speech and anxiety problems

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Social Anxiety

How anxiety can affect speech patterns.

• Anxiety is overwhelming, and it is not surprising that it affects speech.
• We identify at least 5 different examples of how anxiety affects speech.
• Speech typically requires focus and concentration, two things anxiety affects.
• Some types of anxiety are directly related to anxiety while speaking.
• Some public speaking techniques can also help with anxiety-related speech problems, but addressing anxiety itself will still be most important.

Fact Checked

Micah Abraham, BSc

Last updated March 1, 2021

In many ways, anxiety is an overwhelming condition. It overwhelms your senses, it overwhelms your thoughts, and it overwhelms your body. That's why it should come as little surprise to anyone that is suffering from anxiety that it can affect your speech patterns as well.

Anxiety is often apparent in your voice, which is why people can sometimes tell when you're feeling nervous. In this article, we explore some of the ways that anxiety affects speech patterns and what you can do to stop it.

How Anxiety Affects Speech

Different forms of anxiety seem to affect speech in different ways. You should absolutely make sure that you're addressing your anxiety specifically.

Anxiety causes both physical and mental issues that can affect speech. These include:

• Shaky Voice Perhaps the most well-known speech issue is simply a shaky voice. When you're talking, it feels like your voice box is shaking along with the rest of your body (and it is). That can make it sound like it is cracking or vibrating, both of which are a sign to others that you're nervous.
• Quiet Voice Those with anxiety - especially social phobia - often find that they also have a hard time speaking up in public. This type of quietness is very common, and while not technically a speech pattern, it can make your entire voice and the way you speak sound different to others. Although many will think of this in terms of volume, talking down at your feet will also exacerbate the effect.
• Dry Throat/Loss of Voice Some people find that anxiety seems to dry out their throat, or cause them to feel as though they're losing their voice.. One possible reason is that anxiety can make acid reflux symptoms worse, and those with acid reflux do have a tendency to wake up with sore throat and a loss of voice. Anxiety also increases the activity of your nervous system; when your fight or flight response is activated your mouth will naturally produce less saliva as a natural side effect.
• Trouble Putting Thoughts to Words Not all of the speech pattern symptoms of anxiety are physical either. Some of them are mental. Anxiety can make it much harder to for you to think about the words you're going to say, which can cause you to step over yourself, forget words, replace words with incorrect words, and more. Speaking generally has to be natural to be clear, and when you overthink it's not uncommon to find the opposite effect.
• Stuttering Similarly, anxiety can create stuttering. Stuttering itself is a separate disorder that can be made worse by anxiety. But beyond that, those that are overthinking their own sentences and word choices often find they end up stuttering a considerable amount, which in turn can create this feeling of embarrassment.

These are only a few of the issues that anxiety has with speech and speech patterns. There are even those that are bilingual that find that when they have anxiety they mix up the languages. Anxiety can do some unusual things to the way you talk to others, and that means that your speech patterns are occasionally very different than you expect them to be.

Are There Ways to Overcome This Type of Anxiety Issue?

Changes in speech patterns can be embarrassing and very unusual for the person that is suffering from them. It's extremely important for you to address your anxiety if you want these speech issues to go away. Only by controlling your anxiety can you expect your ability to speak with others to improve.

That said, there are a few things that you can do now:

• Start Strong Those with anxiety have a tendency to start speaking quietly and hope that they find it easier to talk later. That rarely works. Ideally, try to start speaking loudly and confidently (even if you're faking it) from the moment you enter a room. That way you don't find yourself muttering as often or as easily.
• Look at Foreheads Some people find that looking others in the eyes causes further anxiety. Try looking at others in the forehead. To them it tends to look the same, and you won't have to deal with the stress of noticing someone's eye contact and gestures.
• Drink Water Keeping your throat hydrated and clear will reduce any unwanted sounds that may make you self-conscious. It's not necessarily a cure for your anxiety, but it will keep you from adding any extra stress that may contribute to further anxiousness.

These are some of the most basic ways to ensure that your anxiety affects your speech patterns less. But until you cure your anxiety, you're still going to overthink and have to consciously control your voice and confidence.  

