Anxiety of children and adolescents who stutter: A review

Highlights

• Stuttering adults are at risk of social anxiety disorder.

• Young people who stutter are at risk for the development of anxiety.

• The timing of anxiety onset related to stuttering is unclear.

• This is due to a range of methodological limitations in the research evidence.

• It is likely anxiety related to stuttering increases over time, exceeding normal levels in adults.

Abstract

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.

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 et al., 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 (DSM-5; 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 and Knappe, 2012, Iverach and Rapee, 2013, Rapee et al., 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 and Norton, 2009, Costello et al., 2003, Kertz and Woodruff-Borden, 2011, Massion et al., 1993, Stevanovic, 2013, Wolitzky-Taylor et al., 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 et al., 2008, Roy-Byrne and Wagner, 2004, Waghorn and Chant, 2005).

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 and 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 and 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 et al., 2010, Iverach et al., 2009b, Menzies et al., 2008, Stein et al., 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 and Tran, 2006), the underlying mechanisms linking stuttering and anxiety remain unclear (Attanasio, 2000). 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.

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.