3 The Story of Speech

Word Finding

The signs of it were unmistakable; he would appear to be in mild torment, something like the brink of a sneeze, and if he found the word his relief was considerable.

—psychologists Roger Brown and David McNeill (1966)

Have you ever had trouble thinking of someone’s name? Perhaps you can even see the face of the person in your mind’s eye, and you would immediately recognize the name if a friend suggested it to you. Although this happens frequently with names, it’s the same for any word. It’s not that you can’t remember the concept but that you can’t find the language label for it.

Word-finding problems are an almost stereotypical aspect of the cognitive issues that plague middle-aged and older adults. These failures occur without warning for even the most familiar words and names a person knows. The most troublesome words are proper nouns and the names of objects.1 This retrieval inability can last anywhere from a split second to minutes or even hours. And as the epigraph above suggests, they can be exasperating. In fact, older adults frequently mention word-finding problems when asked about the annoyances of aging.²

In such cases, a person is certain she knows the word she is searching for. It may seem as if the AWOL term is just on the tip of her tongue, but for some reason she can’t produce it, at least at that moment. In fact, psychologists refer to such experiences as tip-of-the-tongue (TOT) states. But are they really the harbingers of befuddlement that they appear to be?

Studying TOT presents certain challenges to psychologists who want to understand how and why such states occur. Much like astronomers who study ephemeral phenomena like supernovas, researchers know that TOT states will eventually happen, but not exactly when. This uncertainty has led to two distinctly different ways of investigating TOTs: via naturalistic methods and by experimentally inducing word-finding failures in laboratory settings.

Researchers studying word finding and TOT have tried to quantify two aspects in particular: how often these states occur, and the likelihood that they are resolved—that is, the sought-after word is spontaneously recalled by the person without external assistance (such as looking the word up or having a friend offer the solution). Diary studies, in which people write down every time they experience a TOT state, allow researchers to assess both frequency and resolution rates. The results suggest that college students experience about one to two TOT states a week, while for people in their sixties and early seventies, the rate is slightly higher. Research participants in their eighties, however, experience TOT states at a rate almost twice as high as college students.3 Diary studies have shown that TOT episodes are likely to be resolved: the typical success rate in such studies is more than 90 percent.⁴

We need to be cautious, however, when interpreting such naturalistic data. It may be the case that older adults, who are more concerned about their memory lapses, will be more likely to record such instances. They may be more conscientious about writing them down, perhaps because their lives are less hectic than those of younger participants. It may also be the case that participants are simply more likely to record resolved TOT states than episodes that are not resolved.⁵

The alternative method for studying word finding is to experimentally induce a TOT state. A method for doing this was developed by Roger Brown and David McNeill. They found that simply giving participants dictionary definitions of uncommon English words would often trigger a word-finding failure. An example from their study was “A navigational instrument used in measuring angular distances, especially the altitude of the sun, moon, and stars at sea.”⁶ (If this example has caused a TOT state for you, sorry! The word is “sextant.”)

In this study, the participants were often able to provide the desired word without difficulty. On other occasions, the subjects had no idea what word the definition was describing. However, if they found themselves in a TOT state, Brown and McNeill asked them additional questions. The researchers discovered that, while in such a state, people can report partial information about the sought-after word, even as the word itself eludes their grasp. For example, the participants performed far above chance when asked to guess how many syllables the word had, or what its initial letter might be. And not surprisingly, when people made errors, they often produced words that had a similar meaning. When given the definition for “sextant,” the participants sometimes responded with “astrolabe” or “compass.” However, they also sometimes offered up words that only sounded like the intended term. The definition for “sextant” also led to responses of “sextet” and “sexton.” If we assume that sailors wielding their sextants are neither members of six-person musical groups nor gravediggers, then these errors suggest something important about how our knowledge of words is arranged in memory. Studies with older adults, however, suggest that partial information (such as the initial letter of the word) is less available for them.⁷

As with many issues in cognitive aging, we can view the increase in TOT states as a glass half empty or half full. On the one hand, these retrieval failures can be taken as evidence of weakening connections between the meanings of concepts and the words that denote them in long-term memory.⁸ It’s also possible that the increase in word-finding problems with age reflects something very different. Donna Dahlgren has argued that the key issue is not one of age but one of knowledge. If older adults typically have more information in long-term memory, then as a consequence they will experience more TOT states.⁹ It’s also possible that TOT states are useful: they can serve as a signal to the older adult that the sought-for word is known, even if not currently accessible. Such metacognitive information is beneficial because it signals that spending more time trying to resolve the word-finding failure may ultimately lead to success.¹⁰ Viewed this way, TOT states might represent not retrieval failures but valuable sources of information.¹¹ If you are an older adult and still worried about the number of TOT states that you experience, research suggests you might have fewer such episodes if you maintain your aerobic fitness.¹²

Word Naming

These days I have to put in a request to my brain as one does at the library. And then a little worker takes my slip and disappears into the stacks. May take him a while, but he always comes back with the goods.

—Coral Upchurch (age 95), a character in Gail Godwin’s Grief Cottage (2017)

When it comes to plucking words out of memory, researchers have also employed a separate, but similar, task: word naming. Also known as confrontation naming, picture naming, or cued recall, it is typically assessed by asking research participants to identify line drawings of familiar objects as quickly as they can. Word-naming ability has been explored with a variety of groups, such as children or people with language or memory impairments caused by brain injury. Researchers investigating word naming often use the Boston Naming Test (BNT), which is a standardized set of line drawings that increase in difficulty. Easier items require people to name familiar objects like a toothbrush, whereas a harder item to identify is a drawing of a protractor.13

You might suspect, given what we have already reported about processing speed, that older adults would perform more slowly on a naming task than younger adults. The results of experiments designed to measure such a difference, however, have been inconsistent. Some have found no difference between younger and older adults, whereas others have found that older adults are slower. This inconsistency may be due to the fact that some studies didn’t control for extraneous variables that might affect word-naming ability, such as the taking of prescription medications or the health status of the participants.¹⁴ A study that synthesized and analyzed the results of previous word-naming studies concluded that while performance may decline with age, it does so only after age seventy.¹⁵ Likewise, a separate study that included a large number of participants with a wide age range (30–94) also documented a performance decline with age, but the effect was fairly small: only about 2 percent per decade.¹⁶

An analysis of the types of errors made on the Boston Naming Test is also instructive. Rhoda Au and her colleagues gave the BNT to people ranging in age from thirty to seventy. These participants were tested on three occasions over a seven-year period. Consistent with previous studies, older adults tended to make more mistakes than younger adults. But they also made certain types of errors more often than their younger counterparts. For example, older adults produced more circumlocutions, in which multiple word responses were produced instead of the desired term (such as “it adds numbers” for an abacus, or “it draws circles” for a compass). Although circumlocutions were counted as errors, they might ultimately have helped the subject to retrieve the name of the object. By describing its shape or function, participants gave themselves additional cues that guied them to the sought-after word. In addition, older adults also produced more quasi-word responses. These aren’t real words but sound like the intended term (“spinwheel” for pinwheel and “ocupus” for octopus, for instance).¹⁷ The underlying issue therefore seems to be an increasing difficulty in selecting the appropriate word from long-term memory.¹⁸

Other factors besides aging could also influence word naming. A research group led by Christopher Randolph looked for patterns in a large sample of participants who were given the BNT. Predictably, they found that older participants did worse. But people who had more years of education performed better, a result that has also been found in other studies.¹⁹ It is interesting to note that men outperformed women. However, this result may be an artifact of the items that are employed on the battery. Men were faster and more accurate at naming test items like “tripod,” “compass,” and “latch,” while women outperformed men on items like “mushroom,” “trellis,” and “palette.” Since the BNT employs several drawings of tools and related objects, a gender difference may be due to differential familiarity with the test items.²⁰ There may be generational effects with the BNT items as well: a different study found that older adults outperformed younger participants on items like “yoke,” “trellis,” and “abacus.”²¹

It seems, therefore, that word-naming ability does decline with age. And since there appears to be an age bias in the questions themselves, the decline may be larger than has already been reported. However, having a higher education may compensate for some of this age-related decline. Gender bias related to the test items means that the jury is still out on differences between men and women.

