Journal of Fluency Disorders 40 (2014) 58–68

Contents lists available at ScienceDirect

Journal of Fluency Disorders

Axis I anxiety and mental health disorders among stuttering

adolescents
Anthony Gunn a , Ross G. Menzies a , Sue O’Brian a , Mark Onslow a,∗ ,
Ann Packman a , Robyn Lowe a , Lisa Iverach b , Robert Heard c , Susan Block d
a
Australian Stuttering Research Centre, The University of Sydney, Australia
b
Department of Psychology, Macquarie University, Australia
c
Behavioural and Social Sciences in Health, The University of Sydney, Australia
d
School of Human Communication Sciences, La Trobe University, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: The purpose of this study was to evaluate anxiety and psychological functioning
Received 9 July 2013 among adolescents seeking speech therapy for stuttering using a structured, diagnostic
Received in revised form 9 August 2013 interview and psychological questionnaires. This study also sought to determine whether
Accepted 20 September 2013
any differences in psychological status were evident between younger and older adoles-
Available online 29 September 2013
cents.
Method: Participants were 37 stuttering adolescents seeking stuttering treatment. We
Keywords: administered the Computerized Voice Version of the Diagnostic Interview Schedule for Chil-
Stuttering dren, and five psychometric tests. Participants were classified into younger (12–14 years;
Adolescents n = 20) and older adolescents (15–17 years; n = 17).
Anxiety Results: Thirty-eight percent of participants attained at least one diagnosis of a mental dis-
Mental health order, according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental
DSM assessment Disorders, Fourth Edition (DSM-IV; APA, 2000), with the majority of these diagnoses involv-
Axis I
ing anxiety. This figure is double current estimates for general adolescent populations, and
is consistent with our finding of moderate and moderate–severe quality of life impairment.
Although many of the scores on psychological measures fell within the normal range, older
adolescents (15–17 years) reported significantly higher anxiety, depression, reactions to
stuttering, and emotional/behavioral problems, than younger adolescents (12–14 years).
There was scant evidence that self-reported stuttering severity is correlated with mental
health issues. There are good reasons to believe these results are conservative because many
participants gave socially desirable responses about their mental health status.
Discussion: These results reveal a need for large-scale, statistically powerful assessments of
anxiety and other mental disorders among stuttering adolescents with reference to control
populations.

Educational Objectives: The reader will be able to: (a) explain the clinical importance of
assessing for mental health with stuttering adolescents, (b) state the superior method for
adolescent mental health assessment and (c) state a major issue with determining the
genuineness of stuttering adolescent responses to psychological assessment.
© 2013 Elsevier Inc. All rights reserved.

∗ Corresponding author at: Faculty of Health Sciences, The University of Sydney, PO Box 170, Lidcombe, NSW 1825, Australia. Tel.: +61 29351 9061;
fax: +61 29351 9392.
E-mail addresses: agun4874@uni.sydney.edu.au (A. Gunn), ross.menzies@sydney.edu.au (R.G. Menzies), sue.obrian@sydney.edu.au (S. O’Brian),
mark.onslow@sydney.edu.au (M. Onslow), ann.packman@sydney.edu.au (A. Packman), robyn.lowe@sydney.edu.au (R. Lowe), lisa.iverach@mq.edu.au
(L. Iverach), rob.heard@sydney.edu.au (R. Heard), S.Block@latrobe.edu.au (S. Block).

0094-730X/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jfludis.2013.09.002
 A. Gunn et al. / Journal of Fluency Disorders 40 (2014) 58–68 59

1. Introduction

1.1. Stuttering and mental health research

During the past decade, researchers have generated much evidence of an association between stuttering and mental
health problems (Alm & Risberg, 2007; Blumgart, Tran, & Craig, 2010; Craig, Hancock, Tran, & Craig, 2003; Iverach, O’Brian,
et al., 2009a; Iverach, Menzies, O’Brian, Packman, & Onslow, 2011; Menzies et al., 2008; Menzies, Onslow, & Packman, 1999;
Mulcahy, Hennessey, Beilby, & Byrnes, 2008; Stein, Baird, & Walker, 1996). Some of this research has utilized the diagnos-
tic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychological
Association, 2000; Blumgart et al., 2010; Iverach, Jones, et al., 2009; Iverach, O’Brian, et al., 2009a, 2009b), which is a standard
form for determining mental health disorders. Iverach, Jones, et al. (2009) assessed 92 adults seeking treatment for stuttering
using a structured diagnostic DSM-IV assessment. They reported a six- to seven-fold increased odds of DSM-IV anxiety dis-
order diagnosis, with 16- to 34-fold increased odds for social anxiety disorder and four-fold increased odds for generalized
anxiety disorder. Similarly, Blumgart et al. (2010) assessed a sample of 50 stuttering adults, and found that 40% (20/50) met
DSM-IV criteria for Social Anxiety Disorder (SAD).

1.2. Mental health of stuttering adolescents

The bulk of research about anxiety and stuttering has focused on adults, yet it is possible that anxiety and other mental
disorders may occur for stuttering adolescents especially as most anxiety disorders start in adolescence (Albano, DiBartolo,
Heimberg, & Barlow, 1995). Nevertheless, results from the few studies of stuttering adolescents are mixed. Higher anxiety
scores (Davis, Shisca, & Howell, 2007; Mulcahy et al., 2008), psychological distress (McAllister, Collier, & Shepstone, 2013)
and speech apprehension (Blood, Blood, Tellis, & Gabel, 2001) have been found for stuttering adolescents compared to
controls. However, some reports have indicated the opposite (Blood, Blood, Maloney, Meyer, & Dean Qualls, 2007; Craig &
Hancock, 1996), Blood, Blood, Tellis, and Gabel (2003) reported normal self-esteem levels. A limitation of all these studies is
that none have incorporated a DSM-IV structured diagnostic interview for mental health disorders. We believe this mental
health information for stuttering adolescents is vital, as adult studies have shown that mental health disorders impact adult
speech treatment (Iverach, Jones, et al., 2009).

