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Brain sensitivity to print emerges when children learnletterspeech sound correspondencesSilvia Brema,b,1, Silvia Bacha,b, Karin Kucianc, Tomi K. Guttorma,d, Ernst Martinc,e, Heikki Lyytinena,d,Daniel Brandeisb,e,f,2, and Ulla Richardsona,2

aAgora Center and dDepartment of Psychology and Child Research Centre, University of Jyvskyl, 40014 Jyvskyl, Finland; bDepartment of Child and

Adolescent Psychiatry, University of Zrich, 8032 Zrich, Switzerland; cMR Center, University Childrens Hospital, 8032 Zrich, Switzerland; eCenter forIntegrative Human Physiology, University of Zrich, 8057 Zrich, Switzerland; and fDepartment of Child and Adolescent Psychiatry and Psychotherapy, CentralInstitute of Mental Health, Mannheim J5 68072, Germany

Edited by Michael Posner, University of Oregon, Eugene, OR, and approved March 5, 2010 (received for review April 21, 2009)

The acquisition of reading skills is a major landmark process in a

humans cognitive development. On the neural level, a new func-tional network develops during this time, as children typically learn

to associate the well-known sounds of their spoken language with

unfamiliar characters in alphabetic languages and finally access the

meaning of written words, allowing for later reading. A critical com-

ponent of the mature reading network located in the left occipito-

temporal cortex, termed the visual word-form system (VWFS),exhibitsprint-sensitive activation in readers. Whenand how the sen-

sitivity of the VWFS to print comes about remains an open question.

In this study, we demonstrate the initiation of occipito-temporalcortex sensitivity to print using functional MRI (fMRI) (n = 16) and

event-related potentials (ERP) (n = 32) in a controlled, longitudinaltraining study. Print sensitivity of fast (


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terbalance the order of the games so that individual trainingeffects could be compared. Sensitivity to print processing wasassessed with ERP and fMRI at all three test times using a simplemodality judgment task (Fig. 1) including visual, auditory, andaudiovisual word (W)/speech and false font (FF)/nonintelligiblespeech stimuli.

Results

Behavior. Training intensity. The total training time (minutes) andthe training period (days) spent with each game did not differbetween GG and NC training (Table S1) as shown by ANOVAs

with the between-subject factor group [children starting with GG(GG-first) or with NC (NC-first) training] and the within-subjectfactor training game (GG, NC). The children did, however,practice longer with the first training game than with the secondtraining game [F(1,29) = 8.48, P = 0.007, p

2 = 0.23]. Thispreference can be explained by some loss of motivation andinterest over time because of the (intended) similarity ofthe games.

Letter Knowledge and Reading. Letter knowledge did not differbetween groups at the beginning of the study (Table 1). A mul-tivariate repeated-measures ANOVA (MANOVA) showed thatchildren named or sounded out significantly more uppercase thanlowercase letters [F(1,30) = 145.3, P< 0.001, p

2 = 0.83] and thattheir naming performance increased with test time [F(2,29) =51.71, P< 0.001, p

2 = 0.78]. As expected, the improvements inletter knowledge were greater in association with GG practicethan with NC practice [F(2,29) = 13.25, P< 0.001, p

2 = 0.48](Fig. S2). Across all test times, the GG-first group knew moreletters than the NC-first group [F(1,30) = 5.1, P = 0.032, p

2 =0.15] because, having received GG training first, they already hadimproved their letter knowledge by T2.

Despite the gains in letter knowledge, reading skills improvedonly slightly with time [F (2,29) = 4.16, P = 0.026, p2 = 0.22].For all children, reading skills remained very rudimentary evenafter GG training (only three children were able to decodemore than 10 words), as expected from the design and the mainaim of the GGnamely, to teach graphemephoneme corre-spondences.

Task Performance ERP/fMRI. The MANOVA on changes inresponding to W and FF stimuli over time (T1, T2, T3) (sensi-tivity index d; Table S2) in the two groups revealed only a timemain effect [F(2,29) = 4.96, P = 0.014, p

2 = 0.26] in ERPrecordings. Neither condition nor group effects were apparent inreaction-time data for the ERP, or fMRI assessments.

fMRI. For second-level, whole-brain analyses, fMRI groups werepooled as follows: Pre-GG corresponded to the last test beforeGG training (T1 for the GG-first group and T2 for the NC-firstgroup), and Post-GG summarized data immediately after GGtraining (T2 for the GG-first group and T3 for the NC-firstgroup). Pre-NC and Post-NC groups were pooled similarly. Abilateral visual network was activated (Fig. 2A) according to

whether the children processed W or FF stimuli (Table 2 andTable S3). In the whole-brain analyses, the contrast between Wand FF stimuli did not differ in the Pre-GG and Pre-NC groups(P< 0.005, k 15). Fig. S3 shows differences between the fMRIsubgroups at T1.