Finally, as we saw with word naming, health issues that may seem unrelated to cognition have been shown to influence performance on this task. Martin Albert and his colleagues determined a relation between performance on the BNT and high blood pressure. The researchers speculate that changes in the tiny blood vessels of the frontal lobes negatively affect executive function and contribute to word retrieval difficulties.²² Such studies demonstrate that high blood pressure isn’t just bad for your heart; it’s also bad for your head.

Speech Disfluency

Sometimes I’ll start a sentence, and I don’t even know where it’s going. I just hope I find it along the way.

—Steve Carell as Michael Scott in The Office

When we have trouble naming an object or finding the right word, we might buy time by using a filler word—like “uh” or “um.” Although doing so is quite natural, these filler words nevertheless disrupt the normal flow of speech. Other examples of these types of speech interruptions include starting and then restarting a sentence or correcting oneself midsentence. Mothers sometimes do this when they can’t hit upon the name of the child they want to scold (“Rick, I mean Jay, I mean Patrick … BECCA—stop it!”). In addition, whole word repetitions (“I’m not, I’m not, going to say this twice”) and interjections (“He’s, like, really cute”) are all considered speech disfluencies. Such self-interruptions do not, in and of themselves, indicate a speech disorder. In fact, there are both qualitative and quantitative differences between the kinds of disfluencies we discuss in this section and those of a speech disorder such as stuttering, which we discuss in the following section.23

In normal speech, disfluencies occur fairly frequently: several studies have estimated that they occur about six times for every hundred words that are spoken. They also tend to increase when tasks are difficult, such as when one is giving directions. The topic under discussion matters too. One study has shown that university lecturers in the natural sciences, in which the subject matter is more structured and formal, employ fewer filled pauses than lecturers in the humanities.²⁴

In the laboratory, the psychologist Heather Bortfeld and her colleagues found that the disfluency rate, which they defined as repeats, restarts, and fillers, was higher for older adults (an average of 6.7 per hundred words) than for middle-aged (5.7) or younger adults (5.6). Compared to the other two groups, the older adults (average age: 67) were especially prone to utter disfluent fillers within a phrase (“and a brown, uh, belt”) as opposed to between phrases (“and a brown belt and, uh, a white shirt”).²⁵

When it comes to public speaking, such filler words have a bad reputation. Because they can cause speakers to sound unprepared or lacking in confidence, filler words have been referred to as “credibility killers.”²⁶ About two-thirds of a sample of college students reported that they try to avoid using them, with varying degrees of success.²⁷

Let’s consider two filler words that have received considerable attention from psychologists and linguists. At first blush, “uh” and “um” may seem interchangeable, but research suggests that their usage isn’t equivalent. Herb Clark and Jean Fox Tree analyzed the way these fillers were used by British English speakers, and found that “uh” tends to signal a relatively short delay in speech. “Um,” on the other hand, was more commonly employed when the following pause was longer.²⁸ So these fillers actually serve the useful function of giving the listener some idea of how long the speaker’s pause will be.

Other factors also seem to influence how people use filler words. The use of “uh” and “um,” for example, varies by gender. Eric Acton examined the use of these fillers by analyzing thousands of telephone conversations and transcripts of people on speed dates. He found a large difference, with women using “um” more, and men employing “uh.”²⁹

Do these disfluencies become more common with age? Unfortunately, we can’t give a simple answer to this question. As we have seen, processing speed declines as people get older, so if one’s thoughts can’t keep up with one’s words, the result might be an increased reliance on filled pauses. But it turns out that the type of filler word plays a role. Mark Liberman found the same “um” versus “uh” gender difference as Eric Acton, but he also found an age difference: the use of “uh” is higher in people in their sixties compared to those in their twenties and thirties. The pattern for “um” is reversed: its use decreases with age.³⁰ It seems that more research is called for.

A number of studies have compared the speech disfluencies of younger and older adults when given specific tasks, such as describing pictures. Some studies found no differences.³¹ One, however, found that, relative to younger participants, older adults became more disfluent when describing pictures with negative content.³²

In general, older adults more frequently use ambiguous referents and so-called extenders (“that sort of thing,” “stuff like that”). They also use sentences that are shorter and less complex.³³ It’s encouraging to note that the speech disfluency rate for centenarians is not much different than it is for older adults in their seventies, eighties, and nineties.³⁴ Moreover, the rate of filled pauses for people with Alzheimer’s disease is no different than for a comparison group without cognitive impairment.³⁵

Although not technically a type of disfluency, formulaic language also functions to fill pauses in conversations. These expressions include prefabricated phrases that can be easily retrieved from memory, as opposed to laboriously constructing a novel way of expressing something.³⁶ Formulaic expressions include idioms (“once in a blue moon,” “wake up on the wrong side of the bed”); proverbs (“actions speak louder than words,” “look before you leap”); and conventionalized expressions (“you don’t say,” “have a nice day”).³⁷

Although everyone uses formulaic language to some degree, older adults with cognitive impairment or dementia rely heavily on such phrases.³⁸ However, even though they use these phrases more often, people with Alzheimer’s disease still use formulaic language appropriately.³⁹

Taken as a whole, differences in speech disfluencies between men and women, younger and older adults, and those with and without cognitive impairment are relatively minor. It is interesting to note, however, that negative content seems to invoke more disfluent speech among older adults. This finding is consistent with the fact that older adults may have a more difficult time identifying negative emotions, and harkens back to the positivity bias discussed in the section on emotion recognition.

Stuttering

If you can live through a childhood of stuttering, you can live through anything. And if you go into adulthood still stuttering, you can handle anything.… You have been tempered by the fire.

—David Seidler, speech to the National Stuttering Association (2011)

In late 2010, filmgoers were treated to a major motion picture about a somewhat unusual subject: the speech disorder of a future ruler of the United Kingdom. Specifically, The King’s Speech depicted the struggles of “Bertie” (the future George VI, portrayed by Colin Firth) to overcome a severe stuttering problem via the ministrations of Lionel Logue, an Australian speech therapist portrayed by Geoffrey Rush. David Seidler’s screenplay has been criticized for deviating significantly from historical events.40 However, the film serves as an important reminder to its audience that stuttering is not just a problem faced by some children: it is a disorder that adults may struggle with throughout their lives.