Summary: Anxiety is a distracting condition, making it hard to speak. During periods of intense anxiety, adrenaline can also cause a shaky voice and panic attacks can take away the brain’s energy to talk – leading to slurs and stutters. Identifying the type of speech problem can help, but ultimately it is an anxiety issue that will need to be addressed with a long-term strategy. 

Questions? Comments?

Do you have a specific question that this article didn’t answered? Send us a message and we’ll answer it for you!

Where can I go to learn more about Jacobson’s relaxation technique and other similar methods? – Anonymous patient

You can ask your doctor for a referral to a psychologist or other mental health professional who uses relaxation techniques to help patients. Not all psychologists or other mental health professionals are knowledgeable about these techniques, though. Therapists often add their own “twist” to the technqiues. Training varies by the type of technique that they use. Some people also buy CDs and DVDs on progressive muscle relaxation and allow the audio to guide them through the process. – Timothy J. Legg, PhD, CRNP

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Difficulty Talking, Speaking, Moving Mouth and Tongue Anxiety Symptoms

Difficulty speaking and talking, or moving the mouth, tongue, or lips are common symptoms of anxiety disorder , including generalized anxiety disorder , social anxiety disorder , panic disorder , and others.

This article explains the relationship between anxiety and the difficulty talking symptom.

Difficulty speaking, talking, moving mouth, tongue, or lips anxiety symptoms descriptions:

• Having difficulty or unusual awkwardness speaking; pronouncing words, syllables, or vowels.
• Having difficulty moving your mouth, tongue, or lips.
• Suddenly become self-conscious of your problems talking, speaking, moving your mouth, tongue, or lips.
• Uncharacteristically slurring your speech.
• You are uncharacteristically speaking much slower or faster than normal.
• You are uncharacteristically jumbling up words or fumbling over your words when speaking.
• You find that your mouth, tongue, or lips aren’t moving the way they normally would.
• Your mouth, tongue, lips, or facial muscles aren’t responding the way they normally do.
• It can feel as if your face muscles are unusually stiff, which is making talking difficult and forced.
• It can feel as if your face has been anesthetized somewhat, making speaking or moving your mouth, tongue, or lips difficult.

This symptom is often described as “slurred speech.”

This symptom can persistently affect just the mouth, lips, or tongue only, can affect more than one at the same time, can shift from one to another, and can involve all of them over and over again.

Having difficulty speaking can come and go rarely, occur frequently, or persist indefinitely. For example, you might have difficulty speaking once in a while and not that often, have difficulty speaking or moving your mouth, tongue or lips off and on, or have difficulty all the time.

Difficulty speaking can precede, accompany, or follow an escalation of other anxiety sensations and symptoms, or occur by itself. It can also precede, accompany, or follow an episode of nervousness, anxiety, fear, and elevated stress, or occur “out of the blue” and for no apparent reason.

This symptom can range in intensity from slight, to moderate, to severe. It can also come in waves where these mouth and speaking symptoms are strong one moment and ease off the next.

This symptom can change from day to day and from moment to moment.

All of the above combinations and variations are common.

Difficulty speaking or moving your mouth, tongue, or lips can seem more troublesome when in social, professional, or public settings.

To see if anxiety might be playing a role in your anxiety symptoms, rate your level of anxiety using our free one-minute instant results Anxiety Test , Anxiety Disorder Test , or Hyperstimulation Test .

The higher the rating, the more likely it could be contributing to your anxiety symptoms, including having difficulty talking or moving your mouth, tongue, or lips.

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Why does anxiety cause difficulty speaking, talking, or moving your mouth, tongue, or lips?

Medical Advisory

When this symptom is caused by anxiety, there are many reasons why anxiety can cause this symptom. Here are two of the most common:

1. Stress response

Behaving anxiously activates the stress response , also known as the fight or flight response . The stress response causes body-wide changes that prepare the body for immediate emergency action.[ 1 ][ 2 ] Because of the many changes, stress responses stress the body.

A part of these changes include altering brain function so that our attention is primarily focused on danger detection and reaction, and stimulating the nervous system so that the body is energized and can react quickly.[ 2 ] These changes can affect muscle movements, including the muscles in the mouth, tongue, and lips.

Many people experience difficulty talking and moving their mouth, tongue, or lips when anxious and stressed.

