Original Paper

Folia Phoniatr Logop 2007;59:268–272

DOI: 10.1159/000104465

Subjective Burden in Mothers of

Speech-Impaired Children
Michaela Wink a Frank Rosanowski a Ulrich Hoppe a Ulrich Eysholdt a
Elmar Grässel b
a
Department of Phoniatrics and Pedaudiology, and b Psychiatric Clinic, Erlangen University Hospital,
Erlangen, Germany

Key Words Introduction

Speech impairment  Depression  Anxiety  Subjective
burden  Caregiving
Abstract
Objective: Evaluation of perceived subjective burden in
mothers of speech-impaired children against the presence
or absence of an emotional disorder. Methods: 89 mothers
(age 33;3 8 5;5 years, range: 19;6–43;8 years) of 89 preschool
children (23 girls, 66 boys, age: 3;9 8 1;5 years, range: 1; 6–
7;1 years) with specific speech impairment were investigat-
ed. German versions of the Hospital Anxiety and Depression
Scale (HADS) and the Burden Scale for Family Caregivers
(BSFC) were applied. Results: 11% of the mothers met crite-
ria for a depressive disorder (normal controls: 2.5%; p =
0.008). Twenty-eight percent of the mothers met criteria for
anxiety disorders (normal controls: 9.6%; p = 0.000). The
HADS depression subscore and the BSFC correlate with r =
0.75. The HADS anxiety subscore and the BSFC correlate with
r = 0.59. Conclusions: Results suggest the need for routine
clinical assessment of mothers’ well-being when their chil-
dren are affected by speech impairment.
Copyright © 2007 S. Karger AG, Basel
During the last decade, a change of paradigm in as-
sessing the outcome of diagnostic and therapeutic mea-
sures can be noticed. Alongside standard medical param-
eters, the patients’ perception of well-being, satisfaction
with treatment effectiveness and health-related quality of
life became equally important outcome parameters [1, 2]
not only in international classification systems such as
the WHO International Classification of Functioning,
Disability and Health [3] but in clinical guidelines as well
[4]. Today numerous diagnostic tools exist to validly
measure these ‘soft’ parameters [5, 6].
In many cases, it proved to be important to consider
not only the patients’ but also their caregivers’ well-being.
Surprisingly, ‘objective’ aspects of caregivers’ burden
such as the type and degree of disease of the person they
care for and the way they suffer, i.e. their perceived ‘sub-
jective burden’, do not correlate. It is the way caregivers
react that determines their perceived burden [7–13].
Their complaints are both emotional and physical and
concern social facets of life as well: caregiving persons
report emotional distress such as depression, physical
complaints such as backache and a reduction of social
activities due to their commitment to the person they
have to care for [7–9, 14–16]. The way a burden is per-

© 2007 S. Karger AG, Basel Prof. Dr. Frank Rosanowski

1021–7762/07/0595–0268$23.50/0 Department of Phoniatrics and Pedaudiology, Erlangen University Hospital
Fax +41 61 306 12 34 Bohlenplatz 21, DE–91054 Erlangen (Germany)
E-Mail karger@karger.ch Accessible online at: Tel. +49 9131 853 3145, Fax +49 9131 853 9272
www.karger.com www.karger.com/fpl E-Mail frank.rosanowski@phoni.imed.uni-erlangen.de
ceived depends on the gender of the caregiver with moth-
ers more than fathers being at risk for psychosomatic
symptoms as a consequence of their child’s disorder [14,
17]. However, in both genders, a higher subjective burden
relates significantly to an increased risk for psychosomat-
ic symptoms [7–9]. So, caregiving may affect all facets of
caregivers’ life, and subjective burden is an important
outcome variable of the caring process and may even
reach a clinically relevant extent.
In cases of parents caring for an impaired child the
parents’ well-being is not only regarded as a significant
therapeutic but a prognostic cofactor as well, both in par-
ents of children with severe impairments, e.g. Down’s
syndrome [18], and in parents of children with compara-
tively minor disturbances such as an isolated speech de-
velopmental disorder [19–21]. Maternal emotional reac-
tions may be due to a feeling of guilt, worry about the
future or because of the pressure for time-consuming
treatment of the child and less time to pursue their own
interests [13, 15, 21].
In this study, subjective burden related to the caregiv-
ing process itself on the one hand and specific maternal
emotional disturbances, i.e. anxiety and depression, on
the other hand were investigated.
Subjects and Methods
Ninety-two mothers consecutively showing up in the report-
ing department for the first time to have their children examined
for a suspected speech developmental disorder on an outpatient
basis were asked to take part in the study. Three refused to, so 89
German-speaking mothers aged 33;3 8 5; 5 years (range: 19; 6–
43; 8) of 89 preschool children (23 girls, 66 boys, age: 3; 9 8 1; 5
years, range: 1;6–7;1) suffering from an isolated speech develop-
mental disorder were investigated after informed consent. Speech
disorders included delayed speech, vocabulary problems, dyslalia,
dysgrammatism, and disturbed speech comprehension. Mothers
of children with permanent hearing losses and/or with develop-
mental or isolated stuttering, rhinophonia, clefts, syndromes or
other developmental disturbances were excluded from the study.
No specific demographic data of the mothers concerning income,
education or marital status were collected.
To evaluate subjective burden of caregiving mothers against
the presence or absence of emotional disorders two self-rating
scales were applied: the German versions of the Hospital Anxiety
and Depression Scale (HADS-D) [22] and the Burden Scale for
Family Caregivers (BSFC) [23]. The questionnaires were filled out
in a separate, quiet room before the closing meeting with the phy-
sician responsible for the individual case.
The HADS-D [22] is a validated self-assessment questionnaire
developed to screen for anxiety (subscale ‘A’) and depressive dis-
orders (subscale ‘D’). Both subscales consist of 7 items. These
items are based on diagnostic criteria specified in the DSM-III-R
Subjective Burden in Mothers of
Speech-Impaired Children
[24]. Every item is scored from 0 to 3 with higher values indicat-
ing a higher emotional distress. Hence, values from 0 to 21 can be
reached in each subscale. In the anxiety subscale, scores from 0 to
7 are defined as ‘negative’, scores from 8 to 10 as ‘borderline cases’
and a cutoff score of 11 and higher indicates a ‘positive’ case [24].
In contrast to the original English version of the HADS, the de-
pression subscale is rated differently in the German version: the
cutoff score which identifies positive cases is defined as 69. The
German version provides a sensitivity of 83.3% and a specificity
of 61.5%, respectively. For further psychometric properties, see
Herrmann and Buss [22].
The BSFC was developed to measure the level of perceived,
subjective burden of caregivers particularly in the context of
family members who take care of individuals suffering from
health problems of all kinds, degrees and in all age groups [7–9,
23]. The questionnaire consists of 28 items focusing on 5 relevant
aspects associated with caregivers’ burden: overstrain, social
limitations, interpersonal conflicts, identification problems with
the role as caregiver, and physical or psychological exhaustion.
Each item is scored from 0 to 3 with higher values indicating
higher burden. Hence, total scores from 0 to 84 can be reached.
A score from 0 to 41 is defined as a ‘none to mild degree’ of sub-
jective burden and ‘not at risk for psychosomatic symptoms’:
these individuals are rated ‘negative’ in the terms of the BSFC
test. A total score of 42–55 indicates a ‘moderate burden’ with an
‘increased risk for psychosomatic symptoms’: these cases are rat-
ed ‘borderline’. Persons with total scores of more than 55 are con-
sidered as ‘severely to very severely burdened’, corresponding
with a ‘very high risk for psychosomatic symptoms’. These cases
are rated ‘positive’. For further psychometric properties, see
Grässel et al. [23].
Data were documented and analyzed ‘off-line’ using Microsoft
Excel and Matlab software packages. All individual results
were classified as negative, borderline or positive according to the
cutoff values named above as only classified results convey the
clinically relevant information. Classified results were analyzed
statistically: significances were evaluated by a nonparametric test,
i.e. the four-field test (Fisher test), and Spearman’s correlation co-
efficient, respectively.
Results
Ten mothers, i.e. 11% of the test persons, met criteria
for a depressive disorder as assessed by the HADS depres-
sion subscale. This ratio is significantly higher than in
normal controls (p = 0.008) [22]. In the HADS anxiety
subscale, 25 mothers, i.e. 28% of the test persons, were
identified as positive compared to 9.6% in normal con-
trols [22]: these data differ on a significant level (p =
0.000). In the BSFC, 6 mothers (7%) were classified as
positive, 18 (20%) as borderline and 65 (73%) as negative,
irrespective of the individual HADS result.
The correlation between HADS depression score and
BSFC score was rS = 0.75 (fig. 1). The correlation be-
tween HADS anxiety score and BSFC score was rS = 0.59
Folia Phoniatr Logop 2007;59:268–272 269
 70 y = 13.08 + 3.13x 70 y = 12.16 + 1.95x
r = 0.75 r = 0.59
60 60

50 50
BSFC score

BSFC score
40 40

30 30

20 20

10 10

0 0
0 5 10 15 20 0 5 10 15 20
Depression score Anxiety score

Fig. 1. HADS depression subscore and BSFC score in mothers of Fig. 2. HADS anxiety subscore and BSFC score in mothers of chil-
children with speech developmental disorders. dren with speech developmental disorders.

