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Contents lists available at ScienceDirect
Journal of Fluency Disorders
Review
Anxiety of children and adolescents who stutter: A review Kylie A. Smith a,b,∗ , Lisa Iverach c , Susan O’Brian d , Elaina Kefalianos a,e , Sheena Reilly a,b a b c d e
Murdoch Childrens Research Institute, Royal Childrens Research Institute, Flemington Road, Parkville, Victoria 3052, Australia Department of Paediatrics, University of Melbourne, Victoria 3010, Australia Centre for Emotional Health, Department of Psychology, Macquarie University, Balaclava Road, North Ryde, NSW 2109, Australia Australian Stuttering Research Centre, University of Sydney, PO Box 170, Lidcombe, NSW 1825, Australia Department of Audiology and Speech Pathology, University of Melbourne, Victoria 3010, Australia
a r t i c l e
i n f o
Article history: Received 20 December 2013 Received in revised form 22 January 2014 Accepted 30 January 2014 Available online xxx
Keywords: Stuttering Children Adolescents Social anxiety disorder
a b s t r a c t Purpose: Adults who stutter have heightened rates of anxiety disorders, particularly social anxiety disorder, compared with non-stuttering controls. However, the timing of anxiety onset and its development in relation to stuttering is poorly understood. Identifying the typical age of anxiety onset in stuttering has significant clinical implications and is crucial for the management of both disorders across the lifespan. The present review aims to determine the scope of the research pertaining to this topic, identify trends in findings, and delineate timing of anxiety onset in stuttering. Methods: We examine putative risk factors of anxiety present for children and adolescents who stutter, and provide a review of the research evidence relating to anxiety for this population. Results: Young people who stutter can experience negative social consequences and negative attitudes towards communication, which is hypothesised to place them at increased risk of developing anxiety. The prevalence of anxiety of young people who stutter, and the timing of anxiety onset in stuttering could not be determined. This was due to methodological limitations in the reviewed research such as small participant numbers, and the use of measures that lack sensitivity to identify anxiety in the targeted population. Conclusions: In sum, the evidence suggests that anxiety in stuttering might increase over time until it exceeds normal limits in adolescence and adulthood. The clinical implications of these findings, and recommendations for future research, are discussed. Educational Objectives: The reader will be able to: (a) discuss contemporary thinking on the role of anxiety in stuttering and reasons for this view; (b) describe risk factors for the development of anxiety in stuttering, experienced by children and adolescents who stutter (c) outline trends in current research on anxiety and children and adolescents with stuttering; and (d) summarise rationales behind recommendations for future research in this area. © 2014 Elsevier Inc. All rights reserved.
Contents 1.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1. Social anxiety disorder and stuttering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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∗ Corresponding author at: Murdoch Childrens Research Institute, Royal Children’s Hospital, Level 5, Flemington Road, Parkville 3052, Victoria, Australia. Tel.: +61 03 8341 6324. E-mail address:
[email protected] (K.A. Smith). 0094-730X/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jfludis.2014.01.003
Please cite this article in press as: Smith, K. A., et al. Anxiety of children and adolescents who stutter: A review. Journal of Fluency Disorders (2014), http://dx.doi.org/10.1016/j.jfludis.2014.01.003
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2.
3.
4. 5.
1.2. The present review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Risk factors for the development of anxiety, and stuttering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Familial influences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Temperament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Cognitive factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Environmental factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Review of the research evidence: anxiety in children and adolescents with stuttering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Summary of peer reviewed publications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Methodological limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.1. Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.2. Anxiety measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1. Recommendations for future research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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1. Introduction Anxiety is a response to perceived danger, encompassing behavioural, physiological and cognitive components. The behavioural component typically involves avoidance of anxiety provoking situations; the physiological component can include physical reactions such as increased heart rate, and sweating; and the cognitive component is associated with adverse thoughts and beliefs, and an expectation of harm (Craske et al., 2009; Kraaimaat, Vanryckeghem, & Dam-Baggen, 2002). As such, anxiety is regarded as a multidimensional construct (Iverach, Menzies, O’Brian, Packman, & Onslow, 2011). Anxiety is believed to have trait and state components. Trait anxiety is stable across different situations, whereas state anxiety is transitory and only experienced in specific situations (Endler & Parker, 1990). Heightened anxiety can be adaptive when it facilitates survival, (for example, when adrenalin assists with running from danger), or improves performance (for example, when increased attention helps in an exam) (Beesdo-Baum & Knappe, 2012). However, when anxiety becomes persistent and excessive, and interferes significantly with life functioning, it may be classified as a diagnosable mental disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM5; American Psychiatric Association, 2013). Anxiety disorders have an estimated prevalence rate of 10% in the general community (Rapee, 2002), with a median age of onset of 11 years (Kessler et al., 2005). A variety of factors can precipitate their development, including genetics, family and environmental influences, and temperament and cognitive styles (Beesdo-Baum & Knappe, 2012; Iverach & Rapee, 2013; Rapee, Schniering, & Hudson, 2009). Anxiety disorders are associated with a range of negative outcomes, including reduced self-esteem and quality of life, and increased risk of comorbid disorders such as depression and substance abuse (Barrera & Norton, 2009; Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Kertz & Woodruff-Borden, 2011; Massion, Warshaw, & Keller, 1993; Stevanovic, 2013; Wolitzky-Taylor, Bobova, Zinbarg, Mineka, & Craske, 2012). They also pose substantial economic burden on the wider community due to reduced labour force participation, dependence on government assistance, and high medical resource use (Hoffman, Dukes, & Wittchen, 2008; Roy-Byrne & Wagner, 2004; Waghorn & Chant, 2005). 