communicating brains: autism and neurodevelopmental...
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Communicating Brains: Autism and Neurodevelopmental Disorders 12/6/12
Elysa Marco, PhD
BIOGRAPHY: Dr. Marco is the director of research for the UCSF Autism and Neurodevelopment Program (ANP). In addition to the founding and directing research efforts for the UCSF ANP, Dr. Marco directs the cognitive and behavioral child neurology clinic and participates in the neurology, psychiatry, and genetics multidisciplinary autism clinics at UCSF. Dr. Marco’s research laboratory applies her clinical expertise in cognition and behavior to understanding the neural mechanisms of neurodevelopmental disorders related to autism, agenesis of the corpus callosum, sensory processing disorder (SPD), ADHD, and brain injury. Her laboratory is focuses on how individuals with neurodevelopmental differences process basic sensory information from perception to action. Her NIH funded research investigates how children with autism process sensory information using magnetoencephalographic imaging and her expanding treatment projects are targeting computer training as a tool for augmenting positive brain plasticity. BIBLIOGRAPHY: Marco EJ, Hinkley LB, Hill SS, Nagarajan; Sensory Processing in Autism: A Review of Neurophysiologic Findings. Pediatric Research. 2011 May;69(5 Pt 2):48R‐54R. Leekam et. al. Describing the Sensory Abnormalities of Children and Adults with Autism. J Autism Dev Disord. 2007 May;37(5):894‐910. Binder JR et. Al. Human temporal lobe activiation by speech and nonspeech sounds. Cereb Cortex 2000 May; 10(5):512‐28. Taylor N, Isaac C, Milne E; A Comparison of the Development of Audiovisual Integration in Children with Autism Spectrum Disorders and Typically Developing Children. JADD. 2010 Vol 40(11) p1403‐1411. Guiraud JA, Tomalski P, Kushnerenko E, et al. Atypical Audiovisual Speech Integration in Infants at Risk for Autism. PLos One 2012, 7(5): e36428.Published online 2012 May 15.
Nina F. Dronkers, PhD BIOGRAPHY: Nina F. Dronkers is a VA Research Career Scientist and Director of the Center for Aphasia and Related Disorders with the Department of Veterans Affairs Northern California Health Care System. She is also an Adjunct Professor at the University of California, Davis in the Department
of Neurology and a consultant to the UCSF Memory and Aging Center. She received her interdisciplinary Ph.D. degree in Neuropsychology from the University of California, Berkeley in 1985, and has since specialized in the mapping of speech, language, and cognitive disorders that occur after injury to the brain. Using numerous methodologies, Dr. Dronkers and her colleagues have isolated numerous brain regions that play critical roles in the processing of speech and language, as well as how these relate to other cognitive skills. Her latest work involves analyzing the structural and functional connections that contribute to language and cognitive processing through advanced work with diffusion and resting state functional neuroimaging. BIBLIOGRAPHY:
1. Bates, E., Wilson, S.M., Saygin, A.P., Dick, F., Sereno, M., Knight, R.T. & Dronkers, N.F. Voxel‐based lesion‐symptom mapping. Nature Neuroscience, 2003, 6(5), 448‐450.
2. Dronkers, N.F. A new brain region for speech: The insula and articulatory planning. Nature, 1996, 384, 159‐161.
3. Dronkers, N.F. & Ogar, J. Aphasia. In M.J. Aminoff and R.B. Daroff (Eds.), Encyclopedia of the Neurological Sciences, 2nd edition, San Diego, California: Academic Press, in press.
4. Dronkers, N.F., Plaisant, O., Iba‐Zizen, M.T. & Cabanis, E.A. Paul Broca’s historic cases: High resolution MR imaging of the brains of Leborgne and Lelong. Brain, 2007, 130, 1432‐1441.
5. Gorno‐Tempini, M.L., Dronkers, N.F., Rankin, K.P., Ogar, J.M., Phenegrasamy, L., Rosen, H.J., Johnson, J.K., Weiner, M.W., Miller, B.L. Cognition and anatomy in three variants of primary progressive aphasia. Annals of Neurology, 2004, 55(3), 335‐346.
