And why does my child’s stuttering get worse when she’s stressed out?

Parents ask me sensible questions like these all the time, so I thought I’d post my thoughts here.

Over the centuries, lots of researchers (and I use that term loosely) have suggested that children who stutter are more sensitive, or anxious, or shy, or distracted, or more emotionally reactive, or more fearful, or even more mentally ill than children who don’t stutter.  This has led to a fairly widespread idea in the community that stuttering is caused by personality issues or (to use an outdated term) “character flaws”.

A. The evidence is in

Here is what we know based on the most recent peer-reviewed research:

1. Young children who develop stuttering (as a group) are not more shy, anxious or stressed than children who don’t stutter (as a group) (e.g. Reilly et al, 2009; Van der Merwe et al, 2011; Eggers et al., 2010).

2.  A subgroup of children who stutter show somewhat elevated traits of inattention and hyperactivity-impulsivity.  But most don’t.  And, for those that do, only a small minority show symptoms that would warrant an actual diagnosis of ADHD (e.g. Alm & Risberg 2007, Eggers et al., 2013).

3. Many people who stutter develop social anxiety as a result of their stuttering.  This does not occur with pre-school children (as a group).  However, it’s also true that pre-schoolers who stutter sometimes get negative responses from peers, e.g. at pre-school (e.g. Langevin et al. 2010).

4. Social anxiety (understandably) tends to develop during school years – especially in teen years – as children who stutter are exposed to negative peer and other reactions to their speech problems (e.g. Blood et al. 2007; Olyer, 1994).  In other words, social anxiety might be an effect – not a cause – of stuttering.  It’s worth noting that the development of social anxiety may not be specific for stuttering.  Young adults with language impairments are also at risk (e.g. Beitchman, 2001).

5. No correlation has been found between the severity of motor symptoms of stuttering and anxiety or personality traits (e.g. Tumanova et al., 2011, Ehhers et al. 2010, Mulcahy et al., 2008, Oyler, 1994).

6. Reducing anxiety (e.g. with cognitive behaviour therapy) does not generally reduce stuttering (although it increases quality of life and might reduce the relapse risk in adults who have had smooth speech treatment, like the Camperdown Program). You can read more about this research here.

7. Reducing stuttering may reduce anxiety (e.g. Craig, 1990), which makes sense if the source of the anxiety is negative thoughts about speaking.

B. So why do children stutter more in some places and situations than others?

That’s a million dollar question!  We don’t know the answer.  But we hope to get closer to it with brain and other studies currently underway.

Here’s what the evidence suggests so far:

1. Some pre-school children stutter significantly more when in situations of “pressure” e.g. when quizzed aggressively, interrupted or put under time pressure (e.g. Yaruss, 1997).  (This is consistent with my clinical observations/experiences.)

2. Many adults who stutter, stutter more when talking to groups, than when speaking alone (e.g. Hahn, 1940, cf. Armson et al. 1997).  This is certainly consistent with what many adult clients tell me.

3. Some people who stutter are more fluent when talking alone, to a pet or an infant, than when talking to an “examiner” or authority figure (e.g. Rasskazov & Rasskazov, 2007; Svan et al. 1972). Again, this seems logical and gels with my clients’ reports.

4. Although strong emotions can increase stuttering, some people who stutter speak smoothly when experiencing strong excitement, such as anger, enthusiasm, or fear (e.g. during an emergency or war) (Bloodstein & Bernstein-Ratner (2008).

5. Tasks performed simultaneously with speech can either improve stuttering or make it worse, depending on the “other task”:

(a) If the other task involves language processing and attention (e.g. reading), it can make stuttering worse because tasks involving phonological encoding are likely to compete with speech for limited processing capacity (e.g. Bosshardt, 2006).  This is why modern office multitasking, e.g. reading emails and talking on the phone at the same time can be so difficult for some people who stutter. You can read more about this research here.

(b) If the other task is a simple hand motor task, e.g. using a joystick to follow a moving dot on a computer screen, it can reduce stuttering (e.g. Arends et al. 1998).  Some researchers observe that almost any volitional movement concurrent with speech may reduce stuttering (e.g. Bloddstein & Bernstein-Ratner, 2008).  Some of the young children and teenagers I work with report this effect when playing computer games, for example.

Some researchers explain these findings by speculating (and that’s all it is so far) that stuttering is a “threshold phenomenon”: a person who stutters can speak fluently with no symptoms until a certain threshold is passed.  Under one of these theories, social cognition – thoughts about what we think about ourselves, what others expect or think, about how we should behave – can interfere with speech.  This is because (according to the theory), social cognition and speech use overlapping/bordering areas of the brain.  When both speech and social cognition occur at the same time (e.g when a person is giving a speech to a group of people), the threshold is exceeded and the person starts to stutter.

In other words, people who stutter aren’t more shy or anxious than people who stutter, but their speech system is very sensitive to disruption when the person is simultaneously engaged in social cognition tasks.

C. Clinical bottom line

Young children who develop stuttering are not more shy or anxious than their peers.  As they get older and go to school, they can develop social anxiety because of their stuttering.  But reducing anxiety alone is unlikely to eliminate or reduce stuttering.  This is another reason why early intervention for pre-schoolers who stutter is a good idea – especially if they have been stuttering for more than 6 months, are about to start school and/or are frustrated or worried about their speech.

Want information about evidence-based treatments?  Check out our articles on the Lidcombe Program and Westmead Program, and our evidence update on stuttering treatments: what works for whom.

Principal source: Alm, P.A. (2014). Stuttering in relation to anxiety, temperament, and personality: review and analysis with focus on causality. Journal of Fluency Disorders, 40, 5-21.  I’d like to thank Professor Mark Onslow for alerting me to the existence of this study on a teleconference I attended last week.  Any errors of interpretation about this study are mine.

Related articles:

• 5 ways for teachers to help children who stutter – tips from people who stutter themselves
• The Lidcombe Program for stuttering: my 10 favourite therapy activities
• My pre-schooler stutters and has problems with speech sounds: which one should I treat first?

Image: http://bit.ly/1MLYo7l