1.1. Social anxiety disorder and stuttering Of particular relevance to the stuttering population is social anxiety disorder (also known as social phobia). Social anxiety disorder is a type of anxiety disorder characterised by a significant and persistent fear of humiliation and negative evaluation in social or performance-based situations (DSM-5; American Psychiatric Association, 2013; Iverach & Rapee, 2013). As discussed in relation to anxiety disorders in general, there are multiple pathways to acquisition of social anxiety disorder (Iverach & Rapee, 2013). In the general population, social anxiety disorder typically starts in early adolescence (Beesdo et al., 2007; Lieb et al., 2000), with a median age on onset of 13 years (Kessler et al., 2005). While there is an 8–13% prevalence of social anxiety disorder (Iverach & Rapee, 2013; Kessler et al., 2005), research shows greatly inflated rates in clinical samples of stuttering adults with findings ranging from 21 to 60% (Blumgart, Tran, & Craig, 2010; Iverach, O’Brian, et al., 2009; Menzies et al., 2008; Stein, Baird, & Walker, 1996). Effective verbal communication is integral to our ability to learn and develop, establish relationships, and maintain a sense of well-being (Iverach, O’Brian, et al., 2009). Stuttering disrupts the communication process, resulting in unpredictable, impeded, and sometimes visually disfiguring speech (Menzies et al., 2008). This in turn can evoke a variety of physiological, behavioural, cognitive, and emotional reactions in the speaker (Beilby & Yaruss, 2012). When considered in this context, it seems intuitive that stuttering is associated with anxiety affecting the social domain. While contemporary thinking favours anxiety as a consequence and mediator of stuttering rather than a cause (Craig, 2000; Craig & Tran, 2006), the underlying mechanisms linking stuttering and anxiety remain unclear (Attanasio, 2000). Please cite this article in press as: Smith, K. A., et al. Anxiety of children and adolescents who stutter: A review. Journal of Fluency Disorders (2014), http://dx.doi.org/10.1016/j.jfludis.2014.01.003
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Despite the evidence of social anxiety disorder in stuttering adults we still know very little about anxiety in children and adolescents who stutter, and its development across their lifespan. 1.2. The present review While the timing of anxiety onset for people who stutter is unknown, many adult internalising disorders (difficulties characterised by personal emotional distress, including anxiety) have their roots in childhood (Bayer et al., 2011). Understanding the status of anxiety in young stuttering people is therefore an essential starting point. This review identifies the known risk factors for anxiety in stuttering children and adolescents, and appraises the research evidence related to anxiety in this population. The aims were to: (1) ascertain the extent of peer-reviewed publications on the topic; (2) identify trends in the findings and; (3) determine if children and adolescents who stutter have increased levels of anxiety and if so, delineate the timing of anxiety onset in stuttering. The clinical implications of findings, along with recommendations for future research are discussed. This review used thesaurus terms (known as mesh headings) from the Medline database, and classified preschool children (or preschoolers) as 2–5 years of age, children as 6–12 years of age, and adolescents as 13–18 years of age. Criteria for inclusion in the present review included scientific peer-reviewed publications directly investigating anxiety in preschoolers, children and adolescents who stutter. Research evidence was excluded if adolescents were included in an adult sample and results did not provide a breakdown of outcomes specifically obtained by adolescents, or if post treatment anxiety levels were reported but not pre-treatment baseline levels. Combinations of the following search terms were used in Medline, CINAHL and psycINFO databases: stutter, stammer, dysfluency, anxiety, preschool, child, adolescent. Relevant references cited in identified selected publications were also evaluated for inclusion. 2. Risk factors for the development of anxiety, and stuttering There are a number of risk factors associated with the development of anxiety. These include familial influences (Bayer, Sanson, & Hemphill, 2009; Hettema, Neale, & Kendler, 2001; Lieb et al., 2000), temperament (Bayer et al., 2011; Clauss & Blackford, 2012; Prior, Smart, Sanson, & Oberklaid, 2000; Rapee, 2002), cognitive factors (Rapee & Heimberg, 1997; Rapee et al., 2009), and environmental factors (Allen, Rapee, & Sandberg, 2008; Bayer et al., 2009; Lieb et al., 2000). The following discussion pertains to the research evidence for each of these risk factors, in relation to stuttering. 2.1. Familial influences Anxiety disorders can aggregate in families (Beesdo-Baum & Knappe, 2012; Hettema et al., 2001; Knappe, Beesdo-Baum, & Wittchen, 2010; Lieb et al., 2000). This may be due to genetic predispositions (Hartley & Casey, 2013), maternal mental health (O’Connor, Heron, & Glover, 2002; O’Connor, Heron, Golding, & Glover, 2003), over protective, over-controlling, negative parenting styles (Bayer et al., 2009; Knappe et al., 2010; Rapee & Heimberg, 1997), or an interaction between various factors (Beesdo-Baum & Knappe, 2012). Studies have investigated maternal mental health as a predictor of stuttering onset, and found no difference between mothers of stuttering children and mothers of non-stuttering controls (Andrews & Harris, 1964; Reilly et al., 2009). For example, Reilly et al. (2009) assessed a range of predictors hypothesised to be associated with stuttering onset, including maternal mental health, in a large community cohort, prior to the onset of stuttering. Results were similar across mothers whose children went on to experience stuttering onset and those who did not. Similarly, also using a large community cohort, Andrews and Harris (1964) found no evidence that mothers of children with stuttering differed from mothers of non-stuttering children with respect to the presence of neurotic symptoms, anxiety or, their psychiatric histories. In regards to parenting, to the best of our knowledge only one small study has investigated parenting styles of children with stuttering. Lau, Beilby, Byrnes, and Hennessey (2012), assessed parenting styles, and attachment of twenty school aged children with stuttering, and age-matched fluent controls. Results showed that there were no differences in parenting styles between the two groups. Stuttering children did perceive their parents with significantly lower attachment than non-stuttering controls, however, qualitative accounts revealed this appeared to be specifically related to their mothers management of their fluency, and not their overall parenting (Lau et al., 2012). In summary, based on the limited research available, considering there is no evidence for increased maternal psychopathy, or differing parenting styles, between stuttering and non-stuttering children; one may be tentatively optimistic that stuttering children are not at an increased of familial risk factors for anxiety. 2.2. Temperament Temperament is conceptualised as the way in which a person reacts to and interacts with their environment (Kefalianos, Onslow, Block, Menzies, & Reilly, 2012), and consists of multiple dimensions which vary slightly between different theoretical models (Prior, 1992). One dimension of temperament, termed ‘approach’ – which measures traits such as shyness, withdrawal, and inhibition – has been implicated as a precursor to the development of anxiety (Rapee, 2002). A recent prospective longitudinal study examined the predictors of stuttering in a large community cohort of 1619 Australian preschool children Please cite this article in press as: Smith, K. A., et al. Anxiety of children and adolescents who stutter: A review. Journal of Fluency Disorders (2014), http://dx.doi.org/10.1016/j.jfludis.2014.01.003
