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Children and adolescents who stutter: Further investigation of anxiety
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Contents lists available at ScienceDirect
Journal of Fluency Disorders
Children and adolescents who stutter: Further investigation of anxiety Michelle Messenger, Ann Packman, Mark Onslow ∗ , Ross Menzies, Sue O’Brian Australian Stuttering Research Centre, The University of Sydney, Australia
a r t i c l e
i n f o
Article history: Received 3 March 2015 Received in revised form 27 July 2015 Accepted 27 July 2015 Available online xxx Keywords: Stuttering Anxiety Children Adolescents
a b s t r a c t Purpose: Despite the greatly increased risk of social anxiety disorder in adults who stutter, there is no clear indication of the time of onset of this disorder in childhood and adolescence. The purpose of this study was to explore this issue further using the Revised Children’s Manifest Anxiety Scale (RCMAS), so that appropriate interventions can be developed prior to adulthood. This is the first time the RCMAS has been completed by children younger than 11 years. Using the same test for both school-age children and adolescents can potentially identify when anxiety starts to develop from age 6 years through to adulthood. Methods: The RCMAS was administered to 18 school-age boys, five school-age girls, 41 adolescent boys and nine adolescent girls who were seeking treatment for their stuttering. Participants also rated the severity of their own stuttering. Results: All mean scaled scores on the four RCMAS subscales and Total Anxiety scores were within normal limits. However, for both groups of boys, scores on the Lie Scale were significantly higher than scores on the other three subscales. Conclusions: Experts suggest high scores on the RCMAS Lie Scale are indicative of participants attempting to present themselves in a positive light and so cast doubt on the veracity of their other responses on the test. One interpretation, then, is that the boys were concealing true levels of anxiety about their stuttering. The results suggest why findings of anxiety studies in children and adolescents to date are equivocal. Clinical implications are discussed. Educational objectives: The reader will be able to: (a) discuss why understanding when anxiety starts in people who stutter is important, (b) describe the function of the RCMAS Lie sub scale and (c) summarize the possible implications of the RCMAS findings in this study. © 2015 Elsevier Inc. All rights reserved.
1. Introduction 1.1. Anxiety in adults who stutter A recent issue of the Journal of Fluency Disorders was devoted to the topic of anxiety and stuttering. Three literature reviews in that issue (Craig & Tran, 2014; Iverach & Rapee, 2014; Smith, Iverach, O’Brian, Kefalianos, & Reilly, 2014) made
∗ Corresponding author at: Faculty of Health Sciences, The University of Sydney, PO Box 170, Lidcombe, NSW 1825, Australia. Tel.: +61 2 9351 9061; fax: +61 2 9351 9392. E-mail addresses: [email protected] (M. Messenger), [email protected] (A. Packman), [email protected] (M. Onslow), [email protected] (R. Menzies), [email protected] (S. O’Brian). http://dx.doi.org/10.1016/j.jfludis.2015.07.006 0094-730X/© 2015 Elsevier Inc. All rights reserved.
Please cite this article in press as: Messenger, M., et al. Children and adolescents who stutter: Further investigation of anxiety. Journal of Fluency Disorders (2015), http://dx.doi.org/10.1016/j.jfludis.2015.07.006
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clear that adults who stutter are more prone to anxiety and that this anxiety typically involves fear of negative evaluation in social situations (Iverach & Rapee, 2014; Iverach, Menzies, O’Brian, Packman, & Onslow, 2011; Kraaimaat, Vanryckeghem, & Van Dam-Baggen, 2002; Messenger, Onslow, Packman, & Menzies, 2004). This is known as social anxiety and, when extreme, social phobia or social anxiety disorder. In the Iverach and Rapee (2014) review, reports of the prevalence of social anxiety disorder in adults who stutter range up to 66%. As well as impacting on quality of life (Craig, Blumgart, & Tran, 2009), mental health disorders such as social anxiety disorder can significantly reduce the chances of adults who stutter maintaining the benefits of behavioral speech treatment (Iverach et al., 2009). A well-established treatment for social anxiety disorder is cognitive behavior therapy (CBT) and trials of a CBT program designed specifically for anxiety in adults who stutter have shown promising results (Helgadottir, Menzies, Onslow, Packman, & O’Brian, 2009; Menzies et al., 2008). However, to date, there is no clear indication of when that anxiety starts to develop. It is known that in the general population social anxiety typically starts to develop during early adolescence (see Smith et al., 2014). Hence it is very unlikely that the social anxiety disorder that is associated with stuttering develops suddenly in adulthood; rather, the origins are likely to be found during the school-age years and adolescence. According to Iverach and Rapee (2014), “determining the prevalence of social anxiety disorder among children and adolescents who stutter is a critical line of future research” (p. 69). If the origins of social anxiety in adults who stutter can be identified earlier in life, the disorder can be addressed comprehensively before becoming chronic. 1.2. Factors relevant to the development of social anxiety in people who stutter Smith et al. (2014) identified four factors associated with the development of anxiety in general, of which two—environmental and cognitive—are particularly relevant to stuttering. Environmental issues encompass the negative responses of others to stuttering and cognitive issues relate to awareness and evaluation of those negative responses. These are now discussed in relation to age. 1.2.1. Preschoolers Preschool children who do not stutter are aware of stuttering in their peers (Ambrose & Yairi, 1994; Ezrati-Vinacour, Platzky, & Yairi, 2001) and it is known that preschoolers who stutter can suffer social penalty from peers because of their stuttering (Langevin, Packman, & Onslow, 2009, 2010). Many very young children are aware of their stuttering and start to develop negative attitudes about their own speech (Boey et al., 2009; Langevin et al., 2010; Vanryckeghem, Brutten, & Hernandez, 2005). In their large study of 1122 children who stutter, Boey et al. (2009) found that awareness of their own stuttering increased steadily from 56.7% of children at age 2 years to 89% of children at age 7 years. 1.2.2. School-age children (age 7–12 years) It is known that in the general population bullying and victimization in the school-age years are associated with subsequent development of anxiety, including social anxiety (Craig, 1998; Gladstone, Parker, & Malhi, 2006; McCabe, Miller, Laugesen, Antony, & Young, 2010). School-age children are aware of stuttering in their peers (Culatta & Sloane, 1977; Davis, Howell, & Cooke, 2002; Vanryckeghem & Brutten, 1997) and teasing and bullying by peers is common in children who stutter (Davis et al., 2002; DeNil & Brutten, 1991; Hayhow, Cray, & Enderby, 2002; Langevin, Bortnick, Hammer, & Wiebe, 1998). Langevin et al. (1998) reported that 81% of children who stutter reported bullying during the school years, with 56% of those children reporting bullying happening at least once per week. In a survey of adults (Hayhow et al., 2002), 81% of the 332 respondents reported negative experiences at school due to their stuttering. In their survey of 403 children ages 8–14 years, Davis et al. (2002) found that as well as being bullied, children who stutter were rejected significantly more often and were less likely to be popular. DeNil and Brutten (1991) reported that from age 7 years onwards, school-age children who stutter had more negative communication attitudes than their peers and that attitudes progressively worsened for the stuttering children while progressively improving for the control children. 1.2.3. Adolescents The negative environmental and cognitive factors thought to precipitate anxiety in the general population continue into adolescence for those who stutter (Blood & Blood, 2004; Blood, Blood, Maloney, Meyer, & Dean Qualls, 2007; Erickson & Block, 2013; Hearne, Packman, Onslow, & Quine, 2008; Hugh-Jones & Smith, 1999; Mulcahy, Hennessey, Beilby, & Byrnes, 2008; Van Borsel, Brepoels, & De Coene, 2011). Van Borsel et al. (2011) reported that in a study of 736 adolescents and young adults, a third of them in the age range 16–17 years stated that images of young people who were described as a person who stutters were less physically attractive than images without that label. Blood and Blood (2004) reported a 43% risk of bullying for 53 adolescents who stutter. In their survey of 36 adolescents, Erickson and Block (2013) found that 53% had experienced teasing and bullying because of their stuttering. In the Mulcahy et al. (2008) survey of 36 adolescents who stutter, respondents reported apprehension about communicating and feelings of low communicative competence. Erickson and Block also found low self-identified communication competence in their survey, although this may not be universal (see Blood, Blood, Tellis, & Gabel, 2003). Interestingly, 60% of the 48 adolescents in the Blood et al. (2003) study reported that they almost never talked about their stuttering and 42% of the 36 respondents in the Erickson and Block (2013) survey also reported that they often tried to keep their stuttering secret. This reticence emerged as a theme in the Hearne et al. (2008) qualitative study of 13 adolescents who Please cite this article in press as: Messenger, M., et al. Children and adolescents who stutter: Further investigation of anxiety. Journal of Fluency Disorders (2015), http://dx.doi.org/10.1016/j.jfludis.2015.07.006