1.3. The structured diagnostic interview for mental health research

Structured diagnostic interviews are considered to be the gold standard for establishing diagnoses of anxiety and other
mental disorders. The clinician asks a series of structured questions based upon the diagnostic criteria of the DSM-IV. The
Diagnostic Interview Schedule for Children (DISC; Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000) is one of the most
widely used structured diagnostic interviews with adolescents. The DISC has been evaluated and validated for community
and clinical populations (Shaffer et al., 1996, 2000).
The DISC is available as a computerized self-administered test called the C-DISC. A recent update of the C-DISC (for a
review see Shaffer et al., 2000), known as the Voice DISC, is self administered using computerized voice files and does not
require a clinician to be present. The Voice DISC produces a series of reports including a diagnostic report that indicates
symptoms and criteria for 36 DSM-IV mental health disorders that affect children and adolescents.
Research comparing the Voice DISC with the original version of the DISC has found it to be reliable and valid (Ko,
Wasserman, McReynolds, & Katz, 2004; Lucas, 2003; Wasserman, McReynolds, Lucas, Fisher, & Santos, 2002; West, Sweeting,
Der, Barton, & Lucas, 2003). In fact, one report suggested that the Voice DISC is superior to the standard version (Hayes,
McReynolds, & Wasserman, 2005). This may be because adolescents are known to be more forthcoming during a self admin-
istered interview format compared with a psychologist interview when reporting socially undesirable symptoms, such as
drug and alcohol use and suicidal ideation (Turner et al., 1998).

1.4. Existing adolescent mental health research using DSM-IV DISC

Using the Voice DISC with a large adolescent mental health sample in America, Roberts, Roberts, and Xing (2007) reported
DSM-IV psychiatric diagnoses rates for 4175 adolescents aged 11–17 years, 51% of whom were boys and 49% girls. They
reported that 17.1% of the sample met DSM-IV criteria for one or more disorders during the previous year. This figure was
consistent with estimates from earlier DISC studies with substantive samples: 21.1% of 920 adolescents (Angold et al., 2002)
and 19.8% of 1886 adolescents (Canino et al., 2004).

1.5. Study aims

To our knowledge, no previous studies have conducted structured diagnostic interviews with stuttering adolescents.
Hence, the present study sought to evaluate the psychological status of adolescents who stutter, with the following aims:
(1) evaluate the presence of DSM-IV Axis I diagnoses among stuttering adolescents using the Voice DISC; (2) assess anxiety
and psychological functioning via five standard psychological pencil-and-paper assessments, (3) compare the psychological
60 A. Gunn et al. / Journal of Fluency Disorders 40 (2014) 58–68

status of younger (12–14 years) versus older (15–17 years) stuttering adolescents, (4) compare the scores of stuttering
adolescents to their parents scores in relation to the adolescents’ mental health, and (5) determine if self-reported stuttering
severity is correlated with anxiety.

2. Method

2.1. Participants

Thirty-seven stuttering adolescents, 36 boys and one girl, were recruited from waiting lists at two Australian university
stuttering treatment clinics. Participants had a mean age of 14.2 years (SD = 1.6, range 12–17 years). For the purposes of
evaluating potential differences in anxiety and psychological functioning associated with age, participants were grouped
into younger adolescents (12–14 years; n = 20, Mean age = 13.1, SD = 0.9) and older adolescents (15–17 years; n = 17, Mean
age = 15.6, SD = 0.7).

2.2. Eligibility criteria

Eligibility criteria for inclusion in the study were: (1) age 12–17 years, (2) stuttering onset before 12 years, (3) seeking
stuttering treatment, (4) stuttering confirmed by a speech-language pathologist, (5) functional English (written and spoken),
and (6) evidence of unambiguous stuttering in the clinic or on at least one audio recording beyond the clinic.

2.3. Measures

The following is a description of the measures obtained during the initial assessment for stuttering treatment.

2.3.1. Stuttering severity

Stuttering severity was measured using a 9-point self-report severity rating (SR) scale where 1 = no stuttering, 2 = extremely
mild stuttering and 9 = extremely severe stuttering. The scale has been shown to be valid and reliable (O’Brian, Packman, &
Onslow, 2004). Participants were provided with a standard list of eight speaking situations: (1) talking with a family member,
(2) talking with a best friend, (3) talking in a group of friends, (4) talking with an authority figure such as a teacher, (5) verbally
providing name and address, (6) giving a class presentation, (7) talking on the telephone, and (8) ordering food or drink.
Participants were asked to assign a typical and a worst SR score to each situation. Scores from the eight areas were averaged
to produce a mean typical stuttering severity rating, and a mean worst stuttering severity rating.

2.3.2. The Diagnostic Interview Schedule for Children (Voice DISC)

Participants completed the assessment at one of two stuttering treatment clinics. The Voice DISC manual stresses the
importance of privacy during assessment (Shaffer, Lucas, & Fisher, 2010). Accordingly, participants completed it alone in a
room using a computer with Voice DISC installed, and a pair of headphones for the Voice DISC audio commands. A research
assistant initially explained to each participant how the program worked and demonstrated how to control computer
functions such as the volume of the headphones. The research assistant also explained that they were in an office a short
distance away, and if the participant needed to contact the research assistant for any reason they could. Participants were
asked to advise the research assistant once they had finished the assessment. The Voice DISC also has the ability to record
participant completion times, and the manual provides an approximate participant completion time of 63 min for community
samples.