Training effects determined by ANOVA (P< 0.001, k 15)with factors time (Pre, Post) and training(GG, NC) for the WFFcontrast were in line with our hypothesis: A more pronounced

Table 1. Characteristics of training groups

Characteristic

ERP group fMRI group

Mean SD

P value

Mean SD

P valueAll GG-first NC-first All GG-first NC-first

N 32 15 17 16 8 8

Sex (f) 17 8 9 0.98* 13 5 8 0.055*

Risk 14 8 6 0.31* 5 2 3 0.59*

Age (y) 6.4 0.3 6.5 0.3 6.3 0.3 0.18 6.4 0.3 6.5 0.4 6.4 0.3 0.55

IQ 114 16 110 12 117 18 0.25 117 13 113 10 120 16 0.35

Education (y) 16.7 3.1 17 2.6 16.4 3.6 0.55 16.1 2.9 16.4 2.3 15.8 3.6 0.71

UC 10 7.3 11.2 5.8 8.9 8.4 0.39 12.1 7.6 12.8 6.7 11.4 8.8 0.73

LC 5.8 6.1 5.2 5.2 6.3 7.0 0.62 6.8 6.1 5.6 4.0 7.9 7.7 0.48

Reading 0.4 1.2 0.2 0.4 0.7 1.5 0.26 0.5 1.1 0.3 0.5 0.8 1.5 0.39

Phonology 35.3 3.6 35.8 4.2 34.9 3.0 0.48 36.1 2.9 36.9 3.0 35.4 2.8 0.31

Vocabulary 16.3 3.3 16.3 3.7 16.3 3.1 0.98 16.4 3.1 16.6 3.6 16.1 2.9 0.76

ARHQ 0.29 0.10 0.28 0.12 0.30 0.08 0.42 0.30 0.11 0.27 0.14 0.34 0.06 0.25

ARHQ, mean score of adult reading history questionnaire; Education, parents years of education; F, female; LC, knowledge of lowercase letters; Phonology,

phonological awareness (sum score of foursubtests of the Bielefelder screening test); Reading, number of correctly readwords;Risk, children with familialrisk for

dyslexia; UC, knowledge of uppercase letters.

*2 tests.

Fig. 1. Implicit audiovisual word and false font/rotated speech-processing

task, divided into two separate parts: unimodal and bimodal word (Upper)

and false font/rotated speech presentation (Lower). Children had to indicate

whether a stimulus was presented visually (V), auditorily (A), or audiovisually

(AVc/AVi), by pressing response buttons.

7940 | www.pnas.org/cgi/doi/10.1073/pnas.0904402107 Brem et al.
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increase in print sensitivity was detected in two clusters in the leftand right occipito-temporal lobes (fusiform gyrus and inferiortemporal gyrus) as well as in the cuneus over the course of GG(Pre-Post) than during the course of NC training. The changes inprint sensitivity (Post vs. Pre) for each game separately con-firmed this result by pointing to GG-related increases in activa-tion in the left posterior fusiform gyrus, right inferior temporal

gyrus, and cuneus (Fig. 2B and Table 2), whereas no effect wasseen over the course of NC.

Region-of-Interest Analysis. To elucidate further the effects oftraining on print-sensitive processing, we performed a region-of-interest (ROI) analysis of the percent signal change across fivespherical ROIs (R1R5) along the anteriorposterior axes of theoccipito-temporal cortex (Fig. 3). Notably, at T1 group differ-ences in the WFF contrast were already present in three pos-

terior ROIs [R3: left (l), P= 0.069, right (r), P= 0.072; R4: l, P=0.016, r, P = 0.005, R5: l, P = 0.030, r, P = 0.078; Fig. S4]. Themain MANOVA included the factors group (GG-first, NC-first),test time (T1, T2, T3), hemisphere, condition, and ROI (R1-5).Because of the aforementioned between-group condition differ-ences at T1, we verified the results with posthoc MANCOVAs.