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stutter. One participant said of his stuttering, “Maybe I was in denial, it was like if I don’t mention it and no one mentions it, then it’ll go away . . .” (p. 87). 1.3. Anxiety research in children and adolescents who stutter The prevalence of anxiety disorders is reported to be higher in children with communication disorders generally (Beitchman et al., 2001). Yet, the evidence for this in children who stutter is equivocal (Smith et al., 2014). In the Smith et al. (2014) report, which was a review of the literature, the authors concluded that the findings of 12 studies of anxiety and stress in school-age children and adolescents who stutter were inconclusive. Around half the studies found increased anxiety compared to controls while the others did not. The only study of preschoolers (van der Merwe, Robb, Lewis, & Ormond, 2011) found no differences between children who were stuttering and matched controls on anxiety measures and salivary cortisol levels. However, as the authors said, four of the seven stuttering children were receiving treatment at the time, which could have biased the findings. A study of children and adolescents aged 10–17 years (Davis, Shisca, & Howell, 2007) using the Stait-Trait Anxiety Inventory for Children found that those who were still stuttering did not differ from those who had recovered from stuttering and from normally fluent controls for trait anxiety, but scored significantly higher than these two groups for state anxiety. The authors concluded that this suggests stuttering can lead to the development of anxiety. According to Smith et al. (2014), possible reasons for the failure of their review to find conclusive results related to methodological factors such as lack of statistical power and the variety of anxiety measures used across studies. For example, while appropriate measures such as the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 2002) were used with adolescents, this was not the case for younger children. It is also the case that very few girls were included in the studies. The authors concluded, “. . . the timing of anxiety onset in stuttering, and the status of anxiety in stuttering children and adolescents, is unclear.” (p. 30). Given the negative effects that stuttering can have from the preschool years through adolescence, this suggests the need for further research into anxiety in children who stutter. 1.3.1. The RCMAS The aim of the present study is to contribute further knowledge to the development of social anxiety disorder in adults who stutter, using the RCMAS with children and adolescents who stutter. There are a number of reasons the RCMAS was considered to be ideal for this purpose. First, is a widely used psychological assessment for anxiety in both children and adolescents, ranging from age 6–19 years. This provides the ability to determine when anxiety may start to develop and, if starting during childhood, whether it progresses over time. Second, a subscale of the RCMAS, Social Concerns/Concentration, can potentially identify the onset of social anxiety. Third, for each subscale, the RCMAS provides a cut-off score (subscale of 13) to indicate the clinically significant range. Finally, the RCMAS is easy to administer, being a self-report pencil and paper test that takes 10–15 min to complete. The RCMAS has 37 items and consists of four subscales: Physiological Anxiety, Worry/Oversensitivity, Social Concerns/Concentration and the Lie Scale. In addition, it provides a Total Anxiety score. The subscales measure what their names suggest: physiological signs of anxiety, worry and oversensitivity (nervousness, feeling overburdened) and being unduly concerned about other people’s perception. The Lie subscale assesses deception by the respondent in order to mask true feelings; Examples of Lie Scale questions include “I’m always kind,” and “I never get angry”. The Total Anxiety score is the overall score. The RCMAS-2 (Reynolds & Richmond, 2008) is a revised version of the RCMAS. To date in stuttering research, the RCMAS has only been used in studies of older children and adolescents (Blood & Blood, 2007; Blood et al., 2007; Gunn et al., 2014). Blood and Blood (2007) reported the administration of the RCMAS to 18 stuttering children and 18 controls (all boys) aged 11–12 years. Scores for Total Anxiety on the RCMAS were significantly higher in the stuttering group but both group means fell in the normal range. Blood et al. (2007) reported the administration of the RCMAS to 36 adolescents who stutter (30 males and 6 females, mean age 14.3 years) and also found higher Total Anxiety scores for the stuttering group compared to controls. However, again, the mean scores fell within the normal range. Gunn et al. (2014) reported the administration of the RCMAS-2 to 37 adolescents who stutter aged 12–17 years (36 males and one female). The participants were divided into a younger group (age 12–14 years) and an older group (age 15–17 years). Results indicated that the means for Total Anxiety (T scores) and all subscales fell within the normal range, with the older group scoring significantly higher than the younger group for Total Anxiety, Physiological Anxiety and Worry. There was no significant difference between the age groups for Social Anxiety. However, the authors noted that while means for Defensiveness were within the normal range, scores for eight participants in the younger group and six participants in the older group fell within the clinical range. The Defensiveness Scale in the RCMAS-2 is similar to the Lie Scale in the RCMAS and indicates that respondents may be attempting to conceal anxiety, feel isolated and are seeking social approval. In summary, research to date using the RCMAS and the RCMAS-2 has shown that older children and adolescents who stutter score higher than controls on anxiety scores, but as a group do not score in the clinical range for anxiety. It is important to note that the youngest children to be assessed with the RCMAS in these studies were age 11 years (Blood & Blood, 2007). 1.4. The present study The aim of the present study was to use the RCMAS with both children and adolescents who stutter, to attempt to shed more light on the age of onset of the social anxiety disorder that is known to be present in many adults who stutter. There Please cite this article in press as: Messenger, M., et al. Children and adolescents who stutter: Further investigation of anxiety. Journal of Fluency Disorders (2015), http://dx.doi.org/10.1016/j.jfludis.2015.07.006
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is reason to believe that such anxiety should be developing in the school-age and adolescent years but to date this has not been shown to be unequivocally the case. This is the first study in which the RCMAS has been used with younger children who stutter and the first time it has been used for both school-age children and adolescents. The aim of this was to identify the presence of any anxiety from the early school-age years through adolescence. The male:female ratio is similar to that in the stuttering population of around 4:1. There were no control groups; rather the scores were compared to test norms to determine how participants compared to the general population and whether any were above the clinical cut-off scores provided by the RCMAS. 2. Method 2.1. Participants Participants were 73 young people who stuttered, ranging in age from 6 to 18 years and divided into two groups. The school-age group comprised 18 boys aged 6–11 years (mean 8;6) and 5 girls aged 7–11 years (mean 8;8). The Adolescent Group comprised 41 boys aged 13–18 years (mean 14;8) and 9 girls aged 13–16 years (mean 15;1). All had been identified as stuttering by parents and by a speech-language pathologist and were awaiting treatment for their stuttering at speechlanguage pathology clinics at universities and hospitals within Australia. Participants were included as they came on to wait lists, which explains the small number of females in the study. No participants had any concomitant speech or language disorder and none were currently receiving any other treatment for stuttering. The RCMAS was included along with a range of assessments made in these clinics shortly before participants started treatment. The Human Ethics Research Committee of The University of Sydney and other relevant Ethics Committees granted permission to conduct the study. 