A Review on Stuttering and Social Anxiety Disorder in Children

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A Review on Stuttering and Social Anxiety Disorder in Children: Possible Causes and Therapies/Treatments Nadia Nathania [email protected] University of Nottingham Ningbo China Ningbo, China

Abstract In the past two decades, stuttering and its relation to social anxiety disorder have been researched using different approaches in study fields such as neurolinguistics and neuropsychology. This paper presents a review of research publications about social anxiety disorder in children who stutter. It takes into account studies of stuttering, social anxiety disorders, the possible causes as well as attitudes and beliefs towards stuttering. Also, therapies or treatments that have been conducted on both English-speaking children who stutter in the Western context and Mandarin-speaking children stutterers in Asia, Taiwan in particular; will be looked at. Keywords: stuttering, stammering, social anxiety disorder, children, therapies, treatments, English speakers, Mandarin speakers. Introduction Stuttering or stammering is a language childhood and continues in adulthood, relat- disorder in which there is disturbance in the ed to many different brain structures. The speech flow, preventing an individual from second is neurogenic stuttering, acquired in communicating effectively (World Health adulthood due to a neurological event as a Organization 2010; Iverach and Rapee, result of stroke, brain injury or trauma. The 2014). It is most commonly associated with third is psychogenic stuttering, which is a involuntary repetition of sounds, syllables, rare form that arises after severe emotional phrases and words (Carlson, 2013). A stut- trauma. The impact of stuttering on the terer usually becomes unable to produce emotional state of an individual can be se- sounds, which includes pauses or blocks vere, which may lead to fear of stuttering in before speech, and prolongs vowels or sem- social situations, anxiety, stress, and being a ivowels in an attempt to produce fluent target of bullying especially in children. speech (Carlson, 2013). This article focuses on childhood Stuttering can be categorized into three stuttering and aims at giving a deeper in- subtypes (New Scientist 2016). The first is a sight into how both English and Manda- developmental disorder that appears in early rin-speaking children stutterers develop

Beyond Words Vol.4, No. 2, November 2016

STUTTERING AND SOCIAL ANXIETY DISORDER 103 social anxiety disorder, the possible caus- children stutterers both in Western and es of stuttering in children, as well thera- Asian contexts. Next, it will describe and pies or treatments available. Firstly, it will explain the benefits of different therapies introduce stuttering as a childhood lan- on stuttering. Finally, it will conclude cur- guage disorder and also look at the auto- rent status and future directions of social nomic nervous system in children stutter- anxiety disorder in children who stutter, ers. Then, it will look at perceptions of and offer some suggestions for future re- stuttering and social anxiety disorder in search in the field.

Research in the Past Two Decades Stuttering typically begins to occur the preschool years due to significant neu- when children are developing language ronal plasticity (Iverach and Rapee, and speech skills, particularly between the 2014). The disorder becomes far less age of two and five years old (Yairi, Am- treatable after the preschool years, and by brose, and Cox, 1996). Stuttering, howev- adulthood it often turns out to be a long- er, is most responsive to treatment during term problem.

There are two types of stuttering: ter without tension. This type of stutterers more typical disfluencies and less typical shows characteristics of hesitat-ing, using disfluencies (Gregory et al., 1996). Stut- interjections and unfinished words, revis- terers with more typical disfluencies stut- ing sentences, repeating phrases as well as

104 STUTTERING AND SOCIAL ANXIETY DISORDER words. On the contrary, less typical stuttering and anxiety showed ambiguity disfluencies stutterers exper-ience tension and inconsistency, and were difficult to in their stuttering. These could be identi- interpret (Menzies, Onslow, and Pack- fied by their repetitions of words, interjec- man, 1999; Ingham, 1984). The findings tions, sounds, and syllables for three times also included methodological flaws and or more. This type of stutterers also tend weaknesses such as small scope of sam- to prolong the duration of a phoneme, ex- pling, insufficiency to differentiate perience blocks in their speech, and com- groups, and sample selection bias such bine a set of less or more typical that stutterers seeking treatment for their disfluencies characteristics consecutively disorder were recruited as participants in their speech. Several examples of the instead of those who stutter from the gen- stutterer language are shown in the table eral community (Menzies, Onslow, and above. Packman, 1999; Ingham, 1984). The ap- Stuttering has been reported to have plication of physiological and one- effects on the school life as well as emo- dimensional anxiety measurements in- tional functioning of children (Hayhow, stead of measures designed to evaluate Cray, and Enderby, 2002). This is because social anxiety specifically were also defi- it is often associated with negative stereo- ciencies in the methodology (Menzies, types (Blumgart, Tran and Craig, 2010; Onslow, and Packman, 1999; Ingham, Klein and Hood, 2004), affecting quality 1984). of life by putting an individual in threat- Regardless of the uncertainties in the ening states, for example neurotrauma findings, publications of studies in the last (Craig, Blumgart, and Train, 2009). Nega- twenty years have shown evidence of the tive perceptions towards children stutter- relationship between stuttering and social ers are shown by empirical ‘evidence of anxiety disorder to be more convincing. preschool children who stutter experienc- Menzies, Onslow, and Packman (1999) ing bullying, teasing, exclusion, and nega- reported that many studies have particu- tive peer reactions’ (Iverach and Rapee, larly established the existence of intensi- 2014). These negative results that are fied anxiety in stutterers, with developing connected with stuttering are believed to evidence showing that anxiety only oc- be the origin of anxiety (Blood and Blood, curs in performance or social-based situa- 2007). tions. These findings are led by more Before the year of 2000, however, studies that have been centered on social findings about the correlation between anxiety, fear of negative evaluation, and