2. Hyperstimulation

Hyperstimulation can keep the stress response changes active even though a stress response hasn’t been activated. Chronic difficulty speaking, talking, and co-ordination problems with the mouth, tongue, and lips are common symptoms of hyperstimulation.

There are many other reasons why anxiety can cause this symptom. We explain these additional reasons under the symptom “Difficulty Speaking” in the Symptoms section (chapter 9) in the Recovery Support area of our website. The Symptoms section lists and explains all of the symptoms associated with anxiety.

How to stop the difficulty talking and moving the mouth, tongue, or lips anxiety symptoms?

When this anxiety symptom is caused by apprehensive behavior and the accompanying stress response changes, calming yourself down will bring an end to the active stress response and its changes. As your body recovers from the active stress response, this anxiety symptom should subside. Keep in mind it can take up to 20 minutes or more for the body to recover from a major stress response. This is normal and shouldn’t be a cause for concern.

When difficulty speaking or moving your mouth, tongue, or lips is caused by chronic stress (hyperstimulation), such as from overly apprehensive behavior, it can take much longer for the body to calm down and recover, and to the point where this anxiety symptom subsides.

Nevertheless, since this symptom is a common symptom of anxiety and stress, it needn't be a cause for concern or worry. This symptom subsides when you’ve eliminated the active stress response or hyperstimulation.

As the body recovers, difficulty speaking and talking, or moving your mouth, tongue, and lips problems disappear and normal functioning returns.

Many of those who struggle with anxiety worry that MS, ALS, a brain tumor, or other neurological condition may be the cause of their symptoms. Checking on the Internet may cause more anxiety, since co-ordination problems are common symptoms of these medical conditions.

But again, these types of symptoms are common for anxiety and stress. Therefore, they needn’t be a cause for concern.

For a more detailed explanation about all anxiety symptoms, why symptoms can persist long after the stress response has ended, common barriers to recovery and symptom elimination, and more recovery strategies and tips, we have many chapters that address this information in the Recovery Support area of our website.

If you are having difficulty containing your worry, you might want to connect with one of our recommended anxiety disorder therapists to help you learn this important skill. Working with an experienced anxiety disorder therapist is the most effective way to overcome what seem like unmanageable worry and problems with anxiety.

Common Anxiety Symptoms

• Heart palpitations
• Dizziness, lightheadedness
• Muscle weakness
• Numbness, tingling
• Weakness, weak limbs
• Asthma and anxiety
• Shooting chest pains
• Trembling, shaking
• Depersonalization
• Chronic pain
• Chronic fatigue
• Muscle tension
• Lump in throat

Additional Resources

• For a comprehensive list of Anxiety Disorders Symptoms Signs, Types, Causes, Diagnosis, and Treatment.
• Anxiety and panic attacks symptoms  can be powerful experiences. Find out what they are and how to stop them.
• How to stop an anxiety attack and panic.
• Anxiety Test
• Anxiety Disorder Test
• Social Anxiety Test
• Generalized Anxiety Test
• Hyperstimulation Test
• Anxiety 101 is a summarized description of anxiety, anxiety disorder, and how to overcome it.

Return to our anxiety disorders signs and symptoms page.

anxietycentre.com: Information, support, and therapy for anxiety disorder and its symptoms, including Difficulty Talking, Speaking, Moving The Mouth Anxiety Symptoms.

1. Selye, H. (1956). The stress of life. New York, NY, US: McGraw-Hill.

2. Folk, Jim and Folk, Marilyn. “ The Stress Response And Anxiety Symptoms. ” anxietycentre.com, August 2019.

3. Hannibal, Kara E., and Mark D. Bishop. “ Chronic Stress, Cortisol Dysfunction, and Pain: A Psychoneuroendocrine Rationale for Stress Management in Pain Rehabilitation. ” Advances in Pediatrics., U.S. National Library of Medicine, Dec. 2014.

4. Justice, Nicholas J., et al. “ Posttraumatic Stress Disorder-Like Induction Elevates β-Amyloid Levels, Which Directly Activates Corticotropin-Releasing Factor Neurons to Exacerbate Stress Responses. ” Journal of Neuroscience, Society for Neuroscience, 11 Feb. 2015.