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(Reilly et al., 2009). The ‘approach’ dimension of temperament was measured in all children at 2 years of age, and results showed no significant difference in this dimension between children who subsequently started to stutter and those who did not. That is, the temperament traits associated with the development of anxiety was not exhibited at heightened levels in stuttering preschoolers in this cohort (Reilly et al., 2009). This research provides compelling evidence that anxiety experienced by people who stutter emerges as a consequence of stuttering. 2.3. Cognitive factors Interpretation and attentional biases have been implicated in the development of social anxiety disorder, and are central to its maintenance in adults (Rapee & Heimberg, 1997; Rapee et al., 2009). Interpretation bias occurs when an individual interprets ambiguous social situations as threatening, or mildly negative situations as catastrophic, while attentional bias is when attention is drawn towards negative social cues and away from positive social cues (Iverach & Rapee, 2013; Lowe et al., 2012; Stopa & Clark, 2000). There is evidence of attentional bias in stuttering adults. In a study by Lowe et al. (2012), the eye gaze of stuttering adults and non-stuttering controls was measured as they gave a speech to a pre-recorded audience. Results showed that stuttering adults looked less at audience members who displayed positive expressions, relative to negative and neutral expressions, compared with non-stuttering controls. To the best of our knowledge, no studies have investigated interpretation or attentional bias in stuttering children. Research has, however, shown that some children with stuttering have a negative attitude towards communication, which may be indicative of interpretation or attentional bias. A negative attitude towards communication involves perceiving oneself as an incompetent communicator, finding communication difficult, and feeling apprehensive about talking (Blood, Blood, Tellis, & Gabel, 2001; Mulcahy, Hennessey, Beilby, & Byrnes, 2008). Research evidence shows preschoolers, children, and adolescents who stutter have more negative attitudes towards communication than non-stuttering controls (Beilby & Yaruss, 2012; Blood & Blood, 2004; Erikson & Block, 2013; Vanryckeghem, Brutten, & Hernandez, 2005; Vanryckeghem, Hylebos, Brutten, & Peleman, 2001). For example, children as young as three years of age, through to stuttering adolescents 14 years of age have demonstrated a significantly more negative overall attitude towards their speech, compared with non-stuttering controls (De Nil & Brutten, 1991; Vanryckeghem et al., 2005). Further, stuttering adolescents score higher than non-stuttering controls on measures of perceived difficulty with communication (Beilby & Yaruss, 2012; Gunn et al., 2013; Mulcahy et al., 2008) and self-perceived communication competence (Blood & Blood, 2004; Blood et al., 2001; Erikson & Block, 2013). Studies also show that for young people who stutter, communication attitude becomes increasingly negative over time, while improving for non-stuttering controls (De Nil & Brutten, 1991; Vanryckeghem & Brutten, 1997). The increased risk of developing a negative attitude to communication faced by stuttering young people may be due to exposure to unfavourable stereotyping, and negative social consequences (see Section 2.4) (Blood et al., 2001). Considering the association between negative attitude towards communication, and interpretational and attentional bias, and anxiety, these findings may provide insight into the development of anxiety for people who stutter. That is, anxiety in stuttering may emerge at an early age and increase over time. 2.4. Environmental factors A range of adverse environmental factors have been identified as possible risk factors for the development of anxiety in the general community, including stressful life events, and childhood adversity (Beesdo-Baum & Knappe, 2012; Broeren, Newall, Dodd, Locker, & Hudson, 2014). With regards to stuttering, environmental factors may include negative social consequences, and bullying experienced as a result of this disorder (Rigby, 2003; Storch, Brassard, & Masia-Warner, 2003). These negative consequences may manifest in the preschool years, intensify over time, and impact on social functioning in a myriad of ways (Beilby & Yaruss, 2012). Children as young as four years of age have been found to negatively evaluate stuttering and to show a preference for non-stuttering friends (Ezrati-Vinacour, Platzky, & Yairi, 2001). Further, non-stuttering preschool children have been observed to interrupt, mock, walk away from, and ignore stuttering peers (Langevin, Kleitman, Packman, & Onslow, 2009). The demands for effective verbal communication increase as children start school and are required to interact with different people, in a variety of settings. Teachers and special educators may engage in negative stereotyping and perceive stuttering children as shy, nervous, and insecure (Lass et al., 1992; Ruscello, Lass, Schmitt, & Pannbacker, 1994). School-age children who stutter may also be perceived as less popular by their non-stuttering peers, find it difficult to fit in, and be more likely to be considered “victims of bullying” compared with non-stuttering peers (Davis, Howell, & Cooke, 2002; Evans, Healey, Kawai, & Rowland, 2008). Studies investigating the prevalence of bullying in stuttering adolescents compared with non-stuttering controls showed stuttering adolescents are at significantly higher risk of being bullied. Bullying rates range from 43 to 61% in stuttering adolescents, compared with 9 to 22% for non-stuttering controls (Blood & Blood, 2004, 2007; Blood et al., 2011). Stuttering can also impact on the romantic opportunities and social development of adolescents. Van Borsel, Brepoels, and De Coene (2011) investigated the perceptions of non-stuttering adolescents and adults’ towards their stuttering peers. Findings showed that some of the non-stuttering group considered those who stutter less attractive than non-stuttering peers, and if given the option, would prefer to be in a romantic relationship with someone who does not stutter (Van Borsel et al., 2011). Please cite this article in press as: Smith, K. A., et al. Anxiety of children and adolescents who stutter: A review. Journal of Fluency Disorders (2014), http://dx.doi.org/10.1016/j.jfludis.2014.01.003