6. Turken, A.U. & Dronkers, N.F. The neural architecture of the language comprehension network: converging evidence from lesion and connectivity analyses. Frontiers in Systems Neuroscience, 2011, 5, 1‐20.
Communicating Brains: From Autism and Dyslexia to Progressive Aphasia
Maya L. Henry, PhD, CCC‐SLP BIOGRAPHY: Dr. Henry is an Assistant Adjunct Professor and speech‐language pathologist working with the language team at the Memory and Aging Center at UCSF. She is also an Assistant Professor in the Communicative Disorders Program at San Francisco State University. She received her master’s degree and PhD from the University of Arizona, studying the nature and treatment of
acquired neurogenic communication disorders. She has conducted NIH‐funded studies examining the neural bases of spoken and written language in primary progressive aphasia (PPA) and also examining the utility of speech and language treatment in the three variants of this disorder. Her broad research interests include the neural and cognitive bases for speech and language, rehabilitation of speech and language in individuals with aphasia, and ways in which neuroimaging can inform treatment research in individuals with stroke and neurodegenerative disease. Dr. Henry runs a monthly support group for individuals with PPA in the Bay Area. BIBLIOGRAPHY:
Beeson PM, King RM, Bonakdarpour B, Henry ML, Cho H, Rapcsak SZ. Positive effects of language treatment for the logopenic variant of primary progressive aphasia. Journal of Molecular Neuroscience. 2011:1‐13.
Gorno‐Tempini ML, Hillis AE, Weintraub S, et al. Classification of primary progressive aphasia and its variants. Neurology. 2011;76(11):1006‐1014.
Henry ML, Beeson PM, Rapcsak SZ. Treatment for lexical retrieval in progressive aphasia. Aphasiology. 2008;22(7):826‐838.
Henry ML, Beeson PM, Alexander GE, Rapcsak SZ. Written language impairments in primary progressive aphasia: A reflection of damage to central semantic and phonological processes. J Cogn Neurosci. 2012;24(2):261‐275.
Mesulam MM. Primary progressive aphasia. Ann Neurol. 2001;49(4):425‐432.
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Elysa Marco, MD12.6.12
Asst. Prof, UCSF Depts of Neurology, Pediatrics, and PsychiatryDirector of Research, UCSF Autism and Neurodevelopment
Program
Communicating Brains: Autism and Neurodevelopmental Disorders
Communication begins with sensory perception and processing:
Review basics of sensory processing from a neuroscience perspectiveHow does this differ in children with autism and neurodevelopmentaldisorders?What are we doing at UCSF to help?
The first question is:Are there sensory differences in autism at the bedside?… all you need to do is ask!
Or read…
Emergence (pgs 21 & 28)Even today, sudden loud noises such as a
car backfiring, will make me jump and a panicky feeling overwhelms me. Loud high pitched noises such as a motorcycle’s sound, are still painful to me.
Tactile stimulation for me and many autistic children is a no-win situation. Our bodies cry out for human contact but when the contact is made, we withdraw in pain and confusion.
Grandin, T. Publisher: Warner Books (September 1, 1996) Emergence: Labeled A ti ti
Sensory Processing Disruption is Ubiquitous in Autism Sensory behavioral differences occur in over 90%
of individuals with autism
Children with autism are more likely to have multiple domains affects than controls (70% vs. 13%)
Leekam et. al. (2007) Describing the Sensory Abnormalities of Children and Adults with Autism
Sensory Symptoms in Autism
No sensorydifferences
MultipleDomain
SingleDomain
Children with Developmental Disabilities and Language Impairment also have sensory symptoms
Leekam et. al. (2007) Describing the Sensory Abnormalities of Children and Adults with Autism
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Sensory Processing Disruption has long-term impact Sensory symptoms often persist into adulthood Sensory processing is the basis for all learning and
behavior
Leekam et. al. (2007) Describing the Sensory Abnormalities of Children and Adults with Autism
What do I mean by sensory processing-bringing together neuroscience & behavioral sciences?
The steps of sensory processing:Unimodal Perception (Auditory, Somatosensory,
Visual, Olfactory)Multimodal IntegrationAttaching Meaning (Linguistic & Emotional)Creating ResponsePerforming Response (Verbal/Motor)
Some basic neuroanatomy Early Auditory Processing
CN 8 synapses at ipsilateral cochlear nuclear complex (medulla) Only from one ear & gets spectral and
temporal information
Superior olivary complex Bilateral input Sound localization (delay & intensity)
Inferior colliculus medial geniculate nucleus auditory cortex
All neurons tonotopically organized More frequency specific as you go up Information goes up and down!
http://brainconnection.positscience.com/med/medart/l/anat/990705.jpg
Central Auditory Processing Can we measure auditory processing in the scanner?
EEG
Yes!
MEG
fMRI
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How do neurons talk to each other?How can you measure electrical activity?
Using magnetoencephalographicImaging
Milli-second & milli-meter cortical activity resolution (w/MRI co-registration)
Non-invasive
Well tolerated
Let’s use auditory processing as a example.
We find early primary auditory cortex processing differences
But, it depends on who you ask…Faster Slower
Ferri (1000 hz, 100ms tone)
Martineau (1000 hz, 4ms tone)
Marco et. al. (1000 hz, 80ms)
Bruneau (750khz, 200ms)
Oram Cardy (1000hz, 300ms)
Roberts (delay RH, 200, 300, 500, 1000 hz 300ms)
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Nath A R et al. J. Neurosci. 2011;31:13963-13971
©2011 by Society for Neuroscience
Audiovisual Integration-McGurkEffect
What about Auditory and Visual Integration? McGurk (multisensory)
Posterior Parietal Cortex
Whole-brain regression of fMRI responses and McGurksusceptibility–
The more your integrate, the more activity you show in the yellow region below
Nath A R et al. J. Neurosci. 2011;31:13963-13971
Do children with autism show a McGurk effect?
Taylor et. al. 2010. Comparison of the develoment of audiovisual integration in children with autism spectrum disorders and typically developing children. JADD.
High Risk Infants may not process AV mismatch
Guiraud, et. al. (2012) Atypical audiovisual speech integration in infants at risk for autism. PLoS One.
What about other neurodevelopmentaldisorders?
Absent
Images courtesy of Dr. Elliott Sherr
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Atypical Auditory Behavior in AgCC: What does brain activity look like
during communication in AgCC?
How are we planning on helping: Our goal is to build both areas of strength and areas of challenge
Kids and video games:if you can’t beat em, join em…
NeuroRacer:What happens when Neuroscience meets Video Gaming in the bay area
Adam GazzaleyDirector of “The NIC”
Eric JohnstonLucas Arts
a)
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Autism and SPD kids have trouble staying in the center of the road
Gazzaley Lab Unpublished data
Decades of Life
% of time at road center
Sensory Processing Disorder (n=14)
Autistic Children (n=9)
Drive w/ Irrelevant signs
Autism and SPD kids take longer to shoot:with visual distraction
Gazzaley Lab Unpublished data
Decades of Life
RT (m
sec)
Sensory Processing Disorder (n=14)
Autistic Children (n=9)
Sign with Road
Training Study
12 hours
‐13%‐13%
PreTrainPreTrain
1 mo.Later1 mo.Later
6 mo.later6 mo.later
Can we improve accuracy with practice?
Single‐task trainMulti‐task train
No‐contact controlGazzaley Lab Unpublished data
Decades of Life
Sensory Processing Disorder (n=14)
Autistic Children (n=9)
Multi‐tasking In
dex (d
’)
Many Hands with thanks to Lucy Miller & the Wallace Research Foundation:
MEG/DTI Team
SrikantanNagarajan
PratikMukherjee
Elliott Sherr
Leighton Hinkley
Shivani Desai*Ashley Antovich
Julia Harris*
Susannah Hill
Richard Hill
Angelina Jocson
Kasra Khatibi
Anne Bernard
Monica Arroyo
Heidi Kirsch
Anne Findlay
Suzanne Homna
Julia Owens
NeuroracerTeamAdam Gazzaley
Joaquin Anguera
Cammie Rolle
Johno Gibbons
Annie Aiken
MAC
Bruce Miller
Joel Kramer
John Neuhaus
Sensory Processing Foundation
Lucy Miller
Sarah Schoen
UCSF Autism and Neurodevelopment center
Bryna Siegel
Robert Hendren
Lauren Weiss
The kids and their parents!
This research effort has been supported by an NSADA NINDS (K12 NS01692–07) award and UL RR024131-01 from the NCRR a component of NIH and the NIH Roadmap for Medical Research. Ongoing work is supported by the Wallace Research Foundation. No conflicts of interest.
Thank you!
Speech and Language DeficitsAfter Injury to the Adult Brain
Nina F. Dronkers, Ph.D.VA Northern California Health Care System
University of California, Davis
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Why do we study communication abilities in the
injured brain?
• The more we understand about the injured brain, the more we
can help patients toward a more rapid and effective recovery.
• Individuals with brain-injuries teach us a great deal about how
the normal brain processes language; understanding how
language breaks down tells us a lot about it normally
functions.
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Research at our Aphasia Center• We conduct extensive speech, language, and
neuropsychological evaluations of aphasic stroke patients to determine the specific deficits they are experiencing.
• We also scan participants in an MRI scanner to see which part of the brain was affected by the stroke.
Research at our Aphasia Center
We then use these data to test brain-behavior relationships
– Identify patients with the same specific deficits and computer-overlap their lesions to determine if a common area of injury can be found
– Apply new voxel-based lesion symptom mapping techniques that statistically examine brain-behavior relationships at the 1 mm voxel level
– Evaluate the role of fiber pathways in the brain that also support language functions.
Fluency Comprehension
Broca’s aphasia
arcuate fasciculus Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Some Causes of Brain Injury in Adults
• Stroke• Tumor• Head Trauma• Severe Epilepsy• Neurodegenerative disease (e.g., Alzheimer’s
Disease)• Anoxia• Infectious disease• Toxicity
Blood Clot Lodged in Artery
What is a Stroke?
© National Stroke Association
Bleeding into the Brain
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Strokes and Aphasia
• Strokes can lead to speech and language
disorders that severely disrupt one’s
ability to communicate.
• A disruption of core language functions as
a result of injury to the brain is called
“aphasia”.
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Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Strokes Can Affect Language in Different Ways
Strokes in the front regions of the brain can lead to non-fluent speech
(video of individualwith Broca’s aphasia -
not available for distribution)
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Broca’s Aphasia
• Halting, telegraphic, agrammatic speech with reliance on content words and a paucity of function words
• Impaired comprehension for complex grammatical structures
• Repetition of sentences reflects agrammatic style• Word finding difficulty• Almost always accompanied by dysarthria and/or
apraxia of speech• Reading and writing also impaired
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Written Picture Description: Moderate Broca’s Aphasia
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
3-D MRI of an Individual with Broca’s Aphasia
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Lesion Overlapping of 36 Patients with Broca’s Aphasia
The injuries tend to involve more anterior areas.
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Strokes Can Affect Language in Different Ways
Strokes in posterior regions of the brain leave the person with fluent speech, but which is hard to understand.
(video of individualwith Wernicke’s aphasia -
not available for distribution)
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Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Severe Wernicke’s Aphasia
• Reflects extreme disruption of language
system without encumbrance of motor speech
deficits
• Chronic Wernicke’s aphasia occurs very rarely
• Acute Wernicke’s aphasia typically evolves
into milder forms of aphasia
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Lesion Overlapping of Patients with Wernicke’s Aphasia
The injuries tend to involve more posterior areas.
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Strokes Can Affect Language in Different Ways
Larger strokes can leave patients with only automatic sounds, words or phrases with which to communicate
(video of individualwith severe Broca’s aphasia -not available for distribution)
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Tips for Communicatingwith Individuals with Aphasia
• Keep the sentences simple, but avoid talking down.
• Reduce your rate of speech; emphasize key words.
• Make sure you have the person’s attention.
• Try writing, drawing, or gestures in addition to speech.
• Give them time to talk.
• Ask yes/no questions if the aphasia is severe.
• Provide practice trials and give positive feedback.
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Things to Remember• On the other hand, individuals with aphasia have not lost
their intelligence.
• They may find it more difficult to process incoming
information or to solve difficult problems; they may have
lost some of the language that would normally help them.
• Though they may have difficulty expressing their thoughts
with words, their thoughts and ideas are not typically
affected.
What has research with aphasic
individuals taught us about language
processing in the normal brain?
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Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
What Have We Learned?
The areas of the brain that support
language are far more extensive than
previously thought.
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Language Areas in Older Models
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Examples of Additional Language Areas from Recent Research
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
What Have We Learned?
• Brain areas do not work in isolation.
• The fibers that connect them help these
regions to interact with each other to
support complex functions such as
language.
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Fiber Bundles in Dissection
brainmind.com
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Visualization of Fiber Tract Data with Diffusion MRI
Visualization by Betty Lee
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Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Visualization of Language Tracts with Diffusion MRI
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Visualization of the Arcuate Fasciculus with Constrained Spherical Deconvolution Tractography
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Visualization of Language Tracts in Stroke
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
What Have We Learned?
• These techniques have taught us a lot about how the brain
processes language and what happens when the brain suffers
an injury.
• With this information, clinicians know that strokes affecting
certain brain structures will cause a loss of specific functions,
and that these will require special training.
• At the same time, brain structures that were spared can be
recruited to help take over the functions that were lost, or,
develop new strategies to compensate for the dysfunction.
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Summary• A complex system such as language requires an
extensive and interactive network of brain regions.
• Understanding this network provides us with the
tools for assisting our patients in their recovery
from brain injury, and, for understanding how
language is processed in the normal brain.
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Thank You
Image by Yoshihito Yagi
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Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
Supported by:
• VA Clinical Science Research and Development Program
• National Institute on Deafness and other Communication Disorders
• National Institute of Neurological Disorders and Stroke
• National Science Foundation
Center for Aphasia and Related Disorders, VA Northern California Health Care System, Martinez, CA
With special thanks to:
• And Turken, Ph.D.
• Juliana Baldo, Ph.D.
• Our patients and research participants who taught us all we know
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PROGRESSIVE IMPAIRMENTS OF SPEECH AND LANGUAGE: WHEN APHASIA ISN’T CAUSED BY A STROKE
Maya L. Henry, Ph.D, CCC-‐SLP Memory and Aging Center, UC San Francisco Communicative Disorders Program, San Francisco State University
Language and normal aging § Most common complaint: “I just can’t remember the name….” (especially proper names)
§ Word-‐finding does decline with age ú Difficulty with access rather than a deterioration of knowledge Older adults outperform younger adults on vocabulary tests
Semantic memory (conceptual knowledge) is preserved into old age (Burke & Shafto, 2008)
When is language decline not normal? § When the decline is more rapid than would be expected and changes are observed at ages <60 years
§ When cognitive processes not typically affected by age are noticeably impaired ú Motor control for speech ú Ability to speak in complete sentences ú Conceptual knowledge, word meaning ú Ability to “hold on to” heard information (e.g., a phone number)
Primary progressive aphasia (PPA)
§ Slowly progressive aphasia caused by neurodegenerative disease
§ Language processes are affected first and foremost (Mesulam, 2008; Gorno-‐Tempini et al., 2011)
§ There must be no focal lesion (e.g., stroke)
Regional cortical atrophy Primary Progressive Aphasia (PPA)
Normal
L L
PPA affects core speech-‐language processes
§ Like aphasia resulting from stroke, progressive aphasia may involve ú Syntax (grammar) ú Motor speech (articulation/voice) ú Semantics (meaning) ú Phonology (sound system) ú Orthography (written language)
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Deficits tend to arise in patterns: 3 variants of PPA (Gorno-‐Tempini et al., 2011)
§ Nonfluent variant ú Impaired syntax (sentence processing) and/or motor speech (articulation/voice)
§ Semantic variant ú Impaired semantic processing (conceptual knowledge)
§ Logopenic variant ú Impaired phonological processing (sound system for language)
These variants linked to underlying patterns of atrophy caused by different diseases
Nonfluent variant
Semantic variant
Logopenic variant
Wilson et al., 2010
HOW CAN PPA PATIENTS CONTRIBUTE TO OUR UNDERSTANDING OF BRAIN-‐BEHAVIOR RELATIONS FOR LANGUAGE?
§ Converging and complementary evidence regarding brain-‐behavior relations for language ú PPA involves some areas rarely damaged in stroke
Anterior temporal regions implicated in semantic processing
semantic dementia normal
What can PPA tell us about core language domains?
ú Semantics ú Phonology ú Orthography (written language)
Language tasks
§ Semantic tasks
What is this?
Which item goes with the picture on top?
Pyramids and Palm Trees Test (Howard and Patterson, 1992)
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§ Phonological tasks
ú Blend these sounds together /b/ /oi/ /l/ à “boil” ú Say “fat”...now take away “f” à “at” ú Say “mouth”...now change “th” to “s” à “mouse”
Language tasks
Arizona Phonological Battery (Beeson & Rapcsak, unpublished)
§ Written language tasks n Different word types require different types of
processing
yacht circuit doubt choir sword island debt
Irregular Words
flig hoach snite glope boak cheed merber
Nonwords
Semantically-derived Phonologically-derived
Spoken language
Phonology (sounds)
N=15 PPA Henry et al., JoCN, 2011
Semantics (meaning)
Written language
N=15 PPA Henry et al., JoCN, 2011
Phonology (sounds)
Semantics (meaning)
Neural bases of semantic vs. phonologic processing
Spoken language Written language
Treatment for speech and language impairments in PPA § Treatments similar to those applied in stroke aphasia appear promising (Henry et al., 2008 Beeson et al., 2011; Newhart et al., 2009)
§ Treatment effects can be substantial and lasting
§ Behavioral therapy can result in changes in language behaviors and also in imaging findings
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Treatment results in PPA"
§ Semantic PPA: impaired meaning system (semantics)"
§ Therapy for naming: take advantage of spared sound system"
atrophy increased activity
Wilson et al., 2009
0
10
20
30
40
50
60
70
80
90
100
Pre-‐Tx Post-‐Tx 3 mos. Post 6 mos
Trained spoken
Trained written
Treatment results in PPA"
§ Logopenic PPA: impaired sound system (phonology)"§ Therapy for naming: take advantage of spared meaning
system"
atrophy increased activity
Beeson et al., 2011
Beeson et al., 2011
Treatment results in PPA"
§ Nonfluent PPA: impaired speech!§ Therapy: take advantage of spared language
(reading)"
0.00
0.05
0.10
0.15
0.20
Pre-‐Tx Post-‐Tx 3. mos. post 6. mos. post I yr. post
Prop
or6o
n of to
tal m
ul6syllabic words
Speech Errors catastrophe
ca/tas/tro/phe
“catastrophe”
“The meeting was a catastrophe”
In sum
§ PPA is a slow decline in speech and language caused by neurodegenerative disease"
§ Semantic, phonologic, and motor systems can be selectively impaired"
§ Treatment for speech-language can have lasting benefits, taking advantage of spared cognitive and neural systems ""
QUESTIONS?
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