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Understanding And Overcoming Public Speaking Anxiety

Most of us might experience what is commonly known as stage fright or speaking anxiety, nervousness and stress experienced around speaking situations in front of audience members. Even for experienced speakers, this can be a normal response to pressurized situations in which we are the focus of attention—such as we might encounter in front of an audience. For some people, though, the fear of public speaking and nervous energy can be much more severe, and can be a sign of an anxiety disorder. 

Speaking anxiety is considered by many to be a common but challenging form of social anxiety disorder that can produce serious symptoms, and can possibly impact an individual’s social life, career, and emotional and physical well-being. 

In this article, we’ll explore what speaking anxiety is, common symptoms of it, and outline several tips for managing it.

Identifying public speaking anxiety: Definition, causes, and symptoms

According to the American Psychological Association,  public speaking anxiety  is the “fear of giving a speech or presentation in public because of the expectation of being negatively evaluated or humiliated by others”. 

Often associated with a lack of self-confidence, the disorder is generally marked by severe worry and nervousness, in addition to several physical symptoms. The fear can be felt by many, whether they are in the middle of a speech or whether they are planning to speak at a future point. They may also generally fear contact with others in informal settings.

Public speaking anxiety can be a common condition, with an with an  estimated prevalence of 15-30%  among the general population.

Public speaking anxiety is considered by many to be a form of social anxiety disorder (SAD). The Diagnostic and Statistical Manual of Mental Disorder (DSM-V) includes a  performance specifier that allows a SAD diagnosis to relate specifically to anxiety surrounding public speaking or performing. For some extreme forms of this mental health condition, a medical professional may prescribe medication that can help overcome severe symptoms—although for most people this won’t be necessary.

The symptoms of performance-type social anxiety can include:

• Worry or fear surrounding public speaking opportunities or performing, even in front of friendly faces
• Avoiding situations in which public speaking or performing may be necessary
• Shaky voice, especially when one has to speak in public
• Stomach pain or gastrointestinal discomfort
• Rapid breathing

There are several strategies for addressing the symptoms of this and feeling more confident with your oratory skills, whether you need to use them at work, in formal social settings or simply in front of friends. 

The following are several strategies you can employ to address the fear of public speaking and manage your fear when it arises.

While the primary concern for those who experience speaking anxiety might typically be the fear of judgment or embarrassment when speaking publicly, there can be other causes contributing to distress. To figure out how to address this, it can help to understand potential contributing factors—as well as how others may be dealing with it on their own. 

First, it can be helpful to determine where the fear came from in the first place. Here are some  common sources of public speaking anxiety :

• Negative past experiences with public speaking
• Lack of preparedness
• Low self-esteem (this possible cause can cause feelings of overwhelm if one has to give a speech) 
• Inexperience with public speaking 
• Unfamiliar subject matter
• Newness of environment
• Fear of rejection (such as from an audience) 

Practice deep breathing

Public speaking anxiety might often be accompanied by feelings of stress, and also often affects physical factors such as increased speed of heart rate, tension, and rapid breathing. If you’re dealing with speaking anxiety and want to calm your nerves before a public speaking event, it can be helpful to practice deep breathing exercises. Deep breathing is considered by many to be a widely utilized technique  that can help bring your nervous system out of fight-or-flight mode, relax your body, and quiet your mind. Many find it to be one of the most convenient ways to manage symptoms, as many can do it anywhere as needed. 

To practice deep breathing prior to speaking, consider using a method called box breathing: breathe in for a four count, hold for a four-count, breathe out for a four count and hold again for a four count. You can repeat this process three to four times, possibly incorporating it with other relaxation techniques. It can also help to be mindful of your breathing as you’re presenting, which can help you steady your voice and calm your nerves.  

Practice visualization

When we experience nervousness, we can sometimes focus on negative thoughts and worst-case scenarios, despite the reality of the situation. You can work to avoid this by practicing positive visualization—such as imagining friendly faces in the crowd or you acing the main content of your speech. Positive thinking can be an effective technique for managing performance anxiety. 

Visualization is generally regarded as a research-backed method of addressing speaking anxiety that involves imagining the way a successful scenario will progress in detail. 