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The impact of these negative social consequences of stuttering may be particularly potent during adolescence. Considerable physical, neurological, and social change occurs during this period (Hearne, Packman, Onslow, & Quine, 2008; Sawyer et al., 2012), and there is an increase in the emergence and diagnosis of anxiety in the general population during this time (Beesdo et al., 2007; Crockett, Carlo, Wolff, & Hope, 2013; Rapee et al., 2009). As such, adolescence may be a crucial period for research to examine in those who stutter. 3. Review of the research evidence: anxiety in children and adolescents with stuttering As outlined in Table 1, thirteen peer reviewed publications met criteria for inclusion in the present review. 3.1. Summary of peer reviewed publications Of the thirteen publications listed in Table 1, only one investigated anxiety in stuttering preschoolers. van der Merwe, Robb, Lewis, and Ormond (2011) measured salivary cortisol levels in seven preschoolers (3;3–4;11 years) and seven agematched, non-stuttering controls. Cortisol is a steroid stress hormone and is the most commonly measured stress biomarker for investigating anxiety; heightened cortisol levels indicates increased anxiety (van der Merwe et al., 2011). Participants also completed the parent-report Preschool Anxiety Scale (PAS; Edwards, Rapee, Kennedy, & Spence, 2010) and the Communication Attitude Test for Preschool and Kindergarten Children Who Stutter (KiddyCAT; Vanryckeghem & Brutten, 2002). No significant differences were found in cortisol levels or outcomes of the KiddyCAT or PAS between stuttering preschoolers and non-stuttering controls. Ortega and Ambrose (2011) also measured salivary cortisol levels in a sample of nine children who stutter (6–11 years). They found cortisol levels for the stuttering children to be in the low average range, according to normative data. Caution must be taken when interpreting results based on measurement of cortisol in children. While salivary cortisol is arguably an objective measure of anxiety, there are many factors that may influence accurate measurement and evaluation in children, such as gender, age, and body mass index (Jessop & Turner-Cobb, 2008). In a review of the literature on the measurement and interpretation of cortisol levels in children, Jessop and Turner-Cobb (2008) highlighted the inconsistent and conflicting nature of findings. Further, they recommended that future studies be designed to control for these potentially confounding variables. Neither van der Merwe et al. (2011) nor Ortega and Ambrose (2011) reported doing so in their respective studies. Andrews and Harris (1964) also published a study utilising a similar aged cohort to Ortega and Ambrose (2011). These investigators explored differences between a community sample of 80 stuttering children (9–11 years) and 80 age matched, non-stuttering controls on a range of psychological and psychometric variables. All participants completed a psychiatric interview, including the General Anxiety Scale for Children. Results showed no significant difference between the two groups. Five studies identified in the present review (Craig & Hancock, 1996; Craig et al., 1996; Davis, Shisca, & Howell, 2007; Hancock et al., 1998; Mulcahy et al., 2008) utilised the State-Trait Anxiety Inventory for Children (STAIC; Spielberger, 2010), or its adult counterpart, the State Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). The STAIC was designed for children aged 9–12 years, but can be used with younger children or adolescents, and the STAI was designed specifically for adolescents and adults. Both versions consist of a state and trait anxiety questionnaire. The state questionnaire requires participants to rate how they feel at a particular moment in time, while the trait questionnaire requires them to rate how they generally feel. Studies utilising the STAIC/STAI are reviewed below. Craig and Hancock (1996) administered the STAIC to a clinical sample of 96 stuttering children and adolescents aged 9–14 years. Trait anxiety for the stuttering group was compared with 104 non-stuttering age-matched controls, and state anxiety was compared with normative data. Stuttering children and adolescents were found to be no more anxious than non-stuttering controls, and state anxiety levels were well within norms established for the STAIC (Craig & Hancock, 1996). A separate report by the same authors (Craig et al., 1996) further examined the STAIC scores of the stuttering subgroup (97 stuttering children and adolescents) by comparing measures taken pre- and post-stuttering treatment. Investigators reported that anxiety had further reduced up to one year after treatment. Hancock et al. (1998) followed up the Craig et al. (1996) cohort 2–6 years later, again with the STAIC, to investigate long-term outcomes of stuttering treatment. Results showed a trend for children and adolescents who stutter to become less anxious over time, however most of the participants were either no longer stuttering or had very mild stuttering. These findings were consistent with studies showing a reduction in anxiety of stuttering adults following stuttering treatment (Blood, 1995). Davis et al. (2007) used the STAIC with a similar aged cohort (10–16 years) but reported varied results. In particular, they compared outcomes on the STAIC for 18 young people who stuttered, 17 recovered people who had stuttered, and 19 non-stuttering controls. No significant differences in trait anxiety were found between the three groups. State anxiety was assessed in four situations: (1) asking for something in a shop, (2) talking to a friend on the phone, (3) talking with a group of friends, and (4) answering a question in front of the whole class. The persistent stuttering group had higher state anxiety than the recovered and control groups during all situations except talking with a group of friends. Davis et al. (2007) concluded that stuttering is associated with increased anxiety levels in certain communication situations. Finally, Mulcahy et al. (2008) investigated social anxiety in stuttering adolescents but reported contradictory results compared with the four previously mentioned studies that utilised the STAIC. The investigators administered the STAI, Fear of Negative Evaluation scale (FNE; Watson & Friend, 1969), and the Overall assessment of Speakers Experience of Stuttering Please cite this article in press as: Smith, K. A., et al. Anxiety of children and adolescents who stutter: A review. Journal of Fluency Disorders (2014), http://dx.doi.org/10.1016/j.jfludis.2014.01.003
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6 Table 1 Summary of research studies reviewed. Study
Age range
n
Anxiety measure(s)
Findings
Andrews, G., & Harris, M. (1964). The syndrome of stuttering.
9–11 years
80
General Anxiety Scale for Children
Blood, G., & Blood, I. (2007). Preliminary study of self-reported experience of physical aggression and bullying of boys who stutter: Relation to increased anxiety. Blood, G., Blood, I., Maloney, K., Meyer, C., & Qualls, C. (2007). Anxiety levels in adolescents who stutter. Blood, G., Blood, I., Tellis, G., & Gabel, R. (2001). Communication apprehension and self-perceived communication competence in adolescents who stutter. Craig, A., & Hancock, K. (1996). Anxiety in children and young adolescents who stutter.
11–12 years
18
RCMAS
Null; no differences in anxiety compared with age-matched, non-stuttering controls. Stuttering young people had significantly higher anxiety than age-matched, non-stuttering controls.
12 years 8 months–18 years 7 months
36
RCMAS
13–18 years
39
PRCA
9–14 years
96
STAIC
9–14 years
97
STAIC
10 years–16 years 7 months
17
STAIC
11–18 years
36
PRCA
12–17 years
37
RCMAS, FNE, Computerised Voice Version of the Diagnostic Interview Schedule for Children,
Stuttering adolescents received at least one diagnosis of a mental disorder, with the majority of these diagnoses involving anxiety.
11–18 years
62
STAIC
Null; trend for recovered stutterers or those with very low stuttering to have reduced anxiety over time according to normative data.