2.2. Procedure Potential participants and their parents were approached prior to starting treatment by an independent person and asked whether they were willing for their children to participate in a study about mental health and stuttering. All parents approached gave informed consent. Participants completed the RCMAS and rated the severity of their “typical stuttering” and “most severe stuttering” for the situation talking with friends. These two self-rating categories give an indication of ranges of severity. Participants rated the severity of their stuttering on a 9-point scale (1 = “no stuttering”, 9 = “extremely severe stuttering”). Self-reported severity ratings have been shown to correlate with the severity ratings of speech-language pathologists in adults in the clinic (O’Brian, Packman, & Onslow, 2004) but this has not been demonstrated for the age groups in this study. However, self-rating provides a socially valid indication of stuttering severity in the real world and is appropriate for use in this study as participants’ responses to the RCMAS were also self-generated. 2.3. Data analysis Scores on the RCMAS were analyzed separately for boys and girls and were compared with normative data. Given the findings of differences across subscale scores for both the school-age boys and the adolescent boys, one-way repeated measures ANOVAs were conducted to determine the significance of these differences. 3. Results 3.1. School-age group 3.1.1. Boys Mean self-rated stuttering severity for the school-age boys on the 9-point scale was 6.6 (range 5–9) for their most severe stuttering and 5.7 (range 4–8) for their typical stuttering. The scores for the RCMAS are shown in Table 1. All the mean RCMAS scaled scores for the school-age boys fall within the normal range of below of 13. However, for two reasons, the pattern of scores for this group is unusual. First, the mean scaled score of 11 on the Lie Scale was the highest of the subscale scores. When viewed as a percentile, as a group these children scored higher on the Lie Scale than 71% of their peers and five of the boys (28%) scored in the clinically significant range. Second, all other subscale percentiles are low, in the range of 16–28. This is surprising for a group of children for whom there is good reason to believe that anxiety may be developing. The ANOVA showed a significant effect for the RCMAS scaled scores for the four subscales, F(3,51) = 14.77. p < .0001. A post hoc Tukey test showed that the Lie Scale scores differed significantly from the other three subscale scores (p < .01). 3.1.2. Girls Mean self-rated stuttering severity for the girls in this group on the 9-point scale was 8 (range 6–9) for their most severe stuttering and 6.6 (range 5–9) for their typical stuttering. The scores for the RCMAS are shown in Table 1. All mean scores for these girls were within the normal range and the percentile profile was unremarkable.
Please cite this article in press as: Messenger, M., et al. Children and adolescents who stutter: Further investigation of anxiety. Journal of Fluency Disorders (2015), http://dx.doi.org/10.1016/j.jfludis.2015.07.006
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Table 1 RCMAS scores for the school-age boys, school-age girls, adolescent boys and adolescent girls.
School-age boys (n = 18) Mean score SD Scaled score Percentile School age girls (n = 5) Mean score SD Scaled score Percentile Adolescent boys (n = 41) Mean score SD Scaled score Percentile Adolescent girls (n = 9) Mean score SD Scaled score Percentile
Physiological anxiety
Worry/ oversensitive
Social concerns/concentration
Lie Scale
Total Anxiety
2.1 1.61 7 16
2.5 2.12 8 28
1.34 1.28 7 21
5.2 2.26 11 72
6.05 3.65 42 (T-score) 20
3 2.54 7 22
4.8 2.9 9 45
2.4 1.34 9 39
3.2 1.3 9 48
10.2 5.9 45 (T-score) 31
2.3 1.98 9 40
3.2 2.75 9 39
1.8 1.58 9 45
3.8 2.2 12 83
7.4 5.1 46 (T-score) 34
4.5 1.9 11 73
5.7 3 11 65
2.5 2.4 10 50
3.1 1.69 11 68
12.8 5.6 54 (T-score) 50
3.2. Adolescent group 3.2.1. Boys Mean self-rated stuttering severity for the adolescent boys on the 9-point scale was 6.2 (range 3–9) for their most severe stuttering and 3.9 (range 1–8) for their typical stuttering. The scores for the RCMAS are shown in Table 1. All mean subscale scores fall within the normal range. In contrast to the school-age boys, these scores are just below the 50th percentile. However, as was the case for the school-age boys, the mean Lie Scale score is markedly high, in fact higher than for the school-age boys and the mean scaled score only slightly below the clinically significant cut-off of 13. Sixteen of them (39%) scored in the clinically significant range. When viewed as a percentile, as a group the adolescent boys scored higher on the Lie Scale than 82% of their peers. As for the school-age boys, the ANOVA showed a significant effect for RCMAS scaled scores for the four subscales, F(3,120) = 6.47, p < .0001. A post hoc Tukey test showed that the Lie Scale scores differed significantly from the other three subscale scores (p < .01). 3.2.2. Girls Mean self-rated stuttering severity for the adolescent girls in this group on the 9-point scale was 6.0 (range 3–9) for their most severe stuttering and 4.8 (range 1–8) for their typical stuttering. The scores for the RCMAS are shown in Table 1. Again all mean scores are within the normal range. However, three mean scores on subscales were high, with Physiological Anxiety at the 73rd percentile and Lie Scale scores at the 68th percentile. Two of the girls (22%) scored in the clinically significant range for the Lie Scale. 4. Discussion 4.1. Overview of findings The mean self-rated stuttering severity for both the school-age children and the adolescents for an everyday situation, namely talking with friends, ranged from 3 to 8 on the 9-point scale. This suggests a wide range of severity. This study is the first to investigate anxiety in school-age children who stutter using the RCMAS. For this group, the means for Total Anxiety and the subscales on the RCMAS were within the normal range. The study also investigated anxiety in adolescents who stutter with the RCMAS. The findings for this group were similar to those of the younger group, with no means falling within the clinically significant range. This is consistent with previous research into anxiety in this age group. As suggested in Section 1, there is clear evidence that children and adolescents who stutter are at greater risk of exposure to the environmental factors known to lead to social anxiety, the most critical being teasing and bullying (see Smith et al., 2014). It is extraordinary, then, that social anxiety disorder involving fear of negative evaluation in social situations is consistently identified in up to 66% of adults who stutter but that research to date, including the present study, has failed to find consistent evidence of this anxiety developing prior to adulthood. In the present study, for example, both groups were at the 50th percentile or lower for the subscale that measures social concerns. However, close examination of the results of the present study gives an indication of why this might be the case. The profiles of subscale scores show that the boys in both groups had high Lie Scale scores and much lower scores on the other subscales. As shown for the means in Table 1, for the Lie Scale the school-age boys were at the 72nd percentile and the Please cite this article in press as: Messenger, M., et al. Children and adolescents who stutter: Further investigation of anxiety. Journal of Fluency Disorders (2015), http://dx.doi.org/10.1016/j.jfludis.2015.07.006
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adolescent boys were at the 83rd percentile, with scaled scores just below the clinically significant level of 13. In contrast, the other subscale scores for the school-age boys were below the 29th percentile and for adolescent boys were below the 45th percentile. While the mean Lie Scale scores did not identify the groups as falling within the clinically significant range, it is important to note that 28% of the school-age boys and 39% of the adolescent boys were in the clinically significant range. It is of interest that both the school-age and the adolescent girls were more uniform across the RCMAS subscales. In other words, they did not show relatively higher Lie Scale Scores, although 22% of the adolescent girls were within the clinical range. It should be noted, however, that the number of girls was quite small (five in the schoolage group and nine in the adolescent group) compared to boys (18 in the school-age group and 41 in the adolescent group. Interestingly, high Lie Scale scores were not reported for the 36 adolescents who stutter in the Blood et al. (2007) study. Although they scored higher than controls on Total Anxiety, there was no difference in Lie Scale scores, which lay well within the normal range. However, the findings for the Lie Scale scores in the present study are consistent with those of Gunn et al. (2014). Although Gunn et al. used the RCMAS-2, they also reported that while mean Total Anxiety and all subscale scores were within the normal range, Defensiveness Scale scores were high, relative to the scores of the other subscales. The RCMAS-2 Defensiveness Scale is similar to the RCMAS Lie Scale. In Gunn et al. study, 38% of the 37 adolescents who stutter scored in the clinical range for defensiveness. This is comparable to the 39% of adolescent boys and the 22% of adolescent girls in the present study that scored in the clinical range of Lie Scale scores.