2.3.3. The Revised Children’s Manifest Anxiety Scale: second edition (RCMAS-2)
The RCMAS-2 (Reynolds & Richmond, 2008) is a widely used self-report anxiety measure for clinical and research purposes
(Seligman, Ollendick, Langley, & Balducci, 2004; White & Farrell, 2001). The RCMAS-2, has been shown to have consistent
outcomes across cultures (Ang, Lowe, & Yusof, 2011). It is a 49-item, self-report questionnaire for children and adolescents
between 6 and 19 years of age, which uses a yes/no format for 49-items, which are then classified into one of six scales: (1)
physiological anxiety, (2) worry, (3) social anxiety, (4) defensiveness, (5) inconsistent responding, and (6) total anxiety. The
RCMAS-2 was chosen for the present study for its Defensiveness Scale, and the Inconsistent Responding Index. However,
the other scales were also reported.
The Inconsistent Responding Scale and the Defensive Scale are designed to detect respondents giving invalid or biased
responses. The Inconsistent Responding Scale is based on responses to nine pairs of questions. If there are discrepancies
between the answers for each pair, this suggests distraction when completing the assessment or English language problems.
The Defensiveness Scale is also based on responses to nine questions. These items indicate whether the respondent is
willing to admit to common everyday imperfections. High Defensiveness Scale scores suggest the respondent may need
social acceptance and feel social isolation or rejection.
 A. Gunn et al. / Journal of Fluency Disorders 40 (2014) 58–68 61

2.3.4. Children’s Depression Inventory (CDI)

The CDI (Kovacs, 1992) comprises 27 items scored on a three-point scale with values of 0–2, which provide a total
score. Respondents rate each CDI item according to how much they have experienced each depressive symptom during the
previous two weeks. The CDI total score has good internal consistency, with Cronbach’s alpha 0.71–0.89, and good test–retest
reliability, with Pearson correlations 0.87 after 1 week to 0.59 after 6 weeks (Saylor, Finch, Baskin, Furey, & Kelley, 1984).
Some researchers have raised concerns about the CDI being used incorrectly (see Fristad, Emery, & Beck, 1997; Matthey &
Petrovski, 2002). Fristad et al. (1997) reviewed 133 studies that used the CDI to measure depression and found that 68% did
not use a clinical or structured interview to determine diagnostic status, but 44% still gave a diagnosis of “depressed” based
solely on high CDI scores. Hence researchers warn against using the CDI alone without a structured interview to determine
diagnostic status due to issues with cut-off scores (Matthey & Petrovski, 2002), and the manual warns against this practice
(Kovacs, 1992). However, when used in conjunction with other measures for depression, the CDI Total Score is an excellent
continuous measure of depressed mood (Fristad et al., 1997; Matthey & Petrovski, 2002).

2.3.5. The Youth Self Report (YSR) and Child Behavior Checklist (CBCL)
The YSR and CBCL (Achenbach & Rescorla, 2001) are complementary measures designed to evaluate the behavioral and
emotional functioning of adolescents. The YSR is completed by adolescents 11–17 years of age, and the CBCL is completed by
the adolescent’s primary caregiver. Both the YSR and the CBCL consist of 112 items pertaining to behavioral, emotional and
social problems experienced by the adolescent in the present or within the past six months. Responses to these items are
used to calculate scores on the following scales: (1) Competence Scales, (2) Syndrome Scales, and (3) DSM-Oriented Scales.
Firstly, the Competence Scales assess participation in general activities, social activities, and school activities, with lower
scores indicative of numerous problems. Secondly, the Syndrome Scales are based on problem items that can be classi-
fied into two broad Syndrome categories: (1) Internalizing, and (2) Externalizing. The Internalizing category consists of
problems largely within the self, including (i) anxious/depressed, (ii) withdrawn/depressed, and (iii) somatic complaints.
The Externalizing category consists of conflicts with other people, including: (i) rule-breaking behavior; and (ii) aggressive
behavior.
Finally, the DSM Oriented Scales are based on DSM-IV diagnostic criteria, and include Affective Problems, Anxiety Prob-
lems, Somatic Problems, Attention Deficit/Hyperactivity Problems, Oppositional Defiant Problems, and Conduct Problems.
The YSR and CBCL have good reliability and validity (Achenbach & Rescorla, 2001).

2.3.6. Overall assessment of the speaker’s experience of stuttering (OASES-S and OASES-T)
This is a self-assessment item developed originally to assess quality of life with stuttering adults (Yaruss & Quesal, 2010).
There are three versions: OASES-S for ages 7–12, OASES-T for ages 13–17, and OASES-A for ages 18 and above. The former
two versions differ from the latter with simpler language. We used the OASES-S and the OASES-T for our adolescent sample
aged 12–17 years. The OASES-S and OASES-T contain four sections: (1) general information, (2) reactions to stuttering, (3)
communication in daily situations, and (4) quality of life. Scores from these sections are used to calculate the Total Impact
Score, which evaluates the overall impact of stuttering on the respondent’s life. The OASES-A has acceptable reliability and
validity (Blumgart, Tran, Yaruss, & Craig, 2012; Yaruss & Quesal, 2006, 2010). Even though both the OASES-S and OASES-T
have not been assessed as rigorously as the adult version, preliminary findings are positive (see Yaruss & Quesal, 2010).

2.4. Procedure

The computerized assessment (Voice DISC) was completed at one of two stuttering treatment clinics with no assistance
or supervision from a parent or professional person. Participants were posted the five pencil-and-paper assessments. One
of these assessments, the CBCL, was completed by the adolescent’s parent/career. The assessments were completed by the
participants in their homes and returned on the day of the computerized assessment. In the week before completing the
computerized diagnostic assessment each participant received two unscheduled 10-min phone calls from a stranger (a
research assistant from the Australia Stuttering Research Center). Participants were aware that their phone conversations
were being recorded and gave prior written consent.

2.5. Data analysis

After data screening, preliminary analyses used two-sample t-tests to compare scores on the adolescent self-report
measures (RCMAS-2, CDI, OASES, YSR, Stuttering Severity, and Voice DISC completion times) for the younger (12–14 years)
versus older (15–17 years) stuttering adolescents. A series of five multivariate discriminant function analyses (DFA), with
group membership (younger/older) as the outcome variable, sought to identify multivariate relationships between groups
and the continuous measures. The first four DFAs used the subscale scores of the RCMAS-2, OASES, YSR Syndrome and
Competence, and YSR DSM, respectively, as the predictor sets. The final DFA used the total scores of RCMAS-2, CDI and
OASES as predictors. A multivariate model using all potential predictors was not attempted because of concerns about
sample size, and multicolinearity between subscale and total scores.
Paired t-tests were used to make initial comparisons between parent CBCL subscale and total scores with adolescent YSR
subscale and total scores. These were followed by paired multivariate analysis of variance on the subscale scores.
62 A. Gunn et al. / Journal of Fluency Disorders 40 (2014) 58–68

Table 1
Frequency and type of DSM-IV mental disorders diagnosed among younger (12–14 years) and older (15–17 years) stuttering adolescents.

DSM-IV mental disorder type Younger adolescents (12–14 years) Older adolescents (15–17 years)

Anxiety disorders
Agoraphobia 0 1
OCD 0 2
Separation anxiety disorder 1 1
Specific phobia 0 2
Social anxiety disorder 1 2
Total anxiety disorders 2 8

Other mental disorders

Anorexia nervosa 1 0
Conduct disorder 1 0
Chronic motor/vocal tic or Tourette’s disorder 1 2
Major depressive episode 0 1
Selective mutism 1 0

Total other mental disorders 4 3

Total anxiety and other mental disorders 6 11

Note: Two participants met criteria for more than one disorder. In particular, one participant met criteria for Separation Anxiety Disorder, OCD and Major
Depressive Episode; and another met criteria for Selective Mutism and Chronic Motor/Vocal Tic or Tourette’s Disorder.

For most analyses the multivariate models added little information beyond the preliminary t-test analysis. For the sake
of simplicity, results are presented primarily in terms of the t-test outcomes.
The final research question was approached with bivariate correlations followed by two series of multiple regression
analyses. Each multiple regression series used the same predictors as the discriminant function analyses, controlling for age
group. The outcome variables for the two series were typical stuttering, and worst stuttering.

3. Results

3.1. Stuttering severity

Mean typical stuttering severity for the adolescents was 4.5 (SD = 1.7, range = 1.0–8.0), indicating a moderate level of sever-
ity. A t-test showed no significant difference in mean stuttering severity for younger (12–14 years; Mean = 4.34, SD = 1.83,
range = 1.5–8.0) versus older adolescents (15–17 years; Mean = 4.66, SD = 1.62, range = 1.0–6.8): t (35) = −0.56, p = 0.58, 95%
CI [−1.48, 0.85].
Mean worst stuttering severity for the group was 6.4 (SD = 1.7, range = 2–9). A t-test showed no significant difference in
mean worst stuttering severity for younger (12–14 years; Mean = 6.24, SD = 1.72, range = 3.2–9.0) versus older adolescents
(15–17 years; Mean = 6.63, SD = 1.59, range = 2.0–8.5): t (35) = −0.67, p = 0.51, 95% CI [−1.48, 0.75].
Two variables correlated with Typical Stuttering Severity score: CDI total (r = 0.39, p = 0.018) and RCMAS Social (r = 0.34,
p = 0.042). Three variables correlated with Worst Stuttering Severity score: RCMAS Social (r = 0.335, p = 0.042); OASES Three
(r = 0.33, p = 0.044); and YSR DSM Conduct (r = 0.42, p = 0.008). No multivariate models were related to either of the two
stuttering severity measures, with F values ranging from 0.386 to 2.00, and p values from 0.76 to 0.12.

3.2. Voice DISC

Fourteen of the 37 participants (38%) met Voice DISC criteria for at least one mental health diagnosis, 10 (71%) of these
meeting a diagnosis for an anxiety disorder (for the type and frequency of disorders diagnosed see Table 1).
The suggested completion time for the Voice DISC is 63 min (Shaffer et al., 2010). Group mean completion time was
54 min (SD = 22.7 min, range 29–129 min). A t-test showed a significant difference between Voice DISC completion times for
the 12–14 year age group (Mean = 46 min) and the 15–17 year age group (Mean = 63 min) (see Table 2).

3.3. The Revised Children’s Manifest Anxiety Scale: 2nd ed. (RCMAS-2)

3.3.1. Defensiveness Scale

The RCMAS-2 Defensiveness Scale evaluates social desirability. Scores above 60 are regarded as clinically significant, and
indicate participants may be providing misleading answers. Fourteen participants (38%) scored in the clinically significant
range for Defensiveness (Mean = 64.57, SD = 5.14, range = 60–74), of which eight were from the 12–14 year age group, and
six from the 15–17 year age group.
The mean Defensiveness scores for the 12–14 year olds (Mean = 54.90, SD = 8.30, range = 42–69) and the 15–17 year olds
(Mean = 55.29, SD = 9.8, range = 43–74) were both in the normal range with no t-test evidence of a difference (see Table 2).
However, 14 participants evenly spread from both age groups scored 60 or higher (Mean = 63.64, range = 60–74).
 A. Gunn et al. / Journal of Fluency Disorders 40 (2014) 58–68 63

Table 2
Comparison of psychological measures between younger (12–14 years) and older (15–17 years) stuttering adolescents.

Measures Adolescents (12–14 years) Adolescents (15–17 years) t(df) p

M(SD) M(SD)

Voice DISC (completion times) 46.20(14.32) 62.53(21.94) t(35) = −2.71 0.010*

RCMAS-2
Total anxiety 43.80(7.10) 52.18(8.89) t(35) = −3.18 0.003*
Physiological anxiety 39.25(6.35) 48.06(9.20) t(35) = −3.43 0.002*
Worry 44.45(9.15) 53.47(8.91) t(35) = −3.02 0.005*
Social anxiety 49.30(8.31) 53.64(8.96) t(35) = −1.53 0.135
Defensiveness 54.90(8.30) 55.29(9.76) t(35) = −0.13 0.900
Inconsistent responding 2.20(1.15) 2.11(1.27) t(35) = 0.21 0.837
CDI 41.45(6.43) 46.71(5.47) t(35) = −2.65 0.012*
OASES-S & T
General 3.18(0.40)b 3.35(0.40)b t(35) = −1.32 0.197
Reactions 2.94(0.57)a 3.34(0.51)b t(35) = −2.24 0.031*
Communication 2.71(0.60)a 2.86(0.52)a t(35) = −0.84 0.406
Life quality 2.37(0.76)a 2.67(0.60)a t(35) = −1.35 0.186
Total OASES 2.81(0.50)a 3.05(0.40)b t(35) = −1.62 0.114
YSR
Competence 46.42(9.41) 44.67(9.23) t(32) = 0.54 0.590
Syndrome 57.80(6.29) 62.59(7.10) t(35) = −2.18 0.036*
DSM Scales
Affective 53.00(4.30) 55.94(6.97) t(35) = −1.57 0.125
Anxiety 51.55(2.56) 56.18(7.10) t(35) = −2.72 0.010*
Somatic 54.40(5.36) 56.00(6.12) t(35) = −0.85 0.403
Attention D/H 52.40(2.58) 55.76(4.96) t(35) = −2.65 0.012*
Oppositional 53.40(5.57) 54.65(4.99) t(35) = −0.71 0.481
Conduct 58.90(5.82) 60.29(5.17) t(35) = −0.76 0.450
a
Moderate OASES score.
b
Moderate-to-severe OASES score.
*
Statistically significant at p < 0.05.

3.3.2. Inconsistent Responding Scale

Scores above six indicate distraction when completing the assessment, or the presence of language or reading problems.
All 37 participants scored below 6 (Mean = 2.16, SD = 1.2, range = 0–5).

3.3.3. Total anxiety

T-scores above 60 are classed as clinically significant. The mean Total Anxiety T-scores were normal for both the 12–14
year age group (Mean = 43.8, SD = 7.1, range = 42–69) and the 15–17 year group (Mean = 52.18, SD = 8.9, range = 43–74). A
t-test showed a significant difference between the two groups (see Table 2).

3.3.4. Physiological anxiety

T-scores above 60 are clinically significant. The mean Physiological Anxiety T-scores were normal for both the 12–14
year age group (Mean = 39.25, SD = 6.35, range = 30–54) and the 15–17 year group (Mean = 48.06, SD = 9.20, range = 31–63).
A t-test showed a significant difference between the two groups (see Table 2).

3.3.5. Worry
T-scores above 60 are clinically significant. The mean Worry T-scores were normal for both the 12–14 year age group
(Mean = 44.45, SD = 9.15, range = 32–61) and the 15–17 year group (Mean = 53.47, SD = 8.91, range = 39–66). A t-test showed
a significant difference between the two groups (see Table 2).

3.3.6. Social anxiety

T-scores above 60 are clinically significant. The mean Social Anxiety T-scores were normal for both the 12–14 year age
group (Mean = 49.30, SD = 8.31, range = 34–62) and for the 15–17 year group (Mean = 53.64, SD = 8.96, range = 35–66). A t-test
showed no significant difference between the two groups (see Table 2)

3.4. Youth Self Report (YSR) and the Child Behavior Checklist (CBCL)

3.4.1. Syndrome Scales (SS)

Total SS T-scores between 60 and 63 are classed as subclinical, and T-scores greater than 63 are clinically significant. The
mean YSR SS scores were subclinical (Mean = 60, SD = 7.01), but mean CBCL scores (Mean = 51.92, SD = 8.65) were normal.
A t-test showed a significant difference between adolescent and parent scores (see Table 3). A t-test showed a significant
difference between SS scores for the 12–14 year age group (Mean = 57.8, SD = 6.3) and the 15–17 age group (Mean = 62.6,
SD = 7.1) (see Table 2)
64 A. Gunn et al. / Journal of Fluency Disorders 40 (2014) 58–68

Table 3
Comparison of adolescent and parent scores on the Youth Self-Report (YSR) and Child Behavior Checklist (CBCL).

Scales Adolescents (YSR) Parents (CBCL) t(df) p

M(SD) M(SD)

Competence 45.65(9.23) 44.39(10.52) t(32) = −0.58 p = 0.564

Syndrome 60.00(7.01) 51.92(8.65) t(36) = −4.48 p < 0.001*
DSM Scales
Affective 54.35(5.78) 56.03(5.48) t(36) = 1.24 p = 0.222
Anxiety 53.68(5.60) 56.19(7.17) t(36) = 1.69 p = 0.099
Somatic 55.14(5.70) 54.24(5.83) t(36) = −0.61 p = 0.545
Attention D/H 53.95(4.16) 53.92(4.65) t(36) = −0.02 p = 0.982
Oppositional 53.97(5.27) 54.51(4.97) t(36) = 0.46 p = 0.647
Conduct 59.54(5.50) 52.73(3.77) t(36) = −6.84 p < 0.001*

Note: No scores were clinically significant.

*
Statistically significant at p < 0.05.

3.4.2. Competence Scales

Total Competence T-scores are reverse scored, and T-scores between 40 and 37 are classed as subclinical, and T-scores
less than 37 are clinically significant. Four participant scores were missing; three from the adolescent sample, and one from
the parent sample. The mean YSR scores (Mean = 45.65, SD = 9.23) and mean CBCL scores (Mean = 44.39, SD = 10.52) were
normal, with no t-test evidence of a difference (see Table 3)

3.4.3. DSM Oriented Scales (DSM)

The DSM scales contain six subscales, each of which is individually scored. T-scores between 64 and 69 are subclinical,
and T-scores > 69 are clinically significant. Neither mean YSR T-scores nor mean CBCL T-scores showed clinical significance
(see Table 3). One of the six subscales (see Table 3), the Conduct Subscale, showed a significant t-test for YSR T-scores
(Mean = 59.54, SD = 5.50) and CBCL T-scores (Mean = 52.73, SD = 3.77).

3.5. Children’s Depression Inventory (CDI)

Total CDI T-scores above 65 are clinically significant. Mean CDI scores (Mean = 43.86, SD = 6.49) were normal. A t-test
showed a significant difference between the 12–14 age group scores (Mean = 41.5, SD = 6.4) and the 15–17 age group scores
(Mean = 46.71, SD = 5.5) (see Table 2).
The only significant multivariate relationship extended this finding by separating the age groups on a composite measure
of CDI total score and RCMAS total score (F[2,34] = 8.51, p = 0.001, effect size R = 0.58). Direction of coefficients suggested older
adolescents tended to be more anxious and depressed.

3.6. Overall assessment of the speaker’s experience of stuttering (OASES-S and OASES-T)

The OASES classifies quality of life impairment as follows: mild, 1.0–1.49; mild-to-moderate, 1.50–2.24; moderate,
2.25–2.99; moderate-to-severe, 3.00–3.74; and severe, 3.75–5.00. For the four sections and the total score, participants
scored moderate and moderate–severe impairments (see Table 2). The 15–17 year age group had significantly higher Section
2 mean scores (Your Reactions to Stuttering) than the 12–14 year age group (see Table 2).

4. Discussion

Despite the potential for anxiety and other mental health disorders to develop in the adolescent years for those who
stutter, there is scant research on the matter, and previous findings have yielded ambivalent results. There are well-known
mental health and associated anxiety problems associated with chronic stuttering during adulthood (e.g. Iverach, O’Brian,
et al., 2009a). What is less clear is when these problems begin. This study adds DSM-IV Axis I diagnostic data to what is known
of the mental health status of stuttering adolescents, with 38% of our sample attaining such a diagnosis, the majority of those
with a disorder involving anxiety. Even though our sample size was small, it is striking that this figure is double existing
estimates of Axis I disorder rates for non-stuttering adolescents, which are in the 17–21% range (Angold et al., 2002; Canino
et al., 2004; Roberts et al., 2007). This finding is similar to mental health research of stuttering adults that was conducted by
Blumgart et al. (2010), who assessed a sample of 50 stuttering adults, and found that 40% (20/50) met DSM-IV criteria for
SAD. More in line with the previous DSM-IV adolescent studies mentioned above, Iverach, O’Brian, et al. (2009a) diagnosed
27.2% of their stuttering adult sample (N = 92) with a DSM-IV anxiety disorder, in comparison to only 5.3% of controls. Even
though there are discrepancies between the percentages of anxiety disorders found in the two adult studies’ mentioned
above, both rates are still high. Only further clinical diagnostic research with both stuttering adults and adolescents will
help improve the accuracy of anxiety estimates in these populations.
It is important to highlight that correctly identifying mental health disorders in adolescents has been found to be chal-
lenging. Kendall et al. (2010) conducted a study using a large, representative sample of treatment-seeking anxious youth
 A. Gunn et al. / Journal of Fluency Disorders 40 (2014) 58–68 65

(N = 488) and their parents. Participants, aged 7–17 years (Mean = 10.7 years, SD = 2.8 years) had a principal DSM-IV diag-
nosis of separation anxiety disorder, generalized anxiety disorder, or SAD. The diagnostic clinical interview used to assess
the adolescents was the highly regarded Anxiety Disorders Interview Schedule (ADIS: Silverman & Albano, 1996). Even
though the study’s eligibility criteria excluded adolescents with Major Depressive Disorder, depressive symptoms were still
found. The researchers also found that 55.3% of participants meet criteria for at least one DSM-IV disorder that was not tar-
geted in the study. The researchers concluded that anxiety disorders in adolescents often do not present as a single/focused
disorder. Instead, adolescent mental health disorders overlap in symptoms and are highly comorbid. Based on Kendall and
colleagues’ findings, we suggest that it may be more important to focus on the presence of DSM-IV disorders among stuttering
adolescents, as opposed to the specific types of disorders as seen in mental health research for stuttering adults.
It is essential to note that even though DSM diagnostic interviews may be considered a good clinical standard, they do
have their limitations. For example, the Voice DISC relies on adolescents having an awareness of the social and personal
consequences of their disorders when determining the severity of impairment (Wasserman, McReynolds, Fisher, & Lucas,
2005). This is highlighted in a study by Wasserman et al. (2002), which used the Voice DISC to assess 292 incarcerated
male youths. Of the group, 147 met DSM-IV criteria for a Substance Use Disorder, yet 59 denied the disorder impaired
their lives. Of those denying impairment, 19 were currently incarcerated for substance-related offenses. Even though
incarcerated youth cannot be compared to stuttering adolescents, the findings highlight a potential limitation of the Voice
DISC. Therefore, the issue of limited self-awareness among adolescents and the potential bias this causes for self-report
answers to psychological questionnaires must be taken into consideration when interpreting the current study’s results.
Findings from the present study showed a trend for older adolescents (15–17 years) when compared to younger ado-
lescents (12–14 years) to have worsening psychological test scores: RCMAS-2, YSR, CBCL and CDI. However, it is important
to note that the mean total scores for these four measures fell within the normal range. Interestingly, the RCMAS-2’s Social
Anxiety scale suggests that social anxiety was not an issue for either age group even though it was the only variable, which
correlated significantly with both Typical and Worst stuttering severity. Given that only three other variables correlated with
stuttering severity, and none of these correlations were strong, we tentatively conclude from the study’s results that self-
reported stuttering severity is not an indicator for developing anxiety or other mental health issues in stuttering adolescents.
Our reservation in drawing this conclusion comes from the issue of adolescents being at a heightened risk of having
limited self-awareness as outlined above. For example, Craig and Hancock (1996) assessed 96 younger stuttering youths
aged 9–14 (78 boys, 18 girls; Mean age = 11 years, SD = 1.7 years), and found them to be in the normal range for anxiety.
Craig and Hancock’s research gives weight to our findings, as the younger adolescents (12–14 years) in this study had lower
scores on the majority of measures compared to older adolescents (15–17 years). If limited self-awareness is likely to be
an issue for adolescents, especially younger ones, perhaps future research could benefit from using multiple informants’
reports such as a parent, teacher, clinician, another adolescent, or laboratory observation to gain a more accurate picture of
the adolescent’s mental health (see Hunsley & Mash, 2007).
There are good reasons to believe that the present results may be a conservative estimate of mental health problems of
the stuttering adolescent participants, which increases the importance of continued exploration of this area. The RCMAS-2
Defensiveness Scale – Lie Scale in a previous edition – provided 38% of participants’ scores in the clinically significant range,
suggesting participant reluctance to answer test items truthfully. This is likely due to Social Desirability Bias, which has
been shown to be an issue for adolescents by selecting responses on self-report measures that will favor a positive social
impression (e.g. Yeager & Krosnick, 2011).
Although Blood et al. (2007) did not find high Defensiveness scores on the RCMAS, we believe our assertion of participants’
answers being impacted by Social Desirability Bias is supported by the study’s finding that many participants completed
the Voice DISC assessment much quicker than the program’s suggested time. Whether our participants gave misleading
answers due to a lack of self-awareness or due to Social Desirability Bias, respondents giving misleading information about
their mental health status are recognized as a general feature of adolescent mental health research (De Los Reyes et al.,
2012). Frijns and Finkenauer (2009), suggest that adolescents are likely to be non-disclosing because they suffer from the
“fallacy of uniqueness” that they alone are failing. However, to our knowledge, social desirability is an area yet to be explored
in stuttering adolescent research.
The American Psychiatric Association (APA, 2013a) recently replaced the DSM-IV criteria with the DSM-5. Some of these
changes will have an impact on the interpretation of this study’s results, such as Selective Mutism now being classed as an
anxiety disorder, and OCD no longer classed as an anxiety disorder, but classed under Obsessive Compulsive and Related
Disorders. Finally, social anxiety disorder has undergone changes significant both to this study and stuttering in general.
Firstly, “unlike in DSM-IV, which requires that the individual recognize that his or her response is excessive or unreasonable,
the DSM-5 criteria shift that judgment to the clinician” (APA, 2013b). This would require the Voice DISC program to be
updated so it could potentially make this judgment, thereby potentially rendering the current version obsolete with respect
to SAD. Lastly, the DSM-5 SAD diagnosis now states, “If the person suffers from another medical condition – for instance,
stuttering or obesity – the fear or anxiety experienced must be unrelated to the other condition or out of proportion to what
would normally be felt” (APA, 2013b). Many would argue that this is an advantage for the stuttering community as not being
able to use a DSM-IV diagnosis of SAD due to stuttering, has been a point of contention among researchers (e.g. Blumgart
et al., 2010).
There were two limitations to do with this study’s small sample size. Firstly, when the sample was divided into younger
(12–14 years, n = 20) and older (15–17 years, n = 17) groups, this detracted further from the study’s power. The second
66 A. Gunn et al. / Journal of Fluency Disorders 40 (2014) 58–68

limitation was including the 14 participants who had scored in the clinically significant range on the RCMAS-2’s Defensive-
ness scale. Ideally these participants’ scores needed to be treated as unreliable and removed from the data analysis. However,
this would have only left 23 participants, which again would detract from the study’s power.
Our finding of increased rates of DSM-IV diagnoses is also consistent with our finding of moderate and moderate–severe
quality of life impairment with stuttering adolescents. Future research is required to clarify the findings from the present
study. In particular, a large-scale, statistically powerful clinical assessment of this group with reference to a matched control
population, is required to more accurately determine the difference in mental health status for stuttering adolescents and
fluent speaking adolescents. It would also be advisable to have safe guards in place to detect social desirability in adolescent
participants. Such a study may also help reduce doubt in relation to conflicting results in previous stuttering adolescent men-
tal health research. Until such a study is conducted, it will be difficult to make recommendations for treatment approaches
with respect to stuttering adolescents.