Having a clear idea of how your presentation will go, even in your mind’s eye, can help you gain confidence and make you feel more comfortable with the task at hand.

Understand your subject matter 

The fear of speaking in front of others can be related to potential embarrassment that may occur if we make a mistake. To reduce the risk of this possibility, it can help to develop a solid understanding of the material you’ll be presenting or performing and visualize success. For example, if you’re presenting your department’s sales numbers at work, familiarizing yourself with the important points and going over them multiple times can help you better retain the information and feel more comfortable as you give the presentation. 

Set yourself up for success

Doing small things to prepare for a speech or performance can make a big difference in helping to alleviate public speaking anxiety. If possible, you may want to familiarize yourself with the location in which you’ll be speaking. It can also help to ensure any technology or other media you’ll be setting up is functional. For example, if you’re using visual aids or a PowerPoint deck, you might make sure it is being projected properly, the computer is charged and that you can easily navigate the slides as you present.

You might even conduct run-throughs of the presentation for your speaking experience. You can practice walking the exact route you’ll take to the podium, setting up any necessary materials, and then presenting the information within the time limit. Knowing how you’ll arrive, what the environment looks like and where exactly you’ll be speaking can set you up for success and help you feel more comfortable in the moment.

Practicing your presentation or performance is thought to be a key factor in reducing your fear of public speaking. You can use your  practice time  to recognize areas in which you may need improvement and those in which you excel as a speaker. 

For example, you might realize that you start rushing through your points instead of taking your time so that your audience can take in the information you’re presenting. Allowing yourself the chance to practice can help you get rid of any filler words that may come out during a presentation and make sure all your points are clear to keep the audience’s interest. Additionally, a practice run can help you to know when it is okay to pause for effect, take some deep breaths, or work effective body language such as points of eye contact into your presentation. 

It may also be helpful to practice speaking in smaller social situations, in front of someone you trust, or even a group of several familiar people. Research suggests that practicing in front of an audience of supportive, friendly faces can improve your performance—and that the larger the mock audience is, the better the potential results may be. 

To do this, you can go through the process exactly like you would if they were real audience. Once you’re done, you can ask them for feedback on the strengths and weaknesses of your presentation. They may have insights you hadn’t considered and tips you can implement prior to presenting, as well as make you feel confident and relaxed about your material. 

Self-care leading up to the moment you’re speaking in public can go a long way in helping you reduce nervousness. Regular physical activity is generally considered to be one proven strategy for reducing social anxiety symptoms . Exercise can help to release stress and boost your mood. If you’re giving a big presentation or speech, it may be helpful to go for a walk or do some mild cardio in the morning. 

Additionally, eating a healthy diet and drinking enough water can also help promote a sense of well-being and calm. You may choose to be mindful of your consumption of caffeinated beverages, as caffeine may worsen anxiety. 

How online therapy can help

If you experience anxiety when you need to speak in front of other people and want additional support for your communication apprehension, it can help to talk to a licensed mental health professional. According to the American Psychiatric Association, a therapist can work with you to find effective ways to manage public speaking anxiety and feel more confident performing in front of others.

Is Online Therapy Effective?

Studies suggest that online therapy can help individuals who experience anxiety related to presenting or performing in public. In a study of 127 participants with social anxiety disorder, researchers found that online cognitive behavioral therapy was effective in treating the fear of public speaking , with positive outcomes that were sustained for a year post-treatment. The study also noted the increased convenience that can often be experienced by those who use online therapy platforms. 

Online therapy is regarded by many as a flexible and comfortable way of connecting with a licensed therapist to work through symptoms of social anxiety disorder or related mental disorders. With online therapy through  BetterHelp , you can participate in therapy remotely, which can be helpful if speaking anxiety makes connecting in person less desirable. 

BetterHelp works with thousands of mental health professionals—who have a variety of specialties—so you may be able to work with someone who can address your specific concerns about social anxiety.

Therapist reviews

“I had the pleasure of working with Ann for a few months, and she helped me so much with managing my social anxiety. She was always so positive and encouraging and helped me see all the good things about myself, which helped my self-confidence so much. I've been using all the tools and wisdom she gave me and have been able to manage my anxiety better now than ever before. Thank you Ann for helping me feel better!”