Virtually everyone has heard examples of stuttering (or stammering; the words mean the same thing). The most common elements of this speech disfluency are repetitions of words or syllables, prolongations of the same sound or syllable, and periods of silence that break up the flow of speech. Even before The King’s Speech, stuttering had been depicted fairly frequently onscreen. Such depictions, however, were often offensive, since the speech impediment was frequently employed for supposed comic effect (as in the case of Porky Pig’s catchphrase “Th-Th-The, Th-Th-The, Th-Th … that’s all, folks!”), or as shorthand to imply that a character was mentally challenged.⁴¹ An example of this stereotype can be seen in the 1988 film A Fish Called Wanda: Michael Palin plays a character with a pronounced stammer who is repeatedly mocked for his impediment by costar Kevin Kline. The local chapter of the National Stuttering Project protested the film’s release outside the Culver City offices of its producer, MGM.⁴²

Stuttering typically begins in childhood, with an incidence rate of about 5 percent, but the majority of children overcome it, either on their own or through the assistance of a speech language therapist. In about a quarter of all cases, however, the problem is chronic and persistent and remains an issue for about 1 percent of adults.⁴³ One percent may not sound like a large number, but it equates to more than 2.5 million US adults—more than the population of Houston, Texas.

Many people think of stuttering as a manifestation of anxiety, and that is certainly part of the story. People who stutter tend to score higher on tests of anxiety as a trait, and they do report higher levels of social anxiety than those who don’t stutter.⁴⁴ However, stuttering is not caused solely by anxiety. Research suggests there might be a genetic component: as with other heritable conditions, males are more likely to be affected than females. In addition, the rate is higher among identical twins in comparison to fraternal twins, who share on average only half of their genes.⁴⁵ Environmental factors may also play a role, but to date researchers have identified no single cause. Research on underlying neurological factors, while promising, has not yet yielded insights that have translated into specific treatments.⁴⁶

In some ways, stuttering resembles other muscular movement disorders that lead to a partial loss of voluntary control. For example, stuttering has been compared to the “yips,” which are involuntary spasms that disrupt the small stroking motions golfers employ when they are putting.⁴⁷ Similar problems have been observed among competitive darts players (a condition dubbed “dartitis”). Viewed from this perspective, stuttering could be characterized as a specific example of a larger family of movement disorders called action dystonias.⁴⁸

People who stutter often report having an awareness that they are about to stammer.⁴⁹ This is referred to as anticipation, and it is one of the ways that chronic stuttering differs from other types of disfluency. Of course, everyone makes mistakes while speaking, but people who don’t stutter typically do not experience such awareness beforehand. It’s also not the case that episodes of stuttering can be predicted. Measures of the rate of stuttering for specific individuals show wide variability from day to day, and from task to task (such as spontaneous speech versus reading from a text). This variability does not correlate with the perceived severity of a person’s stammer.⁵⁰

A number of studies have assessed the impact of stuttering on quality of life. For example, a study of South African adults who stutter (age range: 20–59) found they generally did not believe that stuttering had affected their occupational choice or personal relationships. However, they also reported that it had negatively affected their performance in school and their relationships with classmates. With regard to the present, several participants asserted that stuttering affected their performance on the job, as well as their promotion chances.⁵¹ A study conducted in Israel found that older and married adults who stutter reported being less affected by their impediment than those who were younger and unmarried.⁵²

A number of adults who stutter have achieved notable success in life: the list includes the Roman emperor Claudius, Isaac Newton, Lewis Carroll, Ty Cobb, and Alan Turing. More impressive, perhaps, the list can be extended to include individuals who achieved prominence in fields that require acting or public speaking: Thomas Jefferson, Theodore Roosevelt, Anthony Quinn, Marilyn Monroe, and James Earl Jones (as well as the aforementioned George VI).

It’s also possible to point to individuals whose severe stammer was debilitating. An example would be Annie Glenn, the wife of John (who in 1962 was the first American to orbit the Earth). She struggled with mundane activities like giving an address to a taxi driver or interacting with store clerks.⁵³ (Annie’s struggles were briefly depicted by the actress Mary Jo Deschanel in the 1983 film The Right Stuff.) However, even Glenn’s story has a happy ending: in 1978, at the age of fifty-three, she underwent several weeks of intensive therapy for her disfluency, which focused on factors like controlling breathing and speech rate.⁵⁴ Although she didn’t consider herself to be cured, the therapy did allow her to start making speeches on behalf of her husband, who served for twenty-five years as a US senator from Ohio. In Glenn’s case, a strong desire to overcome her stammer, combined with appropriate therapy, allowed her to participate more fully in her role as the spouse of a political figure.

But therapy doesn’t help everyone. Many adults who stutter have mixed feelings about the role of speech therapy. Some respondents in a survey said that they had negative experiences with therapy, but they also reported that it had been helpful. Over and above such ambivalence, some also felt that to change the way they talk would be to reject the person they had become.⁵⁵

Another survey of older adults who stutter found that although the severity of their stuttering had not declined with age, they perceived their stuttering as “less handicapping” than when they were younger.⁵⁶ This is not to say, however, that stuttering has no impact on aging. Older adults who stutter may still experience fear of negative evaluation and may limit their social interactions to avoid situations that require them to speak. The choice to self-isolate could cause them to avoid seeking outside assistance, even in important areas such as health and finance.⁵⁷

Aphasia

Doctor What brings you to the hospital?

Patient Boy I’m sweating. I’m awful nervous, you know, once in a while I get caught up, I can’t mention the tarripoi, a month ago, quite a little, I’ve done a lot well, I impose a lot, while, on the other hand, you know what I mean, I have to run around, look it over, trebbin and all that sort of stuff.

—Howard Gardner, The Shattered Mind (1975)

The human brain is seemingly well protected from damage. The skull forms a bony bulwark that shields the brain from external threats, and the meninges and cerebrospinal fluid function like shock absorbers, providing additional protection. The blood-brain barrier serves as an internal shield, preventing pathogens from entering the central nervous system. The brain is, however, vulnerable to another internal threat that many a homeowner can relate to: problems with the plumbing. Just as a clogged or burst pipe can wreak havoc within a building, so a blocked or ruptured artery or blood vessel in the brain can compromise basic cognitive functions. These include a person’s ability to speak and comprehend language.

Although a stroke can occur at any point in one’s life, it becomes more common as a person ages. The majority of strokes occur after age sixty-five. Risk factors include smoking, irregular heartbeat, and high blood pressure. Advances in medicine and prevention have significantly reduced the incidence of stroke, but it remains the third most common cause of death in the United States and is the leading cause of long-term disability. Survivors of stroke may experience paralysis, weakness, numbness, pain, and problems with vision. They may tire easily or experience sudden bursts of emotion. Many develop depression.

Cognitive issues resulting from a stroke include impairments in thinking, memory, learning, and attention. In addition, about a third of stroke victims experience some form of language disruption. The effects on a person’s linguistic abilities can vary considerably and provide important clues about how language is represented in the brain. These language deficits are referred to as aphasia, and there are many different types.

Traditionally, researchers and clinicians have distinguished between expressive and receptive aphasia. People who suffer from expressive aphasia experience considerable difficulty in speaking. Their speech is typically slow, halting, and effortful. Anomia, or difficulty in finding words, is also common. Despite all of this, however, what they say does make sense, and with a little patience on the part of their partners, it is possible for them to participate meaningfully in conversation.

In contrast, those with receptive aphasia have difficulty in understanding speech. And as the epigraph at the beginning of this section suggests, a person with receptive aphasia may produce fluent but impaired speech, running the gamut from the merely odd to a confused jumble that has been likened to “word salad.” Their mistakes include paraphasias (substitutions of related words, such as “window” for “door”) and neologisms (made-up words with no actual meaning, like “doopid” or “pekakis” when asked to identify a picture of a tricycle).58 Strangely, individuals with receptive aphasia don’t seem to be aware that what they’re saying is wrong or doesn’t make sense. The same is not true for people with expressive aphasia: they are very much aware of their linguistic limitations and, as result, often withdraw from communicating with others.

Expressive aphasia has traditionally been associated with injury to a brain region called Broca’s area. It is named after Paul Broca, a nineteenth-century French physician who made the connection between expressive language disorder and its anatomical location in the brain. Receptive aphasia, on the other hand, has traditionally been associated with damage to a different region, one called Wernicke’s area (after the German physician Carl Wernicke). Broca’s area is found toward the front of the brain, whereas Wernicke’s is located toward the back. The two brain regions are connected by a tract of nerve fibers that also play a role in language. Individuals with stroke damage to this tract display yet a third form of impairment, called conduction aphasia. In this disorder, speaking and understanding speech are relatively unaffected, but the ability to repeat words or sentences may be greatly impaired.

Because aphasia can manifest itself in different ways, it can be difficult to diagnose. This is especially true when a person arrives at a hospital unable to communicate effectively. Patients who have had a stroke and are suffering from aphasia can be misdiagnosed as having a psychotic episode, schizophrenia, epilepsy, dementia, or a host of other conditions.59 Misdiagnosis is particularly worrisome in the first few hours after a stroke occurs. If the stroke is the result of a blood clot, and the patient receives a drug called tPA (tissue plasminogen activator) soon afterward, there is a chance the stroke can be “reversed” and the person will regain much of his normal function.⁶⁰

We know that expressive aphasia is a cognitive and not a motor problem because people who communicate via Sign language display similar deficits. They experience great difficulty in producing the physical motions that are required in Sign languages. However, these individuals are relatively unimpaired in their comprehension of the signs of others. In another parallel, a Sign language user with receptive aphasia will display poor comprehension of the signs of others and will produce signs that are meaningless: a “gesture salad.”⁶¹

But what about writing and reading? Since these abilities can also be characterized as expressive and receptive, you might suspect that these skills are preserved or disrupted differentially—and you would be correct. Individuals with expressive aphasia can write meaningful sentences, but they find the act of writing to be effortful. Those with receptive aphasia will write fluidly but produce largely meaningless verbiage. People who suffer from expressive aphasia can read fairly well (paralleling their relatively intact comprehension of spoken language), whereas those with receptive aphasia comprehend the written word poorly.⁶²

Strange as it may seem, brain injury that leads to a loss of the ability to read—referred to as pure alexia—does not necessarily entail the loss of an ability to write. A person with alexia can write something and not be able to read what she has just written! Some individuals with alexia seem to process numbers better than letters, but the same may also be true of cognitively intact individuals.⁶³ People who suffer from alexia can learn to read once again but must do so in a letter-by-letter fashion, which can be tedious and frustrating when words are long.⁶⁴

Although the impairments caused by such language deficits can be severe and long lasting, most people with aphasia experience some degree of improvement, called spontaneous recovery, during the first weeks and months following onset. Not surprisingly, recovery is influenced by a variety of factors, such as the location and extent of the brain injury, type of aphasia, and environmental considerations such as family support.⁶⁵ People with aphasia also benefit from speech and language therapy (SLT). A comprehensive review of the research on this topic has found that SLT does improve the functional communication of people with aphasia and is most effective when it is intensive and continues over an extended period.⁶⁶

Other treatment options are in the works. These include transcranial direct-current stimulation (tDCS), which is a noninvasive electrical stimulation aimed at changing brain function.⁶⁷ Tablet-based home treatment programs have been effective. They are generally liked by patients, can be used independently, and can be customized for each person. In addition, virtual reality and virtual therapist protocols are also being developed.⁶⁸

Dyslexia

Like alexia, which we discussed in the previous section, dyslexia also relates to difficulty in reading. The terms “reading disability” and “dyslexia” are often used synonymously, although the former term refers to a host of factors, whereas dyslexia specifically refers to difficulties in word recognition and spelling. Researchers use the term “developmental dyslexia” to differentiate it from language deficits like alexia that occur later in life as a consequence of brain injury or stroke. These definitional issues are complicated because dyslexia frequently co-occurs with other language development disorders. For example, in language impairment, children experience difficulty with vocabulary and grammar. In speech sound disorder, children have problems in producing speech sounds. Dyslexia also co-occurs with dyscalculia, which refers to difficulties with numbers, mathematics, and calculation.69

Estimates of the incidence of dyslexia are affected by the arbitrary nature of selecting assessment cutoff scores, but a commonly cited figure is 7 percent.⁷⁰ Dyslexia is not the same as having a low IQ, since the term is reserved for individuals who struggle with word decoding despite having normal or above-average intellectual ability.

Researchers have long debated the heritability of dyslexia, and as is typical with such research, it is difficult to tease apart the relative contributions of nature and nurture. However, a growing consensus suggests that genetic factors play an important role.⁷¹ The higher incidence seen in boys may also be due to other factors, such as attention-deficit/hyperactivity disorder (ADHD).

Are the effects of dyslexia greater for the learners of languages like English, in which the mapping of sound to spelling is less consistent than in other languages? In English, for example, /f/ can be rendered as f (as in “flower”), ff (as in “suffer”), ph (as in “philosophy”), or gh (as in “enough”). However, a study comparing children with dyslexia who were learning both English and German (which is more regular than English) found more similarities than differences. This finding suggests that the issue for people with dyslexia is a general phonological decoding deficit and not a language-specific correspondence problem between spelling and sound.⁷²

Before the development of diagnostic assessments that could identify this disorder, children with dyslexia were often labeled as being “slow” or “underperformers,” which only added to the frustration that they experienced as they struggled to keep up with their peers in reading. It’s also the case that many people with dyslexia attempt to conceal their difficulties out of shame or fear.⁷³ The stigma of dyslexia was on full display in September 2000, when an article by Gail Sheehy in Vanity Fair suggested that then-candidate for president George W. Bush had dyslexia.⁷⁴ As evidence, she pointed to Bush’s younger brother Neil, who had been diagnosed as having dyslexia, as well as Bush’s tendency to utter non sequiturs and malapropisms. (As we have seen, however, dyslexia refers to written and not spoken language.) In an interview on ABC’s Good Morning America after the article’s publication, Bush denied Sheehy’s assertion, although he added that he had never been assessed for the condition.⁷⁵

Many adults who struggle with dyslexia are not diagnosed as children and go through life assuming that they are simply poor readers and spellers. And according to a study of people with dyslexia in Norway, it is poor spelling, even more than reading difficulties, that leads adults to the conclusion that they might have dyslexia.⁷⁶ In addition, adults with dyslexia report having more memory issues than those without dyslexia.⁷⁷

Because dyslexia is often thought of as a disorder of childhood, it is also important to screen adults when making a diagnosis of dementia. Both conditions are defined by difficulty with language, attention, and memory. Failure to recognize that a person has underlying dyslexia can lead to misdiagnosis and the selection of inappropriate treatment options.⁷⁸

It would be a mistake to conclude that people with dyslexia are unable to compete in a world that places a premium on linguistic ability. A list of adults with dyslexia who have achieved fame or fortune in their respective fields would include hundreds of individuals. It is difficult, however, to retrospectively identify historical figures as having had dyslexia (but that hasn’t stopped people from trying). Leonardo da Vinci, Napoleon, Beethoven, and Einstein are all frequently found on lists of famous people with dyslexia. They may well have had problems with word recognition and spelling, but a lack of diagnostic criteria during their lifetimes precludes a definitive diagnosis. We are on firmer ground if we consider individuals from the mid-twentieth century onward. A partial inventory would include entrepreneurs and financiers (Richard Branson, Charles Schwab), actors and comedians (Danny Glover, Anthony Hopkins, Jay Leno), filmmakers (Steven Spielberg, Quentin Tarantino), athletes (Caitlyn Jenner, Magic Johnson, Nolan Ryan), and authors (John Irving, John Grisham). The fashion designer Tommy Hilfiger and the journalist Anderson Cooper would be included as well. And the actor Henry Winkler, who did not receive a diagnosis until he was thirty-one, has gone on to coauthor a popular series of children’s books about Hank Zipzer, a boy with dyslexia.

