes something like this: July 1976, 26 children (5-14 year) disappeared for 27 hours and they eventually escaped their captors. The school bus had been stopped by a van blocking the road and masked men had taken over the bus at gun point. The children were transferred to boarded over vans in which they were driven for 11 hours and then transferred into a "hole" (actually a buried truck trailer). The kidnappers covered the truck-trailer with earth. The children were buried for 16 hours until two of the oldest and the strongest boys 14 and 10 dug them out. By then the kidnappers had left the vicinity.

Methods:
The children were interviewed by the author and one or both of the parents had also been interviewed. The school bus driver and the kidnappers were not interviewed. This interview took place between 5-13 months.

Notes:
Initial signs of traumatic disruption (the breach of the ego):
-Omens: Children tend to associate things that happened before the incident and related that as the causal factor of why they were kidnapped.
-Fear of further trauma: Traumatophobia. (am I going to be killed?)
-Disturbances in cognition: During trauma disturbance in cognitive function such as perception, time sense and thought.

Repetitive phenomena (Repetition compulsion):
-Traumatic dreams: 1)terror dreams 2)exact repetition of kidnapped events 3)modified repetitions of kidnapping events 4)deeply disguised dreams
-Post traumatic play
-Reenactment: Direct reenactments of attitudes, fears or actions that have occurred before or after the kidnapping.
-Absence of flashbacks: Adolescents exhibited "voluntary" visions in contrast to the involuntary intrusive thoughts that adults have. Children younger than 9 did not complain of having visions. The ability to day dream develops after 9 and that might be the reason why children below 9 did not have flash backs.

Fears: (Kidnap related fears)
-All children had kidnapping related fears.

Personal Commentary:
Note that the DSM required criteria of a distressing event, re experience, avoidance and increased arousal are necessary for PTSD. Children in this incident also displayed re experience (exeplified by the repetitive phenomena), avoidance (is an end point of multiple psychological factors including omens and fears) and hyperarousal (exemplified by fears) .