Brian has helped me immensely in the 5 months since I joined BetterHelp. I have noticed a change in my attitude, confidence, and communication skills as a result of our sessions. I feel like he is constantly giving me the tools I need to improve my overall well-being and personal contentment.”

If you are experiencing performance-type social anxiety disorder or feel nervous about public speaking, you may consider trying some of the tips detailed above—such as practicing with someone you trust, incorporating deep breathing techniques and visualizing positive thoughts and outcomes. 

If you’re considering seeking additional support with social anxiety disorder, online therapy can help. With the right support, you can work through anxiety symptoms, further develop your oratory skills and feel more confidence speaking in a variety of forums.  

Studies suggest that online therapy can help individuals who experience nervousness related to presenting or speaking in public. In a study of 127 participants with social anxiety disorder, researchers found that online cognitive behavioral therapy was effective in treating the fear of public speaking , with positive outcomes that were sustained for a year post-treatment. The study also noted the increased convenience that can often be experienced by those who use online therapy platforms.

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How to Reduce the Anxiety of Public Speaking

Most people hate it. here's one way to hate it less..

Posted November 22, 2021 | Reviewed by Gary Drevitch

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Anxiety and stress go with public speaking for all but a lucky few. Now a recent study underscores the importance of recognizing and accepting those emotions rather than trying to deny them. According to the study, if you journal about your anxieties and stress, and accept them, letting them run their course, the result is improved mental health compared to the rest of us who judge ourselves. The negative moods don’t last as long and are not as powerful.

I like this strategy. Denying that I was anxious was certainly my standard operating procedure when I was beginning in the business, first as an actor and then as a speaker on speaking, communications, storytelling, and body language . Denial didn’t help me, of course, just as it has helped no one else, and it wasn’t long before my anxiety was reaching epic proportions and the beginnings of speeches were going by in a blur of adrenaline. I had to do something, and so began my lifelong pursuit of ways to reduce the pain of public speaking for myself and others.

In these early days, it never occurred to me to look straight into the heart of darkness: the anxious core of public speaking, the self-consciousness that intrudes when we feel exposed standing before a group of people. Most of my methods involved tricking or distracting my brain long enough to give the speech and get to the bar. For example, getting some moderate exercise before a speech allows some of the nervous energy to dissipate so that you are calmer than you otherwise would be. Meditating can work, too, for those who have some experience with that form of mental discipline. My favorite distraction from those days turned out to be having the airline lose my luggage – with my speaking suit in it – so that I had to go shopping at 9:00 before the speech at 10:00. Good thing I could walk right into a 42 Long. I was so distracted by the suit crisis that I never got nervous for the speech.

That’s an expensive distraction, however, and I don’t recommend it as a long-term solution. Also, I started carrying my suit in my carry-on luggage, so the tactic no longer worked in any case.

My father passed away the day before a speech years ago, and I was too distraught to be nervous. But again, I don’t recommend that as a permanent solution, since our supply of fathers is generally limited to one or two.

Eventually, I focused on three truly helpful strategies.

1. A simple physical exercise that helps control anxiety: deep, slow breathing. The key is to breathe out on a longer count than the in-breath.

2. Positive self-talk . Find your mantra and repeat it ad infinitum. Whenever you have a dull moment, whenever you are nervous or anxious about an upcoming speech, and whenever you have trouble sleeping . I’ve used this technique for years, and I’m pleased to say I’ve just about wiped my mental slate clean of debilitating negative patterns of thinking. I’ve also witnessed many clients and friends benefitting from this technique. If it sounds New-Agey to you, get over yourself and get to work. In the long run, you’ll thank me.

3. Finally, the most powerful technique for getting over stage fright is to realize that a speech is not about you, but about the audience. Put yourself in service to the audience in front of you, get out of your own way, and think about them. You will be liberated and even find the joy in public speaking, and that is indeed a good place for both audience and speaking to be.

Now we can add journaling to our arsenal of mental weapons designed to keep anxiety and stress at bay. May we all write our way to the calm after the storm.

Nick Morgan, Ph.D. , is president of Public Words Inc., a communications consulting company, and the author of books including Can You Hear Me?: How to Connect with People in a Virtual World.