Table 1. Relationship between the BSFC and the HADS depres- Table 2. Relationship between the BSFC and the HADS anxiety
sion subscale subscale

HADS-D HADS-A
positive negative sum positive borderline negative sum

BSFC positive 4 2 6 BSFC positive 4 2 0 6

BSFC borderline 3 15 18 BSFC borderline 5 6 7 18
BSFC negative 3 62 65 BSFC negative 16 15 34 65
Sum 10 79 89 Sum 25 23 41 89

(fig. 2). Table 1 shows the number of individual gradua-
tions (negative, borderline, positive) in the BSFC test
and the individual graduation (negative, positive) in the
HADS depression subscale. Table 2 shows the number
of individual graduations (negative, borderline, posi-
tive) in the BSFC test and the individual graduation
(negative, borderline, positive) in the HADS anxiety
subscale.
Increased subjective burden (BSFC positive) occurs
statistically significantly (p = 0.001) more often in moth-
ers with a depression (HADS depression subscale posi-
tive) than in those without depression (HADS depression
subscale negative). No such correlation was found for
BSFC borderline cases (p 1 0.05). Mothers without sub-
jective burden more often present a negative HADS de-
pression subscale result than a positive one on a signifi-
cant level (p = 0.003).
Increased subjective burden (BSFC positive) occurs
statistically significantly (p = 0.02) more often in mothers
with anxiety (HADS anxiety subscale positive) than in
those without anxiety (HADS anxiety subscale negative).
There is no correlation between a borderline BSFC result
and a positive, borderline or negative anxiety assessment
(p 1 0.05). Mothers without subjective burden (BSFC
negative) do not present any significant correlation (p 1
0.05) with a positive, borderline or negative HADS anxi-
ety result.

270 Folia Phoniatr Logop 2007;59:268–272 Wink /Rosanowski /Hoppe /Eysholdt /

Grässel
 Discussion
Beside individual distress, the impact of subjective
burden experienced by family members caring for im-
paired and handicapped relatives is of growing socioeco-
nomic relevance, as social systems in many western com-
munities are at least at risk of not being able to provide
financial resources for professional care for an increasing
number of elderly and handicapped persons [7–10].
Not only in seriously ill, disturbed or handicapped
children, the self-perception of the parents is of signifi-
cant clinical importance [11, 13, 16], but in parents of
children with intellectual disabilities or behavior prob-
lems as well. They experience an increase in stress and a
deterioration of their physical and mental well-being [11,
13] with mothers being more at risk than fathers [14, 15,
17]. Studies on how parents and families adjust them-
selves reveal a high degree of expressed emotions with an
increase in critical remarks towards the child with coping
strategies depending on the individual socioeconomic
and personality background [12, 18, 25]. So, the literature
offers ample evidence for the clinical importance of sub-
jective aspects in persons giving care for relatives and es-
pecially in parents caring for impaired or handicapped
children. However obvious the clinical relevance of care-
givers’ well-being is, a comprehensive diagnostic tool for
the assessment of subjective burden elicited by the care-
giving process [23] such as the BSFC test used in this
study had not been reported so far and there is no knowl-
edge on how subjective burden relates to specific emo-
tional aspects. It is assumed that subjective burden relates
to the emotional situation of an affected person, and so it
seemed reasonable to specifically assess anxiety and de-
pression because of their outstanding epidemiologic rel-
evance [1, 2, 13–16, 19, 26, 27].
In a previous study on caregiving mothers of speech-
impaired children [20], the reporting group found a sig-
nificantly increased prevalence of depression when com-
pared with normal controls. Data obtained in the present
study confirm the previous result. So we conclude that
there is a significantly higher prevalence for depression
in mothers of speech-impaired children. In the HADS
anxiety subscale, the data obtained in this study differed
on a significant level compared to normal controls [22] as
well as compared to the previous study [20]. The reason
for these different findings cannot be explained: criteria
for selecting participants were identical in both studies.
In the literature, there is no evidence that psychometric
qualities of the HADS test are not as good as previously
reported. However, taking into account the epidemiolog-
Subjective Burden in Mothers of
Speech-Impaired Children
ic importance of emotional disorders both depression
and anxiety should be focused on in mothers of speech-
impaired children. According to the literature, the coin-
cidence of emotional disorders in mothers and speech
impairment of their children cannot be solved as regards
the causal connection [13, 15, 21], but we assume that per-
ceived subjective burden is a significant cofactor for ma-
ternal depression.
According to the BSFC, more than a quarter of the
study group was at risk for psychosomatic symptoms
[23], which again supports the assumption that these as-
pects are of significant clinical importance. Mothers with
a total score close to the cutoff score develop differently
than mothers with a total score differing a lot from the
cutoff score [28, 29]. Longitudinal studies will help to de-
pict development over time.
Comparing the individual results of the HADS and
the BSFC, both tests positively correlate on a high level.
Nevertheless, some individuals do not follow this pattern.
So, the two tests used in this study cannot be replaced by
each other. They have to be applied according to the in-
dividual clinical question.
Data obtained in this study and the discussion against
the background of the literature allow for the following
conclusions on how mothers experience their child’s
speech impairment:
• the prevalence of emotional disorders is higher than
in normal controls;
• subjective burden positively correlates with the preva-
lence of emotional disorders;
• beyond screening, 25% of the mothers require profes-
sional assessment.
Folia Phoniatr Logop 2007;59:268–272 271
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