11–18 years
19
STAI, FNE
Stuttering young people had significantly higher anxiety than age-matched, non-stuttering controls.
Craig, A., Hancock, K., Chang, E., McCready, C., Shepley, A., McCaul, A., Costello, D., Harding, S., Kehren, R., Masel, C., et al. (1996). A controlled clinical trial for stuttering in persons aged 9–14 years. Davis, S., Shisca, D., & Howell, P. (2007). Anxiety in speakers who persist and recover from stuttering. Erikson, S., & Block, S. (in press). The social and communication impact of stuttering on adolescents and their families. Gunn, A., Menzies, R. G., O’Brian, S., Onslow, M., Packman, A., Lowe, R., Block, S. (2013). Axis I anxiety and mental health disorders among stuttering adolescents. Hancock, K., Craig, A., McCready, C., McCaul, A., Costello, D., Campbell, K., & Gilmore, G. (1998). Two- to six-year controlled-trial stuttering outcomes for children and adolescents. Mulcahy, K., Hennessey, N., Beilby, J., & Byrnes, M. (2008). Social anxiety and the severity and typography of stuttering in adolescents. Ortega, A. Y., & Ambrose, N.G. (2011). Developing physiologic stress profiles for school-age children who stutter. van der Merwe, B., Robb, M. P., Lewis, J. G., & Ormond, T. (2011). Anxiety measures and salivary cortisol responses in preschool children who stutter.
Stuttering young people presented with anxiety within normal limits but higher than age-matched, non-stuttering controls. Stuttering young people had significantly higher levels of communication apprehension (anxiety) than age-matched, non-stuttering controls. Null; no differences in anxiety compared with age-matched, non-stuttering controls and anxiety levels in the average range according to normative data. Null; stuttering young people presented with anxiety levels in the average range according to normative data.
Stuttering young people had increased state anxiety compared with age-matched recovered stutterers, and age-matched, non-stuttering controls. The majority of stuttering adolescents reported high levels of communication apprehension.
6–11 years
9
Salivary cortisol measures
Null; no differences in cortisol levels between stuttering children and normative data.
3 years 3 months–4 years 11 months
7
Salivary cortisol measures, PAS
Null; no significant differences in anxiety between stuttering preschoolers and age-matched, non-stuttering controls.
FNE: Fear of Negative Evaluation Scale (Watson & Friend, 1969); PAS: Preschool Anxiety Scale (Edwards et al., 2010); PRCA: Personal Report of Communication Apprehension; RCMAS: Revised Children’s Manifest Anxiety Scale (Reynolds & Richmond, 2008); STAI: State-Trait Anxiety Inventory (Spielberger et al., 1983); STAI-C: State-Trait Anxiety Inventory (Spielberger, 2010).
Please cite this article in press as: Smith, K. A., et al. Anxiety of children and adolescents who stutter: A review. Journal of Fluency Disorders (2014), http://dx.doi.org/10.1016/j.jfludis.2014.01.003
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- Teen Version (OASES-T; Yaruss & Quesal, 2006), to 19 young people who stuttered (11–18 years), and 18 age-matched, non-stuttering controls. The FNE and OASES-T were used to evaluate social anxiety and attitude towards communication respectively. Results of the assessments showed the stuttering group had significantly higher state, trait, and social anxiety when compared with non-stuttering controls. In addition, anxiety correlated with self-reported difficulty with functional communication amongst the stuttering adolescents but not with the non-stuttering controls (Mulcahy et al., 2008). The Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 2008) is another well-researched measure of anxiety. It is a multidimensional measure designed for use with children and adolescents aged 6–19 years. It consists of 37 questions, 28 of these measuring persistent characteristics of trait anxiety based on three subscales (physiological, worry/oversensitivity, fear/concentration). Individual scores are generated for each of the three subscales and a Total Anxiety score is computed based on the entire 28 items. The remaining nine items of the RCMAS constitute a ‘Lie scale’ to identify careless responses or bias towards social desirability. Using the RCMAS, Blood and Blood (2007) investigated anxiety in a cohort of 18 stuttering males aged 11–12 years and 18 age-matched, non-stuttering controls. Investigators also administered the My Life in School checklist (Arora & Thompson, 1987) to evaluate the presence of bullying. A significant discrepancy was found between the groups, with 28% of stuttering children receiving significantly higher anxiety scores (more than one standard deviation above the mean), compared with only 6% of non-stuttering controls. Children with heightened anxiety from both groups were more likely to report experiences of bullying than those with anxiety in the average range. Although stuttering is more prevalent among males than females, a significant limitation of this study pertains to the inclusion of male participants only. In the general community, anxiety disorders are consistently found to be more common among females (Costello et al., 2003), which suggests that the inclusion of females who stutter in this study may have revealed more marked differences between groups. Blood, Blood, Maloney, Meyer, and Qualls (2007) also utilised the RCMAS with an older cohort of 36 stuttering adolescents (12–18 years) and 36 age-matched, non-stuttering controls. The Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965) was also administered to these participants in order to investigate the relationship between anxiety and self-esteem. While 83% of adolescents with stuttering and 97% of non-stuttering controls presented with anxiety levels within the average range on the RCMAS, the anxiety scores from the stuttering group were still significantly higher than those from the control group. There was also a positive relationship between high anxiety and poor self-esteem for both the stuttering and control group. Gunn et al. (2013) investigated anxiety in 37 stuttering adolescents (12–17 years) using a battery of assessments including the revised version of the RCMAS, (RCMAS-2; Reynolds & Richmond, 2008), the Computerised Voice Version of the Diagnostic Interview Schedule for Children (Shaffer, Lucas, & Fisher, 2010), the Children’s Depression Inventory (Kovacs, 1992), the Youth Self Report and the Child Behaviour Checklist (Achenbach & Rescorla, 2001), and the OASES-S for ages 7–12 and OASES-T for ages 13 and over (Yaruss & Quesal, 2010). Thirty eight percent of participants received at least one diagnosis of a DSM-IV mental disorder, with most of these diagnoses involving anxiety. Comparisons were also made between younger adolescents (12–14 years) and older adolescents (15–17 years), with older adolescents reporting significantly higher anxiety, depression, reactions to stuttering, and emotional/behavioural problems. Scores on the RCMAS-2, Social Anxiety scale suggested that social anxiety was not an issue for either the younger or older age groups. The authors acknowledged that findings might have been conservative because many participants gave socially desirable responses about their mental health status. It must also be noted that only one girl participated in the study. Blood et al. (2001) investigated communication apprehension (anxiety) in 39 stuttering adolescents (13–18 years), and 39 age-matched, non-stuttering controls using the Personal Report of Communication Apprehension (PRCA; McCroskey & Beatty, 1984). This is a standardised measure of anxiety associated with oral language, and provides communication