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How to Manage Public Speaking Anxiety

Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

Amy Morin, LCSW, is a psychotherapist and international bestselling author. Her books, including "13 Things Mentally Strong People Don't Do," have been translated into more than 40 languages. Her TEDx talk,  "The Secret of Becoming Mentally Strong," is one of the most viewed talks of all time.

Luis Alvarez / Getty Images

Speech Anxiety and SAD

How to prepare for a speech.

Public speaking anxiety, also known as glossophobia , is one of the most commonly reported social fears.

While some people may feel nervous about giving a speech or presentation if you have social anxiety disorder (SAD) , public speaking anxiety may take over your life.

Public speaking anxiety may also be called speech anxiety or performance anxiety and is a type of social anxiety disorder (SAD). Social anxiety disorder, also sometimes referred to as social phobia, is one of the most common types of mental health conditions.

Public Speaking Anxiety Symptoms

Symptoms of public speaking anxiety are the same as those that occur for social anxiety disorder, but they only happen in the context of speaking in public.

If you live with public speaking anxiety, you may worry weeks or months in advance of a speech or presentation, and you probably have severe physical symptoms of anxiety during a speech, such as:

• Pounding heart
• Quivering voice
• Shortness of breath
• Upset stomach

Causes of Public Speaking Anxiety

These symptoms are a result of the fight or flight response —a rush of adrenaline that prepares you for danger. When there is no real physical threat, it can feel as though you have lost control of your body. This makes it very hard to do well during public speaking and may cause you to avoid situations in which you may have to speak in public.

How Is Public Speaking Anxiety Is Diagnosed

Public speaking anxiety may be diagnosed as SAD if it significantly interferes with your life. This fear of public speaking anxiety can cause problems such as:

• Changing courses at college to avoid a required oral presentation
• Changing jobs or careers
• Turning down promotions because of public speaking obligations
• Failing to give a speech when it would be appropriate (e.g., best man at a wedding)

If you have intense anxiety symptoms while speaking in public and your ability to live your life the way that you would like is affected by it, you may have SAD.

Public Speaking Anxiety Treatment

Fortunately, effective treatments for public speaking anxiety are avaible. Such treatment may involve medication, therapy, or a combination of the two.

Short-term therapy such as systematic desensitization and cognitive-behavioral therapy (CBT) can be helpful to learn how to manage anxiety symptoms and anxious thoughts that trigger them.

Ask your doctor for a referral to a therapist who can offer this type of therapy; in particular, it will be helpful if the therapist has experience in treating social anxiety and/or public speaking anxiety.

Research has also found that virtual reality (VR) therapy can also be an effective way to treat public speaking anxiety. One analysis found that students treated with VR therapy were able to experience positive benefits in as little as a week with between one and 12 sessions of VR therapy. The research also found that VR sessions were effective while being less invasive than in-person treatment sessions.

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If you live with public speaking anxiety that is causing you significant distress, ask your doctor about medication that can help. Short-term medications known as beta-blockers (e.g., propranolol) can be taken prior to a speech or presentation to block the symptoms of anxiety.

Other medications may also be prescribed for longer-term treatment of SAD, including selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). When used in conjunction with therapy, you may find the medication helps to reduce your phobia of public speaking.

In addition to traditional treatment, there are several strategies that you can use to cope with speech anxiety and become better at public speaking in general . Public speaking is like any activity—better preparation equals better performance. Being better prepared will boost your confidence and make it easier to concentrate on delivering your message.

Even if you have SAD, with proper treatment and time invested in preparation, you can deliver a successful speech or presentation.

Pre-Performance Planning

Taking some steps to plan before you give a speech can help you better control feelings of anxiety. Before you give a speech or public performance:

• Choose a topic that interests you . If you are able, choose a topic that you are excited about. If you are not able to choose the topic, try using an approach to the topic that you find interesting. For example, you could tell a personal story that relates to the topic as a way to introduce your speech. This will ensure that you are engaged in your topic and motivated to research and prepare. When you present, others will feel your enthusiasm and be interested in what you have to say.
• Become familiar with the venue . Ideally, visit the conference room, classroom, auditorium, or banquet hall where you will be presenting before you give your speech. If possible, try practicing at least once in the environment that you will be speaking in. Being familiar with the venue and knowing where needed audio-visual components are ahead of time will mean one less thing to worry about at the time of your speech.
• Ask for accommodations . Accommodations are changes to your work environment that help you to manage your anxiety. This might mean asking for a podium, having a pitcher of ice water handy, bringing in audiovisual equipment, or even choosing to stay seated if appropriate. If you have been diagnosed with an anxiety disorder such as social anxiety disorder (SAD), you may be eligible for these through the Americans with Disabilities Act (ADA).
• Don’t script it . Have you ever sat through a speech where someone read from a prepared script word for word? You probably don’t recall much of what was said. Instead, prepare a list of key points on paper or notecards that you can refer to.
• Develop a routine . Put together a routine for managing anxiety on the day of a speech or presentation. This routine should help to put you in the proper frame of mind and allow you to maintain a relaxed state. An example might be exercising or practicing meditation on the morning of a speech.

Practice and Visualization

Even people who are comfortable speaking in public rehearse their speeches many times to get them right. Practicing your speech 10, 20, or even 30 times will give you confidence in your ability to deliver.

If your talk has a time limit, time yourself during practice runs and adjust your content as needed to fit within the time that you have. Lots of practice will help boost your self-confidence .

• Prepare for difficult questions . Before your presentation, try to anticipate hard questions and critical comments that might arise, and prepare responses ahead of time. Deal with a difficult audience member by paying them a compliment or finding something that you can agree on. Say something like, “Thanks for that important question” or “I really appreciate your comment.” Convey that you are open-minded and relaxed. If you don’t know how to answer the question, say you will look into it.
• Get some perspective . During a practice run, speak in front of a mirror or record yourself on a smartphone. Make note of how you appear and identify any nervous habits to avoid. This step is best done after you have received therapy or medication to manage your anxiety.
• Imagine yourself succeeding . Did you know your brain can’t tell the difference between an imagined activity and a real one? That is why elite athletes use visualization to improve athletic performance. As you practice your speech (remember 10, 20, or even 30 times!), imagine yourself wowing the audience with your amazing oratorical skills. Over time, what you imagine will be translated into what you are capable of.
• Learn to accept some anxiety . Even professional performers experience a bit of nervous excitement before a performance—in fact, most believe that a little anxiety actually makes you a better speaker. Learn to accept that you will always be a little anxious about giving a speech, but that it is normal and common to feel this way.

Setting Goals

Instead of trying to just scrape by, make it a personal goal to become an excellent public speaker. With proper treatment and lots of practice, you can become good at speaking in public. You might even end up enjoying it!

Put things into perspective. If you find that public speaking isn’t one of your strengths, remember that it is only one aspect of your life. We all have strengths in different areas. Instead, make it a goal simply to be more comfortable in front of an audience, so that public speaking anxiety doesn’t prevent you from achieving other goals in life.

A Word From Verywell

In the end, preparing well for a speech or presentation gives you confidence that you have done everything possible to succeed. Give yourself the tools and the ability to succeed, and be sure to include strategies for managing anxiety. These public-speaking tips should be used to complement traditional treatment methods for SAD, such as therapy and medication.

Crome E, Baillie A. Mild to severe social fears: Ranking types of feared social situations using item response theory . J Anxiety Disord . 2014;28(5):471-479. doi:10.1016/j.janxdis.2014.05.002

Pull CB. Current status of knowledge on public-speaking anxiety . Curr Opin Psychiatry. 2012;25(1):32-8. doi:10.1097/YCO.0b013e32834e06dc

Goldstein DS. Adrenal responses to stress . Cell Mol Neurobiol. 2010;30(8):1433-40. doi:10.1007/s10571-010-9606-9

Anderson PL, Zimand E, Hodges LF, Rothbaum BO. Cognitive behavioral therapy for public-speaking anxiety using virtual reality for exposure . Depress Anxiety. 2005;22(3):156-8. doi:10.1002/da.20090

Hinojo-Lucena FJ, Aznar-Díaz I, Cáceres-Reche MP, Trujillo-Torres JM, Romero-Rodríguez JM. Virtual reality treