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STUTTERING AND SOCIAL ANXIETY DISORDER

102

A Review on Stuttering and Social Anxiety Disorder in Children:
Possible Causes and Therapies/Treatments
Nadia Nathania
zy14043@nottingham.edu.cn
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

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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,

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

insufficiency

of

to

physiological

differentiate

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

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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 Greenwood, 2003; Klassen, 2001; Ruscello,

STUTTERING AND SOCIAL ANXIETY DISORDER

107

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 develop-

ing 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

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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

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).

child

and

parents,

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 bet-

ter (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
© Nadia Nathania 2016
Suggested reference format for this article:
Nathania, N. (2016, November). A Review on Stuttering and Social Anxiety Disorder in
Children:. Beyond Words, 4(2), 102-111. Retrieved from
http://journal.wima.ac.id/index.php/BW
Nadia Nathania received a Bachelor of Arts with Honors in English Language and Literature from the University of Nottingham with a Second Class, Division One. She is currently continuing her further studies in the University of Nottingham, pursuing her
Master of Science degree in Entrepreneurship and Innovation Management.
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