apprehension scores on four subscales, including Discussion groups, Meetings, Interpersonal conversations, and Public speaking (McCroskey & Beatty, 1984). Results revealed stuttering adolescents had substantially higher scores on the Meetings, and Groups Discussions subscales compared with non-stuttering controls. Further, nearly three times as many stuttering adolescents reported high communication apprehension on the Interpersonal Conversations subscales (Blood et al., 2001). Also using the PRCA with a group of 36 stuttering adolescents (aged 11–18 years), Erikson and Block (2013) found that 64% of participants reported high levels of communication apprehension on the ‘Meeting’ subscale and 81% recorded high levels of communication apprehension on the ‘Public speaking’ subscale. Given that the PRCA has been found to correlate significantly with state anxiety (McCroskey & Beatty, 1984), these findings suggest the presence of heightened speech-related anxiety in adolescents who stutter. Individually, the reviewed studies contribute knowledge to the literature regarding potential psychological issues facing young people who stutter. However, in sum, these findings are inconsistent and inconclusive. This may be due, at least in part, to a number of methodological limitations evident in the reviewed publications. 3.2. Methodological limitations Methodological limitations identified in the reviewed publications pertain to participants and anxiety measures utilised. 3.2.1. Participants In the present review, a number of the research studies had limitations relating to participants. These included utilising samples that: lacked statistical power, consisted of participants in treatment or seeking treatment only and, had participants spanning wide age bands. Please cite this article in press as: Smith, K. A., et al. Anxiety of children and adolescents who stutter: A review. Journal of Fluency Disorders (2014), http://dx.doi.org/10.1016/j.jfludis.2014.01.003
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Insufficient statistical power due to small sample sizes has been raised as a common limitation of research investigating anxiety in stuttering adults (Craig & Tran, 2006; Iverach et al., 2011; Menzies, Onslow, & Packman, 1999). The larger the sample size, the greater the power to detect a difference; smaller sample sizes have less power to detect the same difference (Jones, Gebski, Onslow, & Packman, 2002). Therefore, if the sample size is too small, the failure to find a significant difference in anxiety levels between stuttering and non-stuttering participants may simply be a reflection of insufficient statistical power (Jones et al., 2002; Menzies et al., 1999). Five of the thirteen reviewed studies (Blood & Blood, 2007; Davis et al., 2007; Mulcahy et al., 2008; Ortega & Ambrose, 2011; van der Merwe et al., 2011) had small or very small sample sizes (less than 20 participants). Despite these small sample sizes, three of these studies reported significantly increased anxiety in stuttering participants (Blood & Blood, 2007; Davis et al., 2007; Mulcahy et al., 2008). The two additional studies that did not report significantly heightened anxiety were among those utilising the youngest participants (Ortega & Ambrose, 2011; van der Merwe et al., 2011). Whether the latter findings are due to the true absence of anxiety in preschool and young school-aged children who stutter, or failure to detect a difference due to insufficient statistical power, is unknown. With the exception of Andrews and Harris (1964), all studies included in the present review were based on clinical samples of children or young people who were either waiting for, or actively involved in stuttering treatment. Clinical cohorts represent a subset of the population of people who stutter, and further research is required to determine whether differences in anxiety exist between samples of treated and untreated young people who stutter (Craig, Hancock, Tran, & Craig, 2003; Craig & Tran, 2006; Iverach et al., 2011). Finally, with the exception of Blood and Blood (2007), all studies included participants spanning multiple ages. Childhood and adolescence are periods of significant change, and the inclusion of children of multiple ages may have masked changes or differences occurring at specific ages. 3.2.2. Anxiety measures In addition to limitations related to the choice of participants included in these studies, other methodological limitations pertain to the choice of measures used to evaluate anxiety. The first relates to the measurement of trait anxiety, which encompasses social anxiety, physical anxiety, and novel situation anxiety, all of which may occur independently (Endler & Parker, 1990; Menzies et al., 1999). It is feasible that an individual with stuttering may experience social anxiety as a result of the negative social consequences associated with stuttering, but not physical anxiety or anxiety in novel situations. The STAI and STAIC regard anxiety as a single or global construct and as such, may lack the required sensitivity to detect speech-related anxiety for people who stutter (Blomgren, Roy, Callister, & Merrill, 2005; Endler & Parker, 1990; Ezrati-Vinacour & Levin, 2004; Iverach et al., 2011; Menzies et al., 1999). As discussed earlier, five of the thirteen studies in the present review used the STAI or STAIC with stuttering children and adolescents (Craig & Hancock, 1996; Craig et al., 1996; Davis et al., 2007; Hancock et al., 1998; Mulcahy et al., 2008) and reported conflicting findings. The STAI’s limited ability to measure trait anxiety may have contributed to these discrepancies. Secondly, stuttering adults report increased prevalence of social anxiety disorder. While the median age of onset of social anxiety disorder in the general population is early adolescence, it is unknown if onset may occur earlier in children with stuttering. It is therefore necessary to evaluate features of social anxiety disorder (such as fear of negative evaluation and attentional bias), in young people who stutter, to determine if they also experience similar symptoms. In the reviewed research, Blood and Blood (2007), Blood et al. (2007), Gunn et al. (2013), Mulcahy et al. (2008) used the RCMAS and the FNE, both of which evaluate constructs associated with social anxiety disorder. These four studies used cohorts of older children and adolescents who stuttered (11–18 years) and all reported evidence of anxiety (Blood & Blood, 2007; Blood et al., 2007; Gunn et al., 2013; Mulcahy et al., 2008). Given that measures sensitive to social anxiety disorder were not used in studies with younger children who stutter, comparisons cannot be made between groups. It is therefore unknown whether anxiety in stuttering increases with age, or if positive findings of anxiety in older children who stutter were the product of more sensitive measures being used with this group. Further research including the assessment of social anxiety disorder among children is clearly needed (Iverach & Rapee, 2013). Further, while there is overlap between the presentation of anxiety in adults and children, clear developmental differences exist, and these need to be considered when assessing children (Spence, 1998; Spence, Barrett, & Turner, 2003). Most measures have been developed as ‘downward extensions’ of their adult counterparts, and may include items of lesser relevance to younger populations compared with measures specifically designed for children (Spence et al., 2003). Both the STAI-C and the RCMAS, utilised by three quarters of the reviewed studies, are measures based on an adult version and therefore may lack sensitivity to detect features of anxiety specifically related to children and adolescents. Finally, in the assessment of childhood disorders, multiple informants are recommended to contribute information about different aspects of the child’s emotional functioning (Nauta, Scholing, Rapee, Abbott, Spence, & Waters, 2004). In most of the reviewed studies, it was either the parent or child, not both, who completed anxiety measures. It is feasible that the lack of multiple informants in these studies may have contributed to the under-estimation of anxiety in stuttering children. 4. Clinical implications Increasingly, researchers and clinicians in the field of stuttering are acknowledging the need for assessment and treatment tools that not only address the observable characteristics of stuttering, but also consider the psychological implications of Please cite this article in press as: Smith, K. A., et al. Anxiety of children and adolescents who stutter: A review. Journal of Fluency Disorders (2014), http://dx.doi.org/10.1016/j.jfludis.2014.01.003
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the disorder (Beilby & Yaruss, 2012; Menzies et al., 2008; Menzies, Onslow, Packman, & O’Brian, 2009). In response to the prevalence of social anxiety disorder in clinical samples of stuttering adults, researchers have trialled the efficacy of psychological therapies such as cognitive behaviour therapy (CBT) in this population, and reported encouraging results (Menzies et al., 2008; Stein et al., 1996). However, these treatment strategies focus on anxiety once it is already established. Understanding the timing of anxiety onset could facilitate the development of prevention and early intervention procedures to directly target anxiety associated with stuttering before it emerges or exceeds normal levels. Considering childhood anxiety disorders may predict later anxiety and may be a marker for other mental health problems later in life (Rapee et al., 2009; Spence, 1998), early intervention is critical to prevent or minimise the impact of anxiety in stuttering across the lifespan. Stuttering adults with concomitant speech-related anxiety have poorer outcomes following stuttering treatment in the medium and long term, and are at greater risk of relapse post-treatment compared with those who do not have anxiety (Craig & Hancock, 1995; Iverach, Jones, et al., 2009). In order to maximise stuttering therapy outcomes in young people who stutter, we need to be clear if increased anxiety exists in this population, and if so, what the subsequent impact on treatment outcomes might be. This is particularly relevant for adolescents as this phase may be the last chance to address the development of stuttering before it becomes chronic in adulthood (Hearne et al., 2008). 5. Conclusions The present review explored multiple risk factors for anxiety in relation to stuttering. The research available suggests stuttering children do not have an increased risk of a maternal genetic predisposition to anxiety, nor do they present with a temperament that places them at an increased risk of anxiety, compared with non-stuttering controls. However, there is evidence that stuttering children and adolescents experience negative social consequences and may have a poor attitude towards communication, placing them at risk for anxiety. A comprehensive review of the research revealed the timing of anxiety onset in stuttering, and the status of anxiety in stuttering children and adolescents, is unclear. This was due to a range of methodological limitations that resulted in inconsistent findings. Some studies were based on small, clinical samples of participants with wide age ranges; and some of the anxiety measures utilised lacked the sensitivity required to assess speech-related anxiety, which is particularly pertinent to those who stutter. On balance, when considering the type of the risk factors for anxiety associated with stuttering, and trends across the studies reviewed, it is likely that the risk of anxiety increases as stuttering children approach adolescence and adulthood. This hypothesis is based on the following observations. Firstly, while clinical samples of stuttering adults present with high levels of social anxiety disorder (Blumgart et al., 2010; Iverach, O’Brian, et al., 2009; Menzies et al., 2008; Stein et al., 1996), stuttering preschoolers do not (van der Merwe et al., 2011). This suggests that anxiety in people who stutter manifests sometime in later childhood or adolescence, becoming pervasive in adulthood. Secondly, epidemiological studies investigating maternal mental health of stuttering children and non-stuttering controls, suggest that children with stuttering may be not genetically predisposed to develop anxiety (Andrews & Harris, 1964; Reilly et al., 2009). Further, there are no differences in temperament precursors of anxiety between stuttering and non-stuttering preschoolers (Reilly et al., 2009). Thirdly, stuttering young people may experience various environmental risk factors for the development of anxiety, including exposure to negative social consequences of stuttering. These risk factors may intensify and culminate in adolescence; a period where the prevalence of anxiety and social anxiety disorder increases in the general population. Considering this, adolescence may indeed be a period where anxiety in stuttering populations exceeds normal levels. Finally, more studies report a positive association between anxiety and stuttering in older children and adolescents compared with younger children. For instance, the only study to investigate anxiety of stuttering preschoolers reported a null finding (van der Merwe et al., 2011), whereas six studies of older children and adolescents who stutter (eleven years and over) reported positive findings (Blood & Blood, 2007; Blood et al., 2007, 2001; Davis et al., 2007; Gunn et al., 2013; Mulcahy et al., 2008). It is acknowledged that this hypothesis does not explain the underlying mechanisms between the relationship between stuttering and anxiety, but rather describes the apparent pattern of the emergence of the two disorders in relation to each other. However, until research addresses the methodological limitations identified in the current research, this premise is merely an assumption. 5.1. Recommendations for future research In order to advance our understanding of anxiety of young people who stutter, future research must address the methodological recommendations identified in the present review. In particular, studies require larger sample sizes, with at least 80% power to detect differences between groups (Iverach et al., 2011; Jones et al., 2002; Menzies et al., 1999). Further, samples with smaller age bands will give a clearer indication of specific timing of any changes that occur. In regards to the homogenous nature of samples, it is acknowledged that recruiting participants from the community is time consuming and costly. However, representative samples of young people who stutter are necessary to determine the true prevalence of anxiety associated with stuttering, and not just in a clinical sub-group of this population. To ensure that various facets of speech-related anxiety are not overlooked in young people who stutter, psychological measures need to evaluate anxiety as a multidimensional construct, and account for the presence of social anxiety disorder. Please cite this article in press as: Smith, K. A., et al. Anxiety of children and adolescents who stutter: A review. Journal of Fluency Disorders (2014), http://dx.doi.org/10.1016/j.jfludis.2014.01.003