Many adults with dyslexia develop compensatory strategies to deal with their reading difficulties. Winkler, for example, could barely read as a child and therefore used memorization and improvisational skills to get through auditions and college coursework. And a study of French university students with dyslexia found that they have greater vocabulary depth, in terms of word meaning and semantic knowledge, than their peers.⁷⁹

It has been claimed that adults with dyslexia may also benefit from specially designed typefaces. For example, users of electronic book readers like Amazon’s Kindle can view text in a variety of sizes and fonts, including one called OpenDyslexic. This typeface, which is also available as an extension in Google’s Chrome web browser, has thicker or heavier lines at the bottoms of letters and numbers. These features purportedly make the characters easier to distinguish from one another. In theory, this may be helpful, but a study designed to assess the efficacy of OpenDyslexic found no improvement in either reading speed or accuracy when compared to traditional fonts like Arial or Times New Roman.⁸⁰ Another specially designed font, Dyslexie, was found to increase reading speed, but this result seems to be due to the wide spacing employed by the typeface. When the researchers adjusted the spacing of a comparison font (Arial) to match the spacing used in Dyslexie, they observed no differences in reading speed.⁸¹

Although the difficulties experienced by people with dyslexia are all too real, a countervailing narrative has also been advanced. Because their brains work somewhat differently, people with dyslexia may possess superior reasoning skills in particular domains. The authors of The Dyslexic Advantage, for example, argue that many people with dyslexia possess excellent spatial ability and are heavily represented in fields like computer graphics and architecture.⁸² However, one should take such claims with a grain of salt, since many people with a wide range of learning disabilities may simply use the term “dyslexic,” and the perception of surfeits in certain professions may in fact represent motivated reasoning and confirmation bias.

As we have seen, our language abilities and our identity are closely intertwined. In the chapter’s final section, we delve into an unusual condition that highlights how even subtle shifts in the way we speak can have a dramatic impact on how we (and others) see ourselves.

Foreign Accent Syndrome

I think we are wise, we English speakers, to savor accents. They teach us things about our own tongue.

—David, in Anne Rice’s Merrick (2000)

On September 6, 1941, the German-occupied city of Oslo was attacked by the British Royal Air Force. The frightened citizens caught in the open frantically sought refuge from the falling bombs. One of the casualties of the air raid was a twenty-eight-year-old woman named Astrid, who was hit by shrapnel as she ran toward a shelter. She was seriously wounded on the left side of her head. Hospital staff feared she would not survive. After a few days, however, she regained consciousness and was found to have paralysis on the right side of her body. She was also unable to speak. Over time her paralysis receded, and she gradually recovered her ability to talk. Her speech, however, had changed, and people who heard her detected a pronounced German-like accent. This was a serious problem in Norway, where the military occupation had created intense antipathy toward anything German, and her speech caused shopkeepers to refuse to assist her. Clearly she had no desire to speak as she did. Even more mysteriously, she had never lived outside Norway, nor had she interacted with foreigners.83

Two years after her injury, Astrid’s strange case came to the attention of Georg Herman Monrad-Krohn. He was a professor of neurology at the University of Oslo and had a particular interest in language disorders. He was also struck by Astrid’s distinctly foreign accent and initially thought that she must be German or French.

Astrid’s case is not unique: an occurrence of what is now called foreign accent syndrome (FAS) was described as early as 1907 by Pierre Marie in France, where a Parisian had acquired an “Alsatian” accent.⁸⁴ Over the next century, physicians and language researchers reported dozens of similar cases. As the case studies piled up in the medical journals, scholars struggled to understand what was going on. (FAS has also happened to at least one well-known person today: in 2011 the British singer George Michael, who grew up in London, came out of a three-week coma and initially spoke with a West Country accent.)⁸⁵

A shared element in many FAS cases involves injury to specific areas of the left hemisphere of the brain. In most individuals, language functions are localized in this hemisphere, which controls the right side of the body (this is why most individuals write with their right hand). Brain injury is rarely selective, and in two-thirds of the FAS cases that have been studied, such individuals have some other language deficit, such as aphasia or apraxia (a motor planning problem).⁸⁶ This was the case for Astrid as well. However, in a small number of cases, the syndrome seems to have been caused by a psychological disorder rather than physical damage to the brain. In some of these cases, the foreign accent seems to have faded away as the underlying condition, such as conversion disorder or schizophrenia, was treated successfully. In other cases, however, the foreign accent persisted.⁸⁷

What is it that makes individuals suffering from FAS sound like foreign speakers of their native language? A common element is that the prosody of their language production has changed in some way. Prosody refers to the rhythm, pitch, and intonation of a language as it is spoken. In a language like English, flat intonation is used for statements of fact (“I owe you twenty dollars”), whereas questions are accompanied by rising intonation (“I owe you twenty dollars?”). Languages differ in their prosodic contours, and so any disruption of normal rhythm and flow might be perceived as nonnative or foreign sounding.

For Astrid, the brain injury caused by the shrapnel wound led to prosodic changes in how she spoke her native language. For example, she tended to raise the pitch on the last word of short sentences. (In English, this phenomenon goes by various names, one of which is “upspeak.” It is associated with the speech of younger women in Britain and the United States.)⁸⁸ In addition, whereas Norwegian has fixed pitch on syllables that receive stress, languages like German have a less-consistent relation between pitch and stress. In German, because of this variable pitch, the word that receives the stress depends on the intonation pattern of the sentence. Another characteristic of Astrid’s talk after her injury is important as well: her speech was not always entirely grammatical.

When all these features are combined, it becomes easier to understand how other Norwegians might have perceived Astrid’s speech as foreign sounding. The relatively subtle prosodic and grammatical errors that she made would be consistent with someone who had learned Norwegian as a second language.⁸⁹ Recall that Monrad-Krohn initially thought that Astrid might be a native speaker of German or French. This probably reflects the fact that the nonnative speakers of Norwegian whom he and others encountered hailed from nearby, populous European countries—like Germany and France.