4.2. Interpretation of high Lie Scale scores High Lie Scale scores on the RCMAS do not suggest that respondents lie more in everyday situations than their peers, but rather that they may be deceiving on the present test questions. In the general population, high Lie Scale scores are thought to indicate that respondents are giving the answers they think the examiners want to hear (Dadds, Perrin, & Yule, 1998; Pina, Silverman, Saavedra, & Weems, 2001; Reynolds & Richmond, 2002). Pina et al. (2001) suggested that respondents with high Lie Scale scores might be deliberately misrepresenting the truth to prevent others from seeing their limitations and faults. Similarly, Reynolds and Richmond (2002) suggested that high Lie Scale scores indicate that respondents are presenting an ideal view of themselves that is generally impossible, wishing to establish the examiners’ approval by making their scores more acceptable than they are in reality. These authors suggest that by scoring low or average on anxiety they “fake good” and produce an “ideal image” of themselves (p. 10). Of importance in the present context, Reynolds and Richmond (2002) indicated that high Lie Scale scores may reflect social issues related to anxiety, such as feelings of social isolation or rejection and a desire to be approved and accepted. High Lie Scale scores may also indicate a concern about the evaluations of others, a core component in social anxiety disorder. These explanations could be seen to apply to many young people who stutter. Of importance in the present context, Dadds et al. (1998) reported that high Lie Scale scores were associated with poor outcomes for anxiety treatment. This may have implications for stuttering treatments, in that it may be that individuals with high Lie Scale scores may not respond as well to treatment as those who do not. This would be seem to be a profitable area for future research. These interpretations of high Lie Scale sores on the RCMAS provide some insights into the findings in the present study; that is, while Lie Scale scores were high, in comparison anxiety scores were much lower. In particular, Lie Scale scores were significantly higher than scores for the subscale that indicates social concerns. It should be noted, however, that this applied to the school-age and adolescent boys only. One interpretation is that the boys in the present study were attempting to mask anxiety when completing the RCMAS. Higher levels of anxiety about social situations would have been expected, given the relatively high levels of stuttering severity reported by the participants themselves. Higher levels of anxiety would not have been a surprise in the present study, given the negative psychosocial impact that stuttering can have on children and adolescents and even on preschoolers, including feelings of being incompetent as communicators. One possible explanation for the unremarkable Lie Scale scores of the female participants is that females are reported to feel more comfortable about disclosing their problems during childhood and adolescence than males (Rose et al., 2012). This is also the first study of anxiety to raise the possibility that children who stutter may conceal their true feelings under test conditions. However, the finding that boys were apparently attempting to mask any anxiety about their stuttering is supported by reports of reticence by many adolescents to disclose their stuttering, to talk about their stuttering and to seek treatment for their stuttering (Blood et al., 2003; Erickson & Block, 2013; Huber, Packman, Quine, Onslow, & Simpson, 2004). In light of this, it may also be the case that participants under-reported the severity of their stuttering. Further research could investigate the extent to which self-reported severity ratings in children and adolescents correlate with the severity ratings of speech-language pathologists, similar to the study of O’Brian et al. (2004) with adults. Of interest are reports that Lie Scale scores can be influenced by cultural factors (Pina et al., 2001; Reynolds & Richmond, 1978). The present findings of increased Lie Scale scores and the increased Defensiveness Scale scores of Gunn et al. (2014) for Australian children and adolescents who stutter are in contrast to the findings of Blood and Blood (2007) and Blood et al. (2007), in which there was no suggestion that Lie Scale scores were higher than scores on other subscales. These differences could perhaps be due to cultural differences but they may also be due to other factors relating to the conduct of the studies, such as recruitment procedures and administration.
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4.3. Clinical implications An important implication of the present findings for speech-language pathologists is that they should keep in mind that children and adolescents who present to a clinic because of their stuttering, especially boys, may be more socially anxious than they report. As suggested in the Hearne et al. (2008) study, some adolescents may be in denial about their stuttering. This of course will not be the case for all individuals, but the possibility should be explored. Drawing on the findings of Dadds et al. (1998), it is also important to keep in mind that defensiveness, if not addressed, could limit an individual’s responsiveness to treatment. It would be prudent, then, for speech-language pathologists to question children and adolescents carefully to ascertain whether they are concealing concerns about the impact their stuttering may be having on their psychosocial wellbeing and to instigate appropriate assessment and intervention if this is suspected. 4.4. Conclusions It must be stressed again that the mean Lie Sale findings for the groups in the present study fell within the normal range. Hence, our interpretations of the findings must be regarded with caution. However, the Lie Scale scores for boys in both groups were very high compared to other RCMAS subscores and it is this profile of subscores that is of particular interest. In addition, the present high Lie Scale scores support the findings of Gunn et al. (2014) for adolescents who stutter. They suggest that children and adolescents who stutter may be concealing concerns about their stuttering when asked. The present study is the first to show this effect in both school-age and adolescent boys who stutter; indeed, it is the first study to investigate anxiety using the RCMAS with children who stutter below the age of 11 years. Clearly, more research is needed to determine the true prevalence of social anxiety in these age groups (Iverach & Rapee, 2014). It is suggested that using the same assessment procedure for both groups, as in the present study, could be fruitful. As suggested by Mulcahy et al. (2008), it would also be important to ensure that participants in future research are not receiving treatment for their stuttering at the time of assessment, as this could result in bias. It may be that individuals feel well supported while receiving treatment and so are more likely to report lower levels of anxiety then than they otherwise would. Acknowledgments This research was supported in part by National Health and Medical Research Council Program Grant number 633007. Conflict of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing. CONTINUING EDUCATION Further investigation of anxiety in children and adolescents who stutter QUESTIONS 1. The RCMAS gives a measure of (a) (b) (c) (d) (e)
Depression Personality Anxiety Temperament Aggression
2. The age at which adults who stutter start to develop social anxiety is: (a) (b) (c) (d) (e)
Pre-school years (2–5) School-age years (6–12) Adolescence (13–17 years) Adulthood (18+ years) Unknown
3. High RCMAS Lie subscale scores can indicate (a) (b) (c) (d) (e)
Depression Habitual lying Narcisism Avoidance Desire to mask true feelings
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4. The participants in the present study are, (a) (b) (c) (d) (e)
School-age children and adolescents who stutter Adults who stutter Adolescents who stutter and normally fluent adolescents Children who stutter and normally fluent children Preschoolers who stutter
5. The RCMAS results for the boys in this study are considered noteworthy because: (a) (b) (c) (d) (e)
Mean Total Anxiety score was in the clinical range Mean Lie Scale score was much higher than scores on the other subscales The profile of scores was typical of normally fluent boys Mean score for Physiological Anxiety was in the 80th percentile Mean Total Anxiety score was lower than all subscale scores
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Michelle Messenger, PhD, currently works for Family and Community Services – Ageing, Disability and Home care as a psychologist. Ann Packman, PhD, is Senior Research Officer at the Australian Stuttering Research Centre, the University of Sydney. Mark Onslow, PhD, is Director of the Australian Stuttering Research Centre, the University of Sydney. Ross Menzies, PhD, is a clinical psychologist and researcher at the Australian Stuttering Research Centre, the University of Sydney. Sue O’Brian, PhD, is Senior Research Fellow at the Australian Stuttering Research Centre, the University of Sydney.