CONTINUING EDUCATION

Axis I anxiety and mental health disorders among stuttering adolescents

QUESTIONS

(1) Which area of mental health has been researched for stuttering?
(a) Social anxiety
(b) Generalized anxiety disorder
(c) Social anxiety disorder
(d) DSM-IV diagnoses
(e) All of the above
(2) What is the gold standard assessment for establishing diagnoses in psychiatric research?
(a) The Overall Assessment of Speaker’s Experience of Stuttering
(b) Children’s depression inventory
(c) The Revised Children’s Manifest Anxiety Scale – Version 2
(d) The structured diagnostic interview
(e) All of the above
(3) Which measure was used specifically to assess for DSM-IV diagnoses?
(a) The Overall Assessment of Speaker’s Experience of Stuttering
(b) The Voice DISC
(c) The Revised Children’s Manifest Anxiety Scale – Version 2
(d) Children’s Depression Inventory
(e) The Depression, Anxiety and Stress Scale
(4) Why should the validity of this study’s findings be questioned?
(a) Due to the age of the participants
(b) The adolescent participants didn’t have parental consent for the study
(c) High Defensiveness scores on the RCMAS-2 and low completion times on the Voice DISC
(d) The absence of face-to-face interviews
(e) All of the above
(5) Which of the following participant information in this study is NOT correct?
(a) Participants consisted of 37 adolescents aged 12–17 years.
(b) All participants were currently seeing a psychologist for anxiety management.
(c) Participants were recruited from two University stuttering treatment clinics
(d) Adolescents were broken into two age groups, 12–14 years and 15–17 years.
(e) Parents of the adolescent participants were also assessed.

Financial Disclosures:

The authors Onslow, M., Gunn, A., Menzies, R., O’Brian, S., Packman, A., Lowe, R., Iverach, L., Heard, R., & Block, S. for the
paper “Axis I Anxiety and Mental Health Disorders among Stuttering Adolescents” were support by a grant from NHMRC
(#633007)

Non-Financial Disclosures:

None of the authors Onslow, M., Gunn, A., Menzies, R., O’Brian, S., Packman, A., Lowe, R., Iverach, L., Heard, R., & Block, S. for
the paper “Axis I Anxiety and Mental Health Disorders among Stuttering Adolescents” reported any relevant non-financial
relationships
 A. Gunn et al. / Journal of Fluency Disorders 40 (2014) 58–68 67

Acknowledgements

This research was supported by Program Grant 633007 from the National Health and Medical Research Council of
Australia.

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Anthony Gunn is a psychologist and PhD student at the Australian Stuttering Research Center, The University of Sydney. His research focuses on
developing and testing an online CBT program to treat anxiety in adolescents who stutter.

Ross Menzies is a clinical psychologist with an interest in the origins and management of anxiety. He has developed cognitive behavior therapy
packages for the treatment of obsessive compulsive disorders and published theories of the origins of phobias. He is currently the director of the
Anxiety Clinic at The University of Sydney

Sue O’Brian is a Senior Researcher at the Australian Stuttering Research Center. She has extensive experience in the field of stuttering treatment and
research. Her current interests include the effectiveness of early stuttering intervention in community settings, development of treatments for adults
who stutter and stuttering measurement.

Mark Onslow is the Foundation Director of the Australian Stuttering Research Center, Faculty of Health Sciences, The University of Sydney. His
background is speech pathology. He is a Principal Research Fellow of the National Health and Medical Research Council of Australia. His research
interests are the epidemiology of early stuttering in pre-schoolers, mental health of those who stutter, measurement of stuttering, and the nature and
treatment of stuttering.

Ann Packman is a Senior Research Officer at the Australian Stuttering Research Center. She has worked for more than 30 years in the area of stuttering
as a clinician, teacher and researcher. One of her current interests is theories of the cause of stuttering.

Robyn Lowe is a speech pathologist and researcher at the Australian Stuttering Research Center, The University of Sydney. Her research interests
include exploring information processing biases and anxiety maintenance with adults who stutter as well as telehealth and online applications to the
management of stuttering.

Dr Lisa Iverach is an Early Career Researcher at the Center for Emotional Health, Macquarie University. She currently holds an Australian Research
Fellowship with the National Health and Medical Research Council. Her research interests include the relationship between stuttering and anxiety,
and the mental health of people who stutter.

Susan Block is a senior lecturer in the Department of Human Communication Sciences at La Trobe University. The she co-ordinates the student-
delivered intensive treatment program for adolescents and adults. Her research interests include treatment for stuttering across the lifespan and
student delivered treatment for stuttering

Rob Heard is a senior lecturer in the Discipline of Behavioral and Community Health Sciences at the University of Sydney. His current research interests
include developing predictive models for diagnosis of childhood apraxia of speech, and investigating factors affecting the accuracy of breast screening
mammograms.