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While the typical age of onset of social anxiety disorder is eleven years of age, it is unknown if onset may be earlier in children with stuttering. As discussed by Dalrymple and Zimmerman (2011): “Children are presented with social interactions from a very young age. Anxiety in social situations and social withdrawal/avoidance tend to start a cycle, such that less exposure to social interactions at a young age interferes with the normal development of social skills, which then reinforces the anxiety . . .”. (p. 6) This may be particularly so for the children with stuttering. As such, investigating features such as fear of negative evaluation, and interpretational and attentional bias in stuttering children may help determine the beginnings of social phobia in adults who stutter (Iverach et al., 2011; Iverach & Rapee, 2013). Finally, investigators must also employ multiple informants to gather as much information as possible regarding the young person’s psychological functioning, as is routinely the case in child anxiety research (Nauta et al., 2004). A psychological measure such as the Spence Child Anxiety Scale (SCAS; Spence, 1998) accounts for these requirements. The SCAS was developed to assess the severity of anxiety symptoms broadly in line with the dimensions of anxiety disorder proposed by the DSM-IV and is routinely used by psychologists in clinical practise and in research in Australia. There are both parent and child versions of the SCAS. In conclusion, young people who stutter face a significantly increased risk of developing social anxiety disorder in adulthood (Blumgart et al., 2010; Iverach, O’Brian, et al., 2009; Stein, Torgrud, & Walker, 2000). Further research is required to close the gaps and methodological shortcomings in the literature, to facilitate the development of practices aimed at maximising treatment outcomes, and to assist the development of novel programmes targeting anxiety in young people who stutter. Such research has the potential to change the current speech and psychological outcomes for adults who stutter, and may also improve the lives of children and young people who stutter. Acknowledgements Preparation of this paper was supported by various granting bodies including the Victorian’s Governments Operational Infrastructure Support Program, and the Australian Research Council, who provided support for project grants (#1041947 and #DP0984833). Lisa Iverach is supported by a National Health and Medical Research Council of Australia Project Grant (#1052216). Sheena Reilly is supported by a National Health and Medical Research Council Practitioner Fellowship (#1041892). CONTINUING EDUCATION Anxiety of children and adolescents who stutter: A review QUESTIONS
1. Social anxiety disorder is: (a) Experienced by all people who stutter. (b) One of a number of anxiety disorders experienced by stuttering adults. (c) Evident in stuttering children and adolescents. (d) Not associated with stuttering e. found at higher levels in clinical samples of stuttering adults than in non-stuttering controls. 2. Trends in the research on anxiety of stuttering children and adolescents suggest: (a) Stuttering children have high levels of anxiety compared with non-stuttering controls. (b) Stuttering adolescents have high level of anxiety compared with non-stuttering controls. (c) More significant anxiety in adolescents than in children who stutter. (d) Children and adolescents who stutter are not more anxious than non-stuttering controls. (e) Children and adolescents who stutter are more anxious than non-stuttering controls. 3. Studies on the temperament of stuttering preschoolers are relevant to understanding later onset of anxiety because: (a) Preschoolers who present with a high score on the approach dimension of temperament, often go on to develop stuttering. (b) The approach dimension of temperament may be a precursor to the development of anxiety. (c) Preschoolers who present with a low score on the approach dimension of temperament, often go on to develop stuttering. (d) They are not relevant; temperament and anxiety are not related. (e) Temperament and anxiety are just different names for the same construct. 4. The clinical implications of understanding when anxiety develops in those who stutter are: (a) So preventative and early intervention programmes targeting anxiety associated with stuttering can be developed. (b) To prevent stuttering and anxiety. (c) So preventative and early intervention programmes targeting stuttering can be developed. (d) So anxiety in stuttering can be prevented. (e) So children can be prioritised on treatment waiting lists.
Please cite this article in press as: Smith, K. A., et al. Anxiety of children and adolescents who stutter: A review. Journal of Fluency Disorders (2014), http://dx.doi.org/10.1016/j.jfludis.2014.01.003
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5. Using multidimensional measures of anxiety with stuttering children and adolescents is recommended because: (a) It is important to assess for the presence of all anxiety disorders and this can only be done with such measures. (b) These measures assess both state and trait anxiety. (c) These measures help to identify the cause of stuttering. (d) Global measures of anxiety may lack the sensitivity to detect anxiety specifically related to stuttering. (e) These measures help to identify the cause of anxiety. References Achenbach, T. M., & Rescorla, L. A. (2001). Manual for ASEBA school-age forms and profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families. Allen, J. L., Rapee, R. M., & Sandberg, S. (2008). Severe life events and chronic adversities as antecedents to anxiety in children: A matched control study. Journal of Abnormal Child Psychology, 36(7), 1047–1056. American Psychiatric Association. (2013). 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Kylie Smith is currently completing her PhD through the University of Melbourne, investigating anxiety of stuttering children. She also works as a clinical speech pathologist with a particular interest in the mental health issues associated with stuttering. Dr Lisa Iverach is an early career researcher at the Centre for Emotional Health, Macquarie University. She currently holds an Australian Research Fellowship with the National Health and Medical Research Council. Her research interests include the relationship between stuttering and anxiety, and the mental health of people who stutter. Dr Sue O’Brian is a senior researcher at the Australian Stuttering Research Centre. She has extensive experience in the field of stuttering treatment and research. Her current interests include the effectiveness of early stuttering intervention in community settings, development of treatments for adults who stutter and stuttering measurement. Dr Elaina Kefalianos is a postdoctoral researcher at the Murdoch Children’s Research Institute in Melbourne. Her research is focused on childhood stuttering. Elaina is a lecturer at the University of Melbourne and also works as a clinical speech pathologist with a particular interest in childhood stuttering. Professor Sheena Reilly is associate director, Clinical and Public Health Research at the Murdoch Childrens Research Institute and professor of speech pathology, Department of Paediatrics, University of Melbourne. Her research on childhood communication problems has generated more than 150 publications (111 peer-reviewed papers). She has been awarded competitive research grants totalling more than $15 million.
Please cite this article in press as: Smith, K. A., et al. Anxiety of children and adolescents who stutter: A review. Journal of Fluency Disorders (2014), http://dx.doi.org/10.1016/j.jfludis.2014.01.003