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Contents lists available at ScienceDirect
Journal of Fluency Disorders
Children and adolescents who stutter: Further investigation of anxiety Michelle Messenger, Ann Packman, Mark Onslow ∗ , Ross Menzies, Sue O’Brian Australian Stuttering Research Centre, The University of Sydney, Australia
a r t i c l e
i n f o
Article history: Received 3 March 2015 Received in revised form 27 July 2015 Accepted 27 July 2015 Available online xxx Keywords: Stuttering Anxiety Children Adolescents
a b s t r a c t Purpose: Despite the greatly increased risk of social anxiety disorder in adults who stutter, there is no clear indication of the time of onset of this disorder in childhood and adolescence. The purpose of this study was to explore this issue further using the Revised Children’s Manifest Anxiety Scale (RCMAS), so that appropriate interventions can be developed prior to adulthood. This is the first time the RCMAS has been completed by children younger than 11 years. Using the same test for both school-age children and adolescents can potentially identify when anxiety starts to develop from age 6 years through to adulthood. Methods: The RCMAS was administered to 18 school-age boys, five school-age girls, 41 adolescent boys and nine adolescent girls who were seeking treatment for their stuttering. Participants also rated the severity of their own stuttering. Results: All mean scaled scores on the four RCMAS subscales and Total Anxiety scores were within normal limits. However, for both groups of boys, scores on the Lie Scale were significantly higher than scores on the other three subscales. Conclusions: Experts suggest high scores on the RCMAS Lie Scale are indicative of participants attempting to present themselves in a positive light and so cast doubt on the veracity of their other responses on the test. One interpretation, then, is that the boys were concealing true levels of anxiety about their stuttering. The results suggest why findings of anxiety studies in children and adolescents to date are equivocal. Clinical implications are discussed. Educational objectives: The reader will be able to: (a) discuss why understanding when anxiety starts in people who stutter is important, (b) describe the function of the RCMAS Lie sub scale and (c) summarize the possible implications of the RCMAS findings in this study. © 2015 Elsevier Inc. All rights reserved.
1. Introduction 1.1. Anxiety in adults who stutter A recent issue of the Journal of Fluency Disorders was devoted to the topic of anxiety and stuttering. Three literature reviews in that issue (Craig & Tran, 2014; Iverach & Rapee, 2014; Smith, Iverach, O’Brian, Kefalianos, & Reilly, 2014) made
∗ Corresponding author at: Faculty of Health Sciences, The University of Sydney, PO Box 170, Lidcombe, NSW 1825, Australia. Tel.: +61 2 9351 9061; fax: +61 2 9351 9392. E-mail addresses: [email protected] (M. Messenger), [email protected] (A. Packman), [email protected] (M. Onslow), [email protected] (R. Menzies), [email protected] (S. O’Brian). http://dx.doi.org/10.1016/j.jfludis.2015.07.006 0094-730X/© 2015 Elsevier Inc. All rights reserved.
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clear that adults who stutter are more prone to anxiety and that this anxiety typically involves fear of negative evaluation in social situations (Iverach & Rapee, 2014; Iverach, Menzies, O’Brian, Packman, & Onslow, 2011; Kraaimaat, Vanryckeghem, & Van Dam-Baggen, 2002; Messenger, Onslow, Packman, & Menzies, 2004). This is known as social anxiety and, when extreme, social phobia or social anxiety disorder. In the Iverach and Rapee (2014) review, reports of the prevalence of social anxiety disorder in adults who stutter range up to 66%. As well as impacting on quality of life (Craig, Blumgart, & Tran, 2009), mental health disorders such as social anxiety disorder can significantly reduce the chances of adults who stutter maintaining the benefits of behavioral speech treatment (Iverach et al., 2009). A well-established treatment for social anxiety disorder is cognitive behavior therapy (CBT) and trials of a CBT program designed specifically for anxiety in adults who stutter have shown promising results (Helgadottir, Menzies, Onslow, Packman, & O’Brian, 2009; Menzies et al., 2008). However, to date, there is no clear indication of when that anxiety starts to develop. It is known that in the general population social anxiety typically starts to develop during early adolescence (see Smith et al., 2014). Hence it is very unlikely that the social anxiety disorder that is associated with stuttering develops suddenly in adulthood; rather, the origins are likely to be found during the school-age years and adolescence. According to Iverach and Rapee (2014), “determining the prevalence of social anxiety disorder among children and adolescents who stutter is a critical line of future research” (p. 69). If the origins of social anxiety in adults who stutter can be identified earlier in life, the disorder can be addressed comprehensively before becoming chronic. 1.2. Factors relevant to the development of social anxiety in people who stutter Smith et al. (2014) identified four factors associated with the development of anxiety in general, of which two—environmental and cognitive—are particularly relevant to stuttering. Environmental issues encompass the negative responses of others to stuttering and cognitive issues relate to awareness and evaluation of those negative responses. These are now discussed in relation to age. 1.2.1. Preschoolers Preschool children who do not stutter are aware of stuttering in their peers (Ambrose & Yairi, 1994; Ezrati-Vinacour, Platzky, & Yairi, 2001) and it is known that preschoolers who stutter can suffer social penalty from peers because of their stuttering (Langevin, Packman, & Onslow, 2009, 2010). Many very young children are aware of their stuttering and start to develop negative attitudes about their own speech (Boey et al., 2009; Langevin et al., 2010; Vanryckeghem, Brutten, & Hernandez, 2005). In their large study of 1122 children who stutter, Boey et al. (2009) found that awareness of their own stuttering increased steadily from 56.7% of children at age 2 years to 89% of children at age 7 years. 1.2.2. School-age children (age 7–12 years) It is known that in the general population bullying and victimization in the school-age years are associated with subsequent development of anxiety, including social anxiety (Craig, 1998; Gladstone, Parker, & Malhi, 2006; McCabe, Miller, Laugesen, Antony, & Young, 2010). School-age children are aware of stuttering in their peers (Culatta & Sloane, 1977; Davis, Howell, & Cooke, 2002; Vanryckeghem & Brutten, 1997) and teasing and bullying by peers is common in children who stutter (Davis et al., 2002; DeNil & Brutten, 1991; Hayhow, Cray, & Enderby, 2002; Langevin, Bortnick, Hammer, & Wiebe, 1998). Langevin et al. (1998) reported that 81% of children who stutter reported bullying during the school years, with 56% of those children reporting bullying happening at least once per week. In a survey of adults (Hayhow et al., 2002), 81% of the 332 respondents reported negative experiences at school due to their stuttering. In their survey of 403 children ages 8–14 years, Davis et al. (2002) found that as well as being bullied, children who stutter were rejected significantly more often and were less likely to be popular. DeNil and Brutten (1991) reported that from age 7 years onwards, school-age children who stutter had more negative communication attitudes than their peers and that attitudes progressively worsened for the stuttering children while progressively improving for the control children. 1.2.3. Adolescents The negative environmental and cognitive factors thought to precipitate anxiety in the general population continue into adolescence for those who stutter (Blood & Blood, 2004; Blood, Blood, Maloney, Meyer, & Dean Qualls, 2007; Erickson & Block, 2013; Hearne, Packman, Onslow, & Quine, 2008; Hugh-Jones & Smith, 1999; Mulcahy, Hennessey, Beilby, & Byrnes, 2008; Van Borsel, Brepoels, & De Coene, 2011). Van Borsel et al. (2011) reported that in a study of 736 adolescents and young adults, a third of them in the age range 16–17 years stated that images of young people who were described as a person who stutters were less physically attractive than images without that label. Blood and Blood (2004) reported a 43% risk of bullying for 53 adolescents who stutter. In their survey of 36 adolescents, Erickson and Block (2013) found that 53% had experienced teasing and bullying because of their stuttering. In the Mulcahy et al. (2008) survey of 36 adolescents who stutter, respondents reported apprehension about communicating and feelings of low communicative competence. Erickson and Block also found low self-identified communication competence in their survey, although this may not be universal (see Blood, Blood, Tellis, & Gabel, 2003). Interestingly, 60% of the 48 adolescents in the Blood et al. (2003) study reported that they almost never talked about their stuttering and 42% of the 36 respondents in the Erickson and Block (2013) survey also reported that they often tried to keep their stuttering secret. This reticence emerged as a theme in the Hearne et al. (2008) qualitative study of 13 adolescents who Please cite this article in press as: Messenger, M., et al. Children and adolescents who stutter: Further investigation of anxiety. Journal of Fluency Disorders (2015), http://dx.doi.org/10.1016/j.jfludis.2015.07.006