STUTTERING AND SOCIAL ANXIETY DISORDER 105 expectancies of social harm (Iverach et Level (SCL) to index the activity of both al., 2011; Craig and Tran, 2006; Menzies, parasympathetic nerves that arises from Onslow, and Packman, 1999). the brain and the lower end of the spinal Autonomic Nervous System Activity cord, and sympathetic nerves, which are In relation to stuttering and social located in the ganglia, near the middle anxiety disorder, the association between part of the spinal cord supplying the in- developmental stuttering and emotional ternal organs, blood vessels, and glands processes has been researched using psy- (Oxford Dictionary 2016). The study dis- chophysiological methods to assess the covered that preschool stutterers dis- autonomic nervous system in preschool- played a greater emotional vulnerability age children who stutter to increase un- and mobilization of emotional reactivity derstanding of this connection (Jones et rather than preschool children who do not al., 2014). The autonomic nervous system stutter, showing a link between stuttering is the function of internal organs influ- and the development of anxiety in a child enced by a division of the peripheral stutterer (Jones et al., 2014). nervous system, which is responsible for Attitudes of Children in the West controlling unconscious bodily functions In the United States, Weidner et al. such as breathing, the heartbeat and diges- (2015) has conducted a study on non- tive processes (Schmidt and Thews, stuttering preschool and kindergarten 1989). It is reported that pre-school aged children and their attitudes towards children stutterers show less adaptability, schoolmates who stutter. The purpose of poor attention span and more negative the study is to understand better the ori- mood compared to children who do not gins of attitudes towards stuttering. The stutter (Jones et al., 2014). study examined attitudes toward stuttering Jones and colleagues (2014) investi- using the Public Opinion Survey on Hum- gated the potential differences in the au- an Attributes-Stuttering/Child (POSHA-S/ tonomic nervous system activity to emo- Child) that was suitable to be used with tional stimuli between preschool stutterers young children. The participants were 27 and non-stutterers. The study included 15 preschool and 24 kindergarten non- male and 5 female preschool-age stutter- stuttering children. The findings showed ers as well as 11 male and 9 female pre- that preschool students had more negative school-age non-stutterers as participants. attitudes towards stuttering compared to The experiment used Respiratory Sinus kindergarten students. Although stuttering Arrhythmia (RSA) and Skin Conductance was viewed negatively, children actually

106 STUTTERING AND SOCIAL ANXIETY DISORDER viewed their stuttering peers positively. Following the results, the teachers However, their knowledge and experience who taught the stuttering students were about stuttering were generally limited. interviewed about their students who stut- Overall, investigation of the specific study ter. There were 13 teachers, 8 of them provided empirical evidence for the need were aware of their students’ stuttering, of educating young children about stutter- however, the remaining were not until the ing and how to respond appropriately to researcher informed them. Most of the peers who stutter (Weidner et al., 2015). teachers did not take stuttering seriously Attitudes & Beliefs of Teachers in Asia therefore they did not ask for medical or In Taiwan, Yang (2009) conducted a professional assistance. Seven teachers study to explore Taiwanese teachers’ reported that the stuttering students act views of Mandarin-speaking stuttering openly, actively and are even talkative children. The investigation first started by whereas 3 teachers described the children inviting parents and teachers of first year with negative personalities, such as being elementary students in Pingtung area of nervous and shy. Out of 13 teachers inter- Southern Taiwan to fill out a stuttering viewed, 8 of them did not think that per- screening form for their children or stu- sonality caused stuttering. To add, 3 dents individually. By collecting the stut- teachers also reported that their non- tering screening forms, it was found that stuttering peers did not tease the children 1.38% of the children were reported as who stutter. having stuttering. In addition, speech After analyzing the data collected, samples of the Mandarin-speaking first- the findings of this study were incon- graders were also collected using a digital sistent to what have been found in Eng- audio recorder. Yang (2009) used frame- lish-speaking cultures. Previous studies in works such as Stuttering-Like Disfluency English-speaking cultures suggested that (SLD) and Weighted Stuttering-Like both stutterers and stuttering were per- Disfluency (WSLD) to measure the aver- ceived negatively, considering that chil- age disfluency in two speech samples per dren are able to detect stuttering as early student to identify children who stutter as the age of four and a half years old (Ambrose and Yairi, 1995; Yairi, 1997; leading to an initiation of bullying chil- Ambrose and Yairi, 1999). The results dren stutterers (Craig, Hancock, Tran and showed that 63 students were suspected of Craig, 2003; Dorsey and Guenther, 2000; having stuttering. Franck, Jackson, Pimentel and Green- wood, 2003; Klassen, 2001; Ruscello,