No main effect or interaction with hemisphere was found, butmore anterior ROIs showed less activation than posterior ROIs[F(4,11) = 30.64, P< 0.001, p

2 = 0.92]. This regional differencein activation was modulated by condition [F(4,11) = 3.87, P =0.034, p

2 = 0.58]. The ROI condition group interaction [F(4,11) = 4.5, P = 0.021, p

2 = 0.62] further indicated groupdifferences in regional WFF differentiation. Finally, the ROItest time condition group interaction [F(8,7) = 3.82, P =

0.047, p2

= 0.81] indicated that this difference in activationbetween W stimuli and FF stimuli also depended on time.Based on these interactions, we assessed the training effects in

separate MANOVAs for each ROI. The expected training effectemerged only in R4 [F(2,13) = 5.67, P= 0.017, p

2 = 0.47], andseparate analyses of the left and right R4 revealed that thetraining effect was confined to the left hemisphere [F(2,13) =5.86, P= 0.015, p

2 = 0.47, right: P> 0.1]. Posthoc MANCOVAsincluding the baseline covariates confirmed training effects withinthe occipito-temporal cortex [condition test time group: F(2,10) = 6.12, P = 0.018, p

2 = 0.55] (Fig. S5) as well as theregional training effect in the left R4 [F(2,12) =, P= 0.028, p

2 =0.45; right:P> 0.5]. The training effect mainly reflects the growingresponse to W stimuli during GG and not during NC training,consistent with post hoc t tests showing that changes in print

sensitivity occurred predominantly when children played with GG(Fig. 3 and Fig. S4).

ERPs. Amplitude analyses. Our method for analyzing the N1 fortraining-related increases of print-sensitive activity was similar to

Fig. 2. Emerging print sensitivity seen as differential fMRI activation to

words and false fonts and projected onto a pediatric brain template ( Left)

and on three sections (k 0) of the mean structural image of the group

(Right). (A) fMRI activation to words (orange) and false fonts (blue) for the

whole fMRI sample (n = 16) before (Pre) and after (Post) GG training ( Upper

two rows) or NC training (Lower two rows). For both conditions, Pre- and

Post-training activity was predominantly bilateral occipito-temporal. Note

that no difference was detected for words vs. false font stimuli between Pre-

GG and Pre-NC, but slight group differences in the right inferior occipital

gyrus were found between the fMRI subgroups at T1 ( Fig. S3). (B) Interaction

(two-factorial ANOVA) of training (GG, NC) and time (Pre, Post) revealed

areas with more pronounced activity for the wordfalse font contrast after

GG but not after NC training (green). On the lateral views (Left), Post vs. Pre

GG training of W-FF is superimposed in yellow.

Table 2. Training effects on brain activity (activity greater for

the contrast W-FF after than before training)

Training Brain area

MNI coordinate

Z kx y z

GG L FFG* 45 78 12 4.68 26

L Cuneus 21 90 30 3.93 29

R ITG, FFG 57 69 3 3.88 29

R Cuneus 3 90 33 3.73 52

NC No significant voxel at P< 0.001, k 15

GG > NC L FFG* 45 75 15 4.73 19

Cuneus 6 93 30 4.14 34

R ITG, FFG 57 72 3 4.08 33

NC > GG No significant voxel at P< 0.001, k 15

Listed are MNI coordinates (x, y, z) of cluster maxima for P< 0.001, k 15

(uncorrected). FF, false fonts; FFG, fusiform gyrus, ITG, inferior temporal

gyrus; L, left; R, right, W, words.

*Maxima of clusters survive family-wise error correction at P< 0.05.

Fig. 3. ROI analyses along the occipito-temporal cortex. Mean percent

signal change (error bars, 1 SEM) for the GG-first (Upper) and NC-first

(Lower) groups in five consecutive spherical ROIs plotted at each test time

for the left hemisphere (Fig. S4). The location of the five ROIs is illustrated on

the axial slice at the left. Significant training effects (*) were detected in R4.

Brem et al. PNAS | April 27, 2010 | vol. 107 | no. 17 | 7941

NEUROSCIENCE
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our analysis of fMRI ROI data. Mean ERP amplitudes in leftoccipito-temporal (LOT) and right occipito-temporal (ROT)electrode clusters were compared over an interval of 195289 msfollowing W and FF stimuli. No group difference in print sensitivityoccurred at T1 (LOTP> 0.8, ROTP= 0.095). The MANOVA forN1 amplitudes with factors group, test time, condition, and hemi-sphere pointed to significant differences in condition [F(1,30) =

22.39, P

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