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stutter. One participant said of his stuttering, “Maybe I was in denial, it was like if I don’t mention it and no one mentions it, then it’ll go away . . .” (p. 87). 1.3. Anxiety research in children and adolescents who stutter The prevalence of anxiety disorders is reported to be higher in children with communication disorders generally (Beitchman et al., 2001). Yet, the evidence for this in children who stutter is equivocal (Smith et al., 2014). In the Smith et al. (2014) report, which was a review of the literature, the authors concluded that the findings of 12 studies of anxiety and stress in school-age children and adolescents who stutter were inconclusive. Around half the studies found increased anxiety compared to controls while the others did not. The only study of preschoolers (van der Merwe, Robb, Lewis, & Ormond, 2011) found no differences between children who were stuttering and matched controls on anxiety measures and salivary cortisol levels. However, as the authors said, four of the seven stuttering children were receiving treatment at the time, which could have biased the findings. A study of children and adolescents aged 10–17 years (Davis, Shisca, & Howell, 2007) using the Stait-Trait Anxiety Inventory for Children found that those who were still stuttering did not differ from those who had recovered from stuttering and from normally fluent controls for trait anxiety, but scored significantly higher than these two groups for state anxiety. The authors concluded that this suggests stuttering can lead to the development of anxiety. According to Smith et al. (2014), possible reasons for the failure of their review to find conclusive results related to methodological factors such as lack of statistical power and the variety of anxiety measures used across studies. For example, while appropriate measures such as the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 2002) were used with adolescents, this was not the case for younger children. It is also the case that very few girls were included in the studies. The authors concluded, “. . . the timing of anxiety onset in stuttering, and the status of anxiety in stuttering children and adolescents, is unclear.” (p. 30). Given the negative effects that stuttering can have from the preschool years through adolescence, this suggests the need for further research into anxiety in children who stutter. 1.3.1. The RCMAS The aim of the present study is to contribute further knowledge to the development of social anxiety disorder in adults who stutter, using the RCMAS with children and adolescents who stutter. There are a number of reasons the RCMAS was considered to be ideal for this purpose. First, is a widely used psychological assessment for anxiety in both children and adolescents, ranging from age 6–19 years. This provides the ability to determine when anxiety may start to develop and, if starting during childhood, whether it progresses over time. Second, a subscale of the RCMAS, Social Concerns/Concentration, can potentially identify the onset of social anxiety. Third, for each subscale, the RCMAS provides a cut-off score (subscale of 13) to indicate the clinically significant range. Finally, the RCMAS is easy to administer, being a self-report pencil and paper test that takes 10–15 min to complete. The RCMAS has 37 items and consists of four subscales: Physiological Anxiety, Worry/Oversensitivity, Social Concerns/Concentration and the Lie Scale. In addition, it provides a Total Anxiety score. The subscales measure what their names suggest: physiological signs of anxiety, worry and oversensitivity (nervousness, feeling overburdened) and being unduly concerned about other people’s perception. The Lie subscale assesses deception by the respondent in order to mask true feelings; Examples of Lie Scale questions include “I’m always kind,” and “I never get angry”. The Total Anxiety score is the overall score. The RCMAS-2 (Reynolds & Richmond, 2008) is a revised version of the RCMAS. To date in stuttering research, the RCMAS has only been used in studies of older children and adolescents (Blood & Blood, 2007; Blood et al., 2007; Gunn et al., 2014). Blood and Blood (2007) reported the administration of the RCMAS to 18 stuttering children and 18 controls (all boys) aged 11–12 years. Scores for Total Anxiety on the RCMAS were significantly higher in the stuttering group but both group means fell in the normal range. Blood et al. (2007) reported the administration of the RCMAS to 36 adolescents who stutter (30 males and 6 females, mean age 14.3 years) and also found higher Total Anxiety scores for the stuttering group compared to controls. However, again, the mean scores fell within the normal range. Gunn et al. (2014) reported the administration of the RCMAS-2 to 37 adolescents who stutter aged 12–17 years (36 males and one female). The participants were divided into a younger group (age 12–14 years) and an older group (age 15–17 years). Results indicated that the means for Total Anxiety (T scores) and all subscales fell within the normal range, with the older group scoring significantly higher than the younger group for Total Anxiety, Physiological Anxiety and Worry. There was no significant difference between the age groups for Social Anxiety. However, the authors noted that while means for Defensiveness were within the normal range, scores for eight participants in the younger group and six participants in the older group fell within the clinical range. The Defensiveness Scale in the RCMAS-2 is similar to the Lie Scale in the RCMAS and indicates that respondents may be attempting to conceal anxiety, feel isolated and are seeking social approval. In summary, research to date using the RCMAS and the RCMAS-2 has shown that older children and adolescents who stutter score higher than controls on anxiety scores, but as a group do not score in the clinical range for anxiety. It is important to note that the youngest children to be assessed with the RCMAS in these studies were age 11 years (Blood & Blood, 2007). 1.4. The present study The aim of the present study was to use the RCMAS with both children and adolescents who stutter, to attempt to shed more light on the age of onset of the social anxiety disorder that is known to be present in many adults who stutter. There Please cite this article in press as: Messenger, M., et al. Children and adolescents who stutter: Further investigation of anxiety. Journal of Fluency Disorders (2015), http://dx.doi.org/10.1016/j.jfludis.2015.07.006
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is reason to believe that such anxiety should be developing in the school-age and adolescent years but to date this has not been shown to be unequivocally the case. This is the first study in which the RCMAS has been used with younger children who stutter and the first time it has been used for both school-age children and adolescents. The aim of this was to identify the presence of any anxiety from the early school-age years through adolescence. The male:female ratio is similar to that in the stuttering population of around 4:1. There were no control groups; rather the scores were compared to test norms to determine how participants compared to the general population and whether any were above the clinical cut-off scores provided by the RCMAS. 2. Method 2.1. Participants Participants were 73 young people who stuttered, ranging in age from 6 to 18 years and divided into two groups. The school-age group comprised 18 boys aged 6–11 years (mean 8;6) and 5 girls aged 7–11 years (mean 8;8). The Adolescent Group comprised 41 boys aged 13–18 years (mean 14;8) and 9 girls aged 13–16 years (mean 15;1). All had been identified as stuttering by parents and by a speech-language pathologist and were awaiting treatment for their stuttering at speechlanguage pathology clinics at universities and hospitals within Australia. Participants were included as they came on to wait lists, which explains the small number of females in the study. No participants had any concomitant speech or language disorder and none were currently receiving any other treatment for stuttering. The RCMAS was included along with a range of assessments made in these clinics shortly before participants started treatment. The Human Ethics Research Committee of The University of Sydney and other relevant Ethics Committees granted permission to conduct the study. 2.2. Procedure Potential participants and their parents were approached prior to starting treatment by an independent person and asked whether they were willing for their children to participate in a study about mental health and stuttering. All parents approached gave informed consent. Participants completed the RCMAS and rated the severity of their “typical stuttering” and “most severe stuttering” for the situation talking with friends. These two self-rating categories give an indication of ranges of severity. Participants rated the severity of their stuttering on a 9-point scale (1 = “no stuttering”, 9 = “extremely severe stuttering”). Self-reported severity ratings have been shown to correlate with the severity ratings of speech-language pathologists in adults in the clinic (O’Brian, Packman, & Onslow, 2004) but this has not been demonstrated for the age groups in this study. However, self-rating provides a socially valid indication of stuttering severity in the real world and is appropriate for use in this study as participants’ responses to the RCMAS were also self-generated. 2.3. Data analysis Scores on the RCMAS were analyzed separately for boys and girls and were compared with normative data. Given the findings of differences across subscale scores for both the school-age boys and the adolescent boys, one-way repeated measures ANOVAs were conducted to determine the significance of these differences. 3. Results 3.1. School-age group 3.1.1. Boys Mean self-rated stuttering severity for the school-age boys on the 9-point scale was 6.6 (range 5–9) for their most severe stuttering and 5.7 (range 4–8) for their typical stuttering. The scores for the RCMAS are shown in Table 1. All the mean RCMAS scaled scores for the school-age boys fall within the normal range of below of 13. However, for two reasons, the pattern of scores for this group is unusual. First, the mean scaled score of 11 on the Lie Scale was the highest of the subscale scores. When viewed as a percentile, as a group these children scored higher on the Lie Scale than 71% of their peers and five of the boys (28%) scored in the clinically significant range. Second, all other subscale percentiles are low, in the range of 16–28. This is surprising for a group of children for whom there is good reason to believe that anxiety may be developing. The ANOVA showed a significant effect for the RCMAS scaled scores for the four subscales, F(3,51) = 14.77. p < .0001. A post hoc Tukey test showed that the Lie Scale scores differed significantly from the other three subscale scores (p < .01). 3.1.2. Girls Mean self-rated stuttering severity for the girls in this group on the 9-point scale was 8 (range 6–9) for their most severe stuttering and 6.6 (range 5–9) for their typical stuttering. The scores for the RCMAS are shown in Table 1. All mean scores for these girls were within the normal range and the percentile profile was unremarkable.
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Table 1 RCMAS scores for the school-age boys, school-age girls, adolescent boys and adolescent girls.
School-age boys (n = 18) Mean score SD Scaled score Percentile School age girls (n = 5) Mean score SD Scaled score Percentile Adolescent boys (n = 41) Mean score SD Scaled score Percentile Adolescent girls (n = 9) Mean score SD Scaled score Percentile
Physiological anxiety
Worry/ oversensitive
Social concerns/concentration
Lie Scale
Total Anxiety
2.1 1.61 7 16
2.5 2.12 8 28
1.34 1.28 7 21
5.2 2.26 11 72
6.05 3.65 42 (T-score) 20
3 2.54 7 22
4.8 2.9 9 45
2.4 1.34 9 39
3.2 1.3 9 48
10.2 5.9 45 (T-score) 31
2.3 1.98 9 40
3.2 2.75 9 39
1.8 1.58 9 45
3.8 2.2 12 83
7.4 5.1 46 (T-score) 34
4.5 1.9 11 73
5.7 3 11 65
2.5 2.4 10 50
3.1 1.69 11 68
12.8 5.6 54 (T-score) 50
3.2. Adolescent group 3.2.1. Boys Mean self-rated stuttering severity for the adolescent boys on the 9-point scale was 6.2 (range 3–9) for their most severe stuttering and 3.9 (range 1–8) for their typical stuttering. The scores for the RCMAS are shown in Table 1. All mean subscale scores fall within the normal range. In contrast to the school-age boys, these scores are just below the 50th percentile. However, as was the case for the school-age boys, the mean Lie Scale score is markedly high, in fact higher than for the school-age boys and the mean scaled score only slightly below the clinically significant cut-off of 13. Sixteen of them (39%) scored in the clinically significant range. When viewed as a percentile, as a group the adolescent boys scored higher on the Lie Scale than 82% of their peers. As for the school-age boys, the ANOVA showed a significant effect for RCMAS scaled scores for the four subscales, F(3,120) = 6.47, p < .0001. A post hoc Tukey test showed that the Lie Scale scores differed significantly from the other three subscale scores (p < .01). 3.2.2. Girls Mean self-rated stuttering severity for the adolescent girls in this group on the 9-point scale was 6.0 (range 3–9) for their most severe stuttering and 4.8 (range 1–8) for their typical stuttering. The scores for the RCMAS are shown in Table 1. Again all mean scores are within the normal range. However, three mean scores on subscales were high, with Physiological Anxiety at the 73rd percentile and Lie Scale scores at the 68th percentile. Two of the girls (22%) scored in the clinically significant range for the Lie Scale. 4. Discussion 4.1. Overview of findings The mean self-rated stuttering severity for both the school-age children and the adolescents for an everyday situation, namely talking with friends, ranged from 3 to 8 on the 9-point scale. This suggests a wide range of severity. This study is the first to investigate anxiety in school-age children who stutter using the RCMAS. For this group, the means for Total Anxiety and the subscales on the RCMAS were within the normal range. The study also investigated anxiety in adolescents who stutter with the RCMAS. The findings for this group were similar to those of the younger group, with no means falling within the clinically significant range. This is consistent with previous research into anxiety in this age group. As suggested in Section 1, there is clear evidence that children and adolescents who stutter are at greater risk of exposure to the environmental factors known to lead to social anxiety, the most critical being teasing and bullying (see Smith et al., 2014). It is extraordinary, then, that social anxiety disorder involving fear of negative evaluation in social situations is consistently identified in up to 66% of adults who stutter but that research to date, including the present study, has failed to find consistent evidence of this anxiety developing prior to adulthood. In the present study, for example, both groups were at the 50th percentile or lower for the subscale that measures social concerns. However, close examination of the results of the present study gives an indication of why this might be the case. The profiles of subscale scores show that the boys in both groups had high Lie Scale scores and much lower scores on the other subscales. As shown for the means in Table 1, for the Lie Scale the school-age boys were at the 72nd percentile and the Please cite this article in press as: Messenger, M., et al. Children and adolescents who stutter: Further investigation of anxiety. Journal of Fluency Disorders (2015), http://dx.doi.org/10.1016/j.jfludis.2015.07.006
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adolescent boys were at the 83rd percentile, with scaled scores just below the clinically significant level of 13. In contrast, the other subscale scores for the school-age boys were below the 29th percentile and for adolescent boys were below the 45th percentile. While the mean Lie Scale scores did not identify the groups as falling within the clinically significant range, it is important to note that 28% of the school-age boys and 39% of the adolescent boys were in the clinically significant range. It is of interest that both the school-age and the adolescent girls were more uniform across the RCMAS subscales. In other words, they did not show relatively higher Lie Scale Scores, although 22% of the adolescent girls were within the clinical range. It should be noted, however, that the number of girls was quite small (five in the schoolage group and nine in the adolescent group) compared to boys (18 in the school-age group and 41 in the adolescent group. Interestingly, high Lie Scale scores were not reported for the 36 adolescents who stutter in the Blood et al. (2007) study. Although they scored higher than controls on Total Anxiety, there was no difference in Lie Scale scores, which lay well within the normal range. However, the findings for the Lie Scale scores in the present study are consistent with those of Gunn et al. (2014). Although Gunn et al. used the RCMAS-2, they also reported that while mean Total Anxiety and all subscale scores were within the normal range, Defensiveness Scale scores were high, relative to the scores of the other subscales. The RCMAS-2 Defensiveness Scale is similar to the RCMAS Lie Scale. In Gunn et al. study, 38% of the 37 adolescents who stutter scored in the clinical range for defensiveness. This is comparable to the 39% of adolescent boys and the 22% of adolescent girls in the present study that scored in the clinical range of Lie Scale scores.
4.2. Interpretation of high Lie Scale scores High Lie Scale scores on the RCMAS do not suggest that respondents lie more in everyday situations than their peers, but rather that they may be deceiving on the present test questions. In the general population, high Lie Scale scores are thought to indicate that respondents are giving the answers they think the examiners want to hear (Dadds, Perrin, & Yule, 1998; Pina, Silverman, Saavedra, & Weems, 2001; Reynolds & Richmond, 2002). Pina et al. (2001) suggested that respondents with high Lie Scale scores might be deliberately misrepresenting the truth to prevent others from seeing their limitations and faults. Similarly, Reynolds and Richmond (2002) suggested that high Lie Scale scores indicate that respondents are presenting an ideal view of themselves that is generally impossible, wishing to establish the examiners’ approval by making their scores more acceptable than they are in reality. These authors suggest that by scoring low or average on anxiety they “fake good” and produce an “ideal image” of themselves (p. 10). Of importance in the present context, Reynolds and Richmond (2002) indicated that high Lie Scale scores may reflect social issues related to anxiety, such as feelings of social isolation or rejection and a desire to be approved and accepted. High Lie Scale scores may also indicate a concern about the evaluations of others, a core component in social anxiety disorder. These explanations could be seen to apply to many young people who stutter. Of importance in the present context, Dadds et al. (1998) reported that high Lie Scale scores were associated with poor outcomes for anxiety treatment. This may have implications for stuttering treatments, in that it may be that individuals with high Lie Scale scores may not respond as well to treatment as those who do not. This would be seem to be a profitable area for future research. These interpretations of high Lie Scale sores on the RCMAS provide some insights into the findings in the present study; that is, while Lie Scale scores were high, in comparison anxiety scores were much lower. In particular, Lie Scale scores were significantly higher than scores for the subscale that indicates social concerns. It should be noted, however, that this applied to the school-age and adolescent boys only. One interpretation is that the boys in the present study were attempting to mask anxiety when completing the RCMAS. Higher levels of anxiety about social situations would have been expected, given the relatively high levels of stuttering severity reported by the participants themselves. Higher levels of anxiety would not have been a surprise in the present study, given the negative psychosocial impact that stuttering can have on children and adolescents and even on preschoolers, including feelings of being incompetent as communicators. One possible explanation for the unremarkable Lie Scale scores of the female participants is that females are reported to feel more comfortable about disclosing their problems during childhood and adolescence than males (Rose et al., 2012). This is also the first study of anxiety to raise the possibility that children who stutter may conceal their true feelings under test conditions. However, the finding that boys were apparently attempting to mask any anxiety about their stuttering is supported by reports of reticence by many adolescents to disclose their stuttering, to talk about their stuttering and to seek treatment for their stuttering (Blood et al., 2003; Erickson & Block, 2013; Huber, Packman, Quine, Onslow, & Simpson, 2004). In light of this, it may also be the case that participants under-reported the severity of their stuttering. Further research could investigate the extent to which self-reported severity ratings in children and adolescents correlate with the severity ratings of speech-language pathologists, similar to the study of O’Brian et al. (2004) with adults. Of interest are reports that Lie Scale scores can be influenced by cultural factors (Pina et al., 2001; Reynolds & Richmond, 1978). The present findings of increased Lie Scale scores and the increased Defensiveness Scale scores of Gunn et al. (2014) for Australian children and adolescents who stutter are in contrast to the findings of Blood and Blood (2007) and Blood et al. (2007), in which there was no suggestion that Lie Scale scores were higher than scores on other subscales. These differences could perhaps be due to cultural differences but they may also be due to other factors relating to the conduct of the studies, such as recruitment procedures and administration.
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4.3. Clinical implications An important implication of the present findings for speech-language pathologists is that they should keep in mind that children and adolescents who present to a clinic because of their stuttering, especially boys, may be more socially anxious than they report. As suggested in the Hearne et al. (2008) study, some adolescents may be in denial about their stuttering. This of course will not be the case for all individuals, but the possibility should be explored. Drawing on the findings of Dadds et al. (1998), it is also important to keep in mind that defensiveness, if not addressed, could limit an individual’s responsiveness to treatment. It would be prudent, then, for speech-language pathologists to question children and adolescents carefully to ascertain whether they are concealing concerns about the impact their stuttering may be having on their psychosocial wellbeing and to instigate appropriate assessment and intervention if this is suspected. 4.4. Conclusions It must be stressed again that the mean Lie Sale findings for the groups in the present study fell within the normal range. Hence, our interpretations of the findings must be regarded with caution. However, the Lie Scale scores for boys in both groups were very high compared to other RCMAS subscores and it is this profile of subscores that is of particular interest. In addition, the present high Lie Scale scores support the findings of Gunn et al. (2014) for adolescents who stutter. They suggest that children and adolescents who stutter may be concealing concerns about their stuttering when asked. The present study is the first to show this effect in both school-age and adolescent boys who stutter; indeed, it is the first study to investigate anxiety using the RCMAS with children who stutter below the age of 11 years. Clearly, more research is needed to determine the true prevalence of social anxiety in these age groups (Iverach & Rapee, 2014). It is suggested that using the same assessment procedure for both groups, as in the present study, could be fruitful. As suggested by Mulcahy et al. (2008), it would also be important to ensure that participants in future research are not receiving treatment for their stuttering at the time of assessment, as this could result in bias. It may be that individuals feel well supported while receiving treatment and so are more likely to report lower levels of anxiety then than they otherwise would. Acknowledgments This research was supported in part by National Health and Medical Research Council Program Grant number 633007. Conflict of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing. CONTINUING EDUCATION Further investigation of anxiety in children and adolescents who stutter QUESTIONS 1. The RCMAS gives a measure of (a) (b) (c) (d) (e)
Depression Personality Anxiety Temperament Aggression
2. The age at which adults who stutter start to develop social anxiety is: (a) (b) (c) (d) (e)
Pre-school years (2–5) School-age years (6–12) Adolescence (13–17 years) Adulthood (18+ years) Unknown
3. High RCMAS Lie subscale scores can indicate (a) (b) (c) (d) (e)
Depression Habitual lying Narcisism Avoidance Desire to mask true feelings
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4. The participants in the present study are, (a) (b) (c) (d) (e)
School-age children and adolescents who stutter Adults who stutter Adolescents who stutter and normally fluent adolescents Children who stutter and normally fluent children Preschoolers who stutter
5. The RCMAS results for the boys in this study are considered noteworthy because: (a) (b) (c) (d) (e)
Mean Total Anxiety score was in the clinical range Mean Lie Scale score was much higher than scores on the other subscales The profile of scores was typical of normally fluent boys Mean score for Physiological Anxiety was in the 80th percentile Mean Total Anxiety score was lower than all subscale scores
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Michelle Messenger, PhD, currently works for Family and Community Services – Ageing, Disability and Home care as a psychologist. Ann Packman, PhD, is Senior Research Officer at the Australian Stuttering Research Centre, the University of Sydney. Mark Onslow, PhD, is Director of the Australian Stuttering Research Centre, the University of Sydney. Ross Menzies, PhD, is a clinical psychologist and researcher at the Australian Stuttering Research Centre, the University of Sydney. Sue O’Brian, PhD, is Senior Research Fellow at the Australian Stuttering Research Centre, the University of Sydney.
Please cite this article in press as: Messenger, M., et al. Children and adolescents who stutter: Further investigation of anxiety. Journal of Fluency Disorders (2015), http://dx.doi.org/10.1016/j.jfludis.2015.07.006