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Lass, Schmitt and Pannbacker, 1994; more positive attitudes and beliefs toward Ambrose and Yairi, 1994). On the contra- the personality of their stuttering students. ry, the study of views towards stuttering Taiwanese teachers, however, had a lack in Taiwan found that most first-grade stu- of knowledge on managing their students’ dents were not aware of the disfluencies stuttering appropriately. Therefore, this of their classmates (Yang, 2009). It also suggests that the teachers need to receive displayed that Taiwanese teachers had more training about stuttering. Therapy Cognitive Behavior Therapy las, 2008). Unlike traditional therapy of Reviews have found that Cognitive Be- stuttering which focuses only on provid- havior Therapy (CBT) is effective for ing strategies for a stutterer to manage treating children with anxiety disorders fluency, CBT focuses on discussing chal- (James et al., 2013; Cartwright-Hatton et lenges about how language can be al., 2004). Evidence has shown that CBT adapted to support a child stutterer, par- engages children who stutter, particularly ticularly focusing on helping the child to those who have experienced social exclu- access their thoughts and develop strate- sion and negative peer reactions (Grave & gies to manage challenging situate-ions Blisset, 2004; Friedburg & McClure, (Kelman and Wheeler, 2015). It is aimed 2002; Langevin et al., 2009). At the Mi- at supporting children stutterers to identi- chael Palin Center (MPC) in London, fy and understand the connection of their England, CBT is applied as ‘an integrated emotions and cognitions that impacts their approach to the management of stuttering’ speech by using a cognitive model (Kelman and Wheeler, 2015; Cook and (Kelman and Wheeler, 2015). It also Botterill, 2005). The therapy center builds trains them to create their experiences a child-friendly environ-ment, incorporat- more normal by predicting and developing speech management techniques as ing more helpful responses in situations in well as trainings on cognitive and social which they are likely to stutter by explor- communicative skills for children of 5 to ing the link of their behavior, emotions 14 years old and their parents (Kelman and cognitions. and Wheeler, 2015; Cook and Botterill, CBT applies creativity through methods 2005). With younger children the therapy such as children’s drawing, analogies and starts indirectly to help the family by stories (Stallard, 2014; Lamb-Shapiro, providing the foundations that support the 2000; Sobel, 2000; Thomas and Jolley; fluency of the child (Kelman and Nicho- 1998). The children stutterers are asked to

108 STUTTERING AND SOCIAL ANXIETY DISORDER imagine situations they fear and think of and secondary symptoms of stuttering possible outcomes if the worst were to through sharing sessions about stuttering happen. Then, they are helped to develop experiences and emotional states during strategies to cope with these situations the occurrences (Yang, 2015). They are through problem solving involving both also taught of the skills to modify stutter- the child and parents, encouraging ing and rehearse an easy and relaxed him/her to seek out solutions by thinking speaking manner (Yang, 2015). In general flexibly and increasing the internal locus direct therapy is suitable for stuttering of control of the child (Kelman and children because it has helped decrease Wheeler, 2015). It also involves action their disfluencies (Yang, 2015). planning, using collaborative approach Equally important to treating children that involves the child and the therapist who stutter, it is also suggested that par- working together, giving him/her an own- ents have sufficient education regard-ing ership of the whole process by planning their stuttering children (Guitar, 2014; the agenda for each meeting and home- Ramig and Dodge, 2010). Indeed, Yang work tasks that can be problem-solved (2015) reported that parents are the most together (Kelman and Wheeler, 2015). critical people for stuttering children due Direct Therapy and the Efficacy of to a primary role they play in shaping Parent Education speech behavior and reducing stressful Studies reported that direct therapy is rec- factors in the surroundings of their chil- ommended for school-age children who dren. By receiving education about stut- stutter provided that it can improve their tering, parents are encouraged to under- speech by treating them with skills that stand and accept their children’s stutter- shape their fluency and modify their stut- ing, recognize speech mechanism and the tering (Yang, 2015; Guitar, 2014; Ramig cause of stuttering, facilitate communica- and Dodge, 2010). The treatment includes tive environment and attent-ion, as well as sessions that help different grades of strategies to improve the language abili- school-age children to discover primary ties of their children (Yang, 2015). Conclusion and Suggestions Based on the discussion above, research pointed out how social anxiety disorder has shown methodological improvements can develop in stutterers, especially chil- leading to more consistent evidence that dren, and the possible negative conse- support how stuttering is associated with quences that threaten the life quality of social anxiety disorder. This essay has stutterers. It has also reviewed therapies

STUTTERING AND SOCIAL ANXIETY DISORDER 109 or treatments that are suitable for children was limited. Therefore, further research of due to its critical contribution in creating Mandarin-speaking stutterers in China is better quality of life for children who stut- necessary to understand and provide better (Iverach and Rapee, 2014). However, ter assistance to stutterers in the Manda- access to published papers in English rin-speaking culture. about stuttering in the context of China

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