The subjective nature of how we perceive others’ accents is exemplified by the case of Linda Walker, a sixty-year-old British woman from Newcastle who suffered a stroke in 2006. Her sister-in-law asserted that, after regaining consciousness in the hospital, Linda sounded Italian. Her brother, on the other hand, claimed that her speech resembled someone from Slovakia. Others thought they detected a French Canadian or even a Jamaican lilt to her speech. In cases like this, even small changes in the way vowels are pronounced seem to drive major differences in how speech is perceived.⁹⁰

Such variability has been demonstrated in the laboratory as well. Experiments in which participants heard recordings of FAS speakers, as well as a control group of native speakers, also showed a great deal of inconsistency with regard to accent attribution. For example, a Scottish FAS speaker was correctly perceived by some participants to be Scottish, but by others to be Irish, Welsh, English, or even Spanish, German, Portuguese, and Polish. In contrast, the control Scottish speaker was always identified as a native speaker of some variety of English (Scottish, English, Irish, or American).⁹¹ Clearly, many of the study participants heard something that didn’t sound quite right, but they didn’t agree about what that “something” actually was. In a similar study, participants were able to reliably distinguish between native and foreign speakers but perceived FAS speakers as existing in some sort of linguistic netherworld: clearly not native, but not totally foreign either.⁹²

Perhaps not surprisingly, therefore, people afflicted with FAS often feel that their sense of self has been undermined. Linda Walker, for example, said, “I’ve lost my identity, because I never talked like this before. I’m a very different person and it’s strange and I don’t like it.”⁹³ An American woman with FAS, who sounded British to her Midwestern neighbors, went so far as to travel to England “in search of someone who sounded like me.”⁹⁴ People in England, however, thought that she sounded South African! As these examples make clear, our self-concept is intimately tied up with how we speak and how we sound to others.

Notes

1. Names of objects: Deborah M. Burke and Meredith A. Shafto, “Aging and Language Production,” Current Directions in Psychological Science 13, no. 1 (2004): 21–24.

2. Annoyances of aging: Deborah M. Burke and Meredith A. Shafto, “Language and Aging,” in The Handbook of Aging and Cognition, 3rd ed., ed. Fergus I. Craik and Timothy A. Salthouse (New York: Psychology Press, 2008), 373–443.

3. As college students: Marilyn K. Heine, Beth A. Ober, and Gregory K. Shenaut, “Naturally Occurring and Experimentally Induced Tip-of-the-Tongue Experiences in Three Adult Age Groups,” Psychology and Aging 14, no. 3 (1999): 445–457.

4. More than 90 percent: Bennett L. Schwartz, Tip-of-the-Tongue States: Phenomenology, Mechanism, and Lexical Retrieval (Mahwah, NJ: Erlbaum, 2002).

5. That are not resolved: Alan S. Brown, The Tip of the Tongue State (New York: Psychology Press, 2012).

6. Stars at sea: Roger Brown and David McNeill, “The ‘Tip of the Tongue’ Phenomenon,” Journal of Verbal Learning and Verbal Behavior 5, no. 4 (1966): 333.

7. Less available for them: Alan S. Brown and Lori A. Nix, “Age-Related Changes in the Tip-of-the-Tongue Experience,” American Journal of Psychology 109, no. 1 (1996): 79–91.

8. Long-term memory: Bennett L. Schwartz and Leslie D. Frazier, “Tip-of-the-Tongue States and Aging: Contrasting Psycholinguistic and Metacognitive Perspectives,” Journal of General Psychology 132, no. 4 (2005): 377–391.

9. Experience more TOT states: Donna J. Dahlgren, “Impact of Knowledge and Age on Tip-of-the-Tongue Rates,” Experimental Aging Research 24, no. 2 (1998): 139–153.

10. Ultimately lead to success: Bennett L. Schwartz and Janet Metcalfe, “Tip-of-the-Tongue (TOT) States: Retrieval, Behavior, and Experience,” Memory and Cognition 39, no. 5 (2011): 737–749.

11. Valuable sources of information: Anne M. Cleary and Alexander B. Claxton, “The Tip-of-the-Tongue Heuristic: How Tip-of-the-Tongue States Confer Perceptibility on Inaccessible Words,” Journal of Experimental Psychology: Learning, Memory, and Cognition 41, no. 5 (2015): 1533–1539.

12. Maintain your aerobic fitness: Katrien Segaert et al., “Higher Physical Fitness Levels Are Associated with Less Language Decline in Healthy Ageing,” Scientific Reports 8, 6715 (2018): 1–10.

13. Drawing of a protractor: Edith Kaplan, Harold Goodglass, and Sandra Weintraub, Boston Naming Test (Philadelphia: Lea & Febiger, 1983).

14. Health status of the participants: Pierre Goulet, Bernadette Ska, and Helen J. Kahn, “Is There a Decline in Picture Naming with Advancing Age?” Journal of Speech, Language, and Hearing Research 37, no. 3 (1994): 629–644.

15. After age seventy: Pierre Feyereisen, “A Meta-analytic Procedure Shows an Age-Related Decline in Picture Naming: Comments on Goulet, Ska, and Kahn (1994),” Journal of Speech, Language, and Hearing Research 40, no. 6 (1997): 1328–1333.

16. Two percent per decade: Lisa Tabor Connor et al., “Change in Object Naming Ability during Adulthood,” Journals of Gerontology Series B: Psychological Sciences and Social Sciences 59, no. 5 (2004): P203–P209.

17. “Ocopus” for octopus: Rhoda Au et al., “Naming Ability across the Adult Life Span,” Aging, Neuropsychology, and Cognition 2, no. 4 (1995): 303.

18. Long-term memory: Linda Mortensen, Antje S. Meyer, and Glyn W. Humphreys, “Age-Related Effects on Speech Production: A Review,” Language and Cognitive Processes 21, nos. 1–3 (2006): 238–290.

19. Found in other studies: Christopher Randolph et al., “Determinants of Confrontation Naming Performance,” Archives of Clinical Neuropsychology 14, no. 6 (1999): 489–496; Ronald F. Zec et al., “A Cross-Sectional Study of the Effects of Age, Education, and Gender on the Boston Naming Test,” Clinical Neuropsychologist 21, no. 4 (2007): 587–616.

20. Familiarity the with the test items: Randolph et al., “Determinants of Confrontation.”

21. “Trellis” and “abacus”: Maureen Schmitter-Edgecombe, M. Vesneski, and D. W. R. Jones, “Aging and Word-Finding: A Comparison of Spontaneous and Constrained Naming Tests,” Archives of Clinical Neuropsychology 15, no. 6 (2000): 479–493.

22. Word retrieval difficulties: Martin L. Albert et al., “Effects of Health Status on Word Finding in Aging,” Journal of the American Geriatrics Society 57, no. 12 (2009): 2300–2305.

23. In the following section: Victoria Tumanova et al., “Speech Disfluencies of Preschool-Age Children Who Do and Do Not Stutter,” Journal of Communication Disorders 49 (2014): 25–41.

24. Lecturers in the humanities: Stanley Schachter et al., “Speech Disfluency and the Structure of Knowledge,” Journal of Personality and Social Psychology 60, no. 3 (1991): 362–367.

25. “A white shirt”: Heather Bortfeld et al., “Disfluency Rates in Conversation: Effects of Age, Relationship, Topic, Role, and Gender,” Language and Speech 44, no. 2 (2001): 123–147.

26. Lacking in confidence: David Zielinski, ed., Master Presenter: Lessons from the World’s Top Experts on Becoming a More Influential Speaker (San Francisco: Wiley, 2013).

27. Varying degrees of success: Jean E. Fox Tree, “Folk Notions of Um and Uh, You Know, and Like,” Text and Talk 27, no. 3 (2007): 297–314.

28. Following pause was longer: Herbert H. Clark and Jean E. Fox Tree, “Using Uh and Um in Spontaneous Speaking,” Cognition 84, no. 1 (2002): 73–111.

29. Men employing “uh”: Eric K. Acton, “On Gender Differences in the Distribution of Um and Uh,” University of Pennsylvania Working Papers in Linguistics 17, no. 2 (2011): 1–9.

30. Decreases with age: Mark Liberman, “Language Log: Young Men Talk like Old Women,” November 6, 2005, http://itre.cis.upenn.edu/~myl/languagelog/archives/002629.html.

31. No differences have been found: Patricia V. Cooper, “Discourse Production and Normal Aging: Performance on Oral Picture Description Tasks,” Journal of Gerontology 45, no. 5 (1990): 210–214; Sandra W. Duchin and Edward D. Mysak, “Disfluency and Rate Characteristics of Young Adult, Middle-Aged, and Older Males,” Journal of Communication Disorders 20, no. 3 (1987): 245–257.

32. Pictures with negative content: Nichol Castro and Lori E. James, “Differences between Young and Older Adults’ Spoken Language Production in Descriptions of Negative versus Neutral Pictures,” Aging, Neuropsychology, and Cognition 21, no. 2 (2014): 222–238.

33. “Shorter and less complex”: Barbara B. Shadden, “Discourse Behaviors in Older Adults,” Seminars in Speech and Language 18, no. 2 (1997): 143–157.

34. Seventies, eighties, and nineties: Jeffrey P. Searl, Rodney M. Gabel, and J. Steven Fulks, “Speech Disfluency in Centenarians,” Journal of Communication Disorders 35, no. 5 (2002): 383–392.

35. Without cognitive impairment: Frederique Gayraud, Hye-Ran Lee, and Melissa Barkat-Defradas, “Syntactic and Lexical Context of Pauses and Hesitations in the Discourse of Alzheimer Patients and Healthy Elderly Subjects,” Clinical Linguistics and Phonetics 25, no. 3 (2011): 198–209.

36. Novel way of expressing something: Allison Wray, Formulaic Language and the Lexicon (Cambridge: Cambridge University Press, 2002).

37. “Have a nice day”: Diana Van Lancker-Sidtis and Gail Rallon, “Tracking the Incidence of Formulaic Expressions in Everyday Speech: Methods for Classification and Verification,” Language and Communication 24, no. 3 (2004): 207–240.

38. On such phrases: Kelly Ann Bridges and Diana Van Lancker Sidtis, “Formulaic Language in Alzheimer’s Disease,” Aphasiology 27, no. 7 (2013): 799–810.

39. Use formulaic language appropriately: Boyd H. Davis and Margaret Maclagan, “Pauses, Fillers, Placeholders, and Formulaicity in Alzheimer’s Discourse,” in Fillers, Pauses and Placeholders, ed. Nino Amiridze, Boyd H. Davis, and Margaret Maclagan (Amsterdam: John Benjamins, 2010), 189–216.

40. Historical events: Steve Luxemberg, “‘The King’s Speech’: Brilliant Filmmaking, Less-than-Brilliant History,” Washington Post, January 28, 2011.

41. Mentally challenged: Jeffrey K. Johnson, “The Visualization of the Twisted Tongue: Portrayals of Stuttering in Film, Television, and Comic Books,” Journal of Popular Culture 41, no. 2 (2008): 245–261.

42. Dennis McLellan, “Stutter Group Pickets over ‘Wanda’ Role,” Los Angeles Times, March 29, 1989, http://articles.latimes.com/1989-03-29/entertainment/ca-716_1_wanda-insults-people.

43. One percent of adults: Carlos Frigerio-Domingues and Dennis Drayna, “Genetic Contributions to Stuttering: The Current Evidence,” Molecular Genetics and Genomic Medicine 5, no. 2 (2017): 95–102.

44. Than those who don’t stutter: Ashley Craig and Yvonne Tran, “Trait and Social Anxiety in Adults with Chronic Stuttering: Conclusions following Meta-analysis,” Journal of Fluency Disorders 40 (2014): 35–43.

45. Half of their genes: Corrado Fagnani et al., “Heritability and Environmental Effects for Self-Reported Periods with Stuttering: A Twin Study from Denmark,” Logopedics Phoniatrics Vocology 36, no. 3 (2011): 114–120.

46. Translated into specific treatments: Roger J. Ingham et al., “Stuttering Treatment and Brain Research in Adults: A Still Unfolding Relationship,” Journal of Fluency Disorders 55 (2018): 106–119.

47. When they are putting: David Owens, “The Yips: What’s behind the Condition That Every Golfer Dreads?” New Yorker, May 26, 2014, https://www.newyorker.com/magazine/2014/05/26/the-yips.

48. Action dystonias: G. Kiziltan and M. A. Akalin, “Stuttering May Be a Type of Action Dystonia,” Movement Disorders 11, no. 3 (1996): 278–282.

49. About to stammer: Eric S. Jackson et al., “Responses of Adults Who Stutter to the Anticipation of Stuttering,” Journal of Fluency Disorders 45 (2015): 38–51.

50. Severity of a person’s stammer: Christopher D. Constantino et al., “A Preliminary Investigation of Daily Variability of Stuttering in Adults,” Journal of Communication Disorders 60 (2016): 39–50.

51. Their promotion chances: Michelle Klompas and Eleanor Ross, “Life Experiences of People Who Stutter, and the Perceived Impact of Stuttering on Quality of Life: Personal Accounts of South African Individuals,” Journal of Fluency Disorders 29, no. 4 (2004): 275–305.

52. Younger and unmarried: Debora Freud et al., “The Relationship between the Experience of Stuttering and Demographic Characteristics of Adults Who Stutter,” Journal of Fluency Disorders 52 (2017): 53–63.

53. Interacting with store clerks: Travis M. Andrews, “Annie Glenn: ‘When I Called John, He Cried. People Just Couldn’t Believe That I Could Really Talk.’” Washington Post, December 9, 2016, https://www.washingtonpost.com/news/morning-mix/wp/2016/12/09/to-john-glenn-the-real-hero-was-his-wife-annie-conqueror-of-disability/?noredirect=on&utm_term=.c02f21305c42.

54. Controlling breathing and speech rate: The Stuttering Foundation, “Annie Glenn,” June 17, 2015, https://www.stutteringhelp.org/content/annie-glenn.

55. Person that they had become: Klompas and Ross, “Life Experiences of People Who Stutter.”

56. Than when they were younger: Walther H. Manning, Deborah Dailey, and Sue Wallace, “Attitude and Personality Characteristics of Older Stutterers,” Journal of Fluency Disorders 9 (1984): 213.

57. Health and finance: Geraldine Bricker-Katz, Michelle Lincoln, and Patricia McCabe, “A Life-Time of Stuttering: How Emotional Reactions to Stuttering Impact Activities and Participation in Older People,” Disability and Rehabilitation 31, no. 21 (2009): 1742–1752.

58. Picture of a tricycle: Jonathan D. Rohrer, Martin N. Rossor, and Jason D. Warren, “Neologistic Jargon Aphasia and Agraphia in Primary Progressive Aphasia,” Journal of the Neurological Sciences 277, no. 1 (2009): 155–159.

59. Host of other conditions: Zac Lane et al., “Differentiating Psychosis versus Fluent Aphasia,” Clinical Schizophrenia and Related Psychoses 4, no. 4 (2010): 258–261.

60. His normal function: Maarten G. Lansberg, Erich Bluhmki, and Vincent N. Thijs, “Efficacy and Safety of Tissue Plasminogen Activator 3 to 4.5 Hours after Acute Ischemic Stroke: A Meta-analysis,” Stroke 40, no. 7 (2009): 2438–2441.

61. “Gesture salad”: Ruth Campbell, Mairéad MacSweeney, and Dafydd Waters, “Sign Language and the Brain: A Review,” Journal of Deaf Studies and Deaf Education 13, no. 1 (2008): 3–20.

62. Comprehend the written word poorly: Norman Geschwind, “The Organization of Language and the Brain,” Science 170, no. 3961 (1970): 940–944.

63. Cognitively intact individuals: Randi Starrfelt and Marlene Behrmann, “Number Reading in Pure Alexia—a Review,” Neuropsychologia 49, no. 9 (2011): 2283–2298.

64. When words are long: E. H. Lacey et al., “Transcranial Direct Current Stimulation for Pure Alexia: Effects on Brain and Behavior,” Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation 8, no. 2 (2015): 305–307.

65. Family support: M. M. Watila and S. A. Balarabe, “Factors Predicting Post-stroke Aphasia Recovery,” Journal of the Neurological Sciences 352, no. 1 (2015): 12–18.

66. Extended period: Marian C. Brady et al., “Speech and Language Therapy for Aphasia following Stroke,” Cochrane Database of Systematic Reviews, no. 6, article number CD000425 (2016).

67. Changing brain function: Andrea Gomez Palacio Schjetnan et al., “Transcranial Direct Current Stimulation in Stroke Rehabilitation: A Review of Recent Advancements,” Stroke Research and Treatment, article ID 170256 (2013).

68. Are also being developed: Michael Pugliese et al., “Mobile Tablet-Based Therapies following Stroke: A Systematic Scoping Review of Administrative Methods and Patient Experiences,” PloS One 13, no. 1 (2018): e0191566; Sarel Van Vuuren and Leora R. Cherney, “A Virtual Therapist for Speech and Language Therapy,” in Intelligent Virtual Agents, ed. T. Bickmore, S. Marsella, and C. Sidner (New York: Springer, 2014), 438–448.

69. Numbers, mathematics, and calculation: Anna J. Wilson et al., “Dyscalculia and Dyslexia in Adults: Cognitive Bases of Comorbidity,” Learning and Individual Differences 37 (2015): 118–132.

70. Figure is 7 percent: Robin L. Peterson and Bruce F. Pennington, “Developmental Dyslexia,” Annual Review of Clinical Psychology 11 (2015): 283–307.

71. Play an important role: Suzanne C. Swagerman et al., “Genetic Transmission of Reading Ability,” Brain and Language 172 (2015): 3–8.

72. Spelling and sound: Johannes C. Ziegler et al., “Developmental Dyslexia in Different Languages: Language-Specific or Universal?” Journal of Experimental Child Psychology 86, no. 3 (2003): 169–193.

73. Shame or fear: Kathleen Tanner, “Adult Dyslexia and the ‘Conundrum of Failure,’” Disability and Society 24, no. 6 (2009): 785–797.

74. Bush had dyslexia: Gail Sheehy, “The Accidental Candidate,” Vanity Fair, October 2000.

75. For the condition: Andrew Cohen, “Bush’s Mangling of Language Points to Dyslexia: Writer,” Globe and Mail, September 13, 2000.

76. Might have dyslexia: Trude Nergård-Nilssen and Charles Hulme, “Developmental Dyslexia in Adults: Behavioural Manifestations and Cognitive Correlates,” Dyslexia 20, no. 3 (2014): 191–207.

77. Those without dyslexia: James H. Smith-Spark, Adam P. Zięcik, and Christopher Sterling, “Self-Reports of Increased Prospective and Retrospective Memory Problems in Adults with Developmental Dyslexia,” Dyslexia 22, no. 3 (2016): 245–262.

78. Inappropriate treatment options: Claudia Metzler-Baddeley, Amanda Salter, and Roy W. Jones, “The Significance of Dyslexia Screening for the Assessment of Dementia in Older People,” International Journal of Geriatric Psychiatry 23, no. 7 (2008): 766–768.

79. Than their peers: Eddy Cavalli et al., “Vocabulary Skills Are Well Developed in University Students with Dyslexia: Evidence from Multiple Case Studies,” Research in Developmental Disabilities 51 (2016): 89–102.

80. Times New Roman: Jessica J. Wery and Jennifer A. Diliberto, “The Effect of a Specialized Dyslexia Font, OpenDyslexic, on Reading Rate and Accuracy,” Annals of Dyslexia 67, no. 2 (2017): 114–127.

81. No differences in reading speed: Eva Marinus et al., “A Special Font for People with Dyslexia: Does It Work and, If So, Why?” Dyslexia 22, no. 3 (2016): 233–244.

82. Computer graphics and architecture: Brock L. Eide and Fernette F. Eide, The Dyslexic Advantage: Unlocking the Hidden Potential of the Dyslexic Brain (New York: Plume, 2012).

83. Interacted with foreigners: Georg Herman Monrad-Krohn, “Dysprosody or Altered ‘Melody of Language,’” Brain 70 (1947): 405–415; J. Ryalls and I. Reinvang, “Some Further Notes on Monrad-Krohn’s Case Study of Foreign Accent Syndrome,” Folia Phoniatrica et Logopaedica 37, nos. 3–4 (1985): 160–162.

84. “Alsatian” accent: Inger Moen, “Monrad-Krohn’s Foreign Accent Syndrome Case,” in Classic Cases in Neuropsychology, ed. Chris Code et al. (Hove, UK: Psychology Press, 1996), 145–156.

85. West Country accent: Ryan Jaslow, “George Michael Wakes from Coma with New Accent: What’s Foreign Accent Syndrome?” CBS News, July 19, 2012, https://www.cbsnews.com/news/george-michael-wakes-from-coma-with-new-accent-whats-foreign-accent-syndrome.

86. Motor planning problem: Sheila E. Blumstein and Kathleen Kurowski, “The Foreign Accent Syndrome: A Perspective,” Journal of Neurolinguistics 19, no. 5 (2006): 346–355.

87. Foreign accent persisted: Stefanie Keulen et al., “Foreign Accent Syndrome as a Psychogenic Disorder: A Review,” Frontiers in Human Neuroscience 10, no. 168 (2016).

88. And the United States: Barbara Bradford, “Upspeak in British English,” English Today 13, no. 3 (1997): 29–36.

89. As a second language: Moen, “Monrad-Krohn’s Foreign Accent Syndrome.”

90. How speech is perceived: BBC News, “Stroke Gives Woman a Foreign Accent,” July 4, 2006, http://news.bbc.co.uk/2/hi/uk_news/england/tyne/5144300.stm.

91. Scottish, English, Irish, or American: Cinzia Di Dio, Joerg Schulz, and Jennifer Gurd, “Foreign Accent Syndrome: In the Ear of the Beholder?” Aphasiology 20, no. 9 (2006): 951–962.

92. Not totally foreign either: Jo Verhoeven et al., “Accent Attribution in Speakers with Foreign Accent Syndrome,” Journal of Communication Disorders 46, no. 2 (2013): 156–168.

93. “I don’t like it”: BBC News, July 4, 2006.

94. “Someone who sounded like me”: Anthony DiLollo, Julie Scherz, and Robert A. Neimeyer, “Psychosocial Implications of Foreign Accent Syndrome: Two Case Examples,” Journal of Constructivist Psychology 27, no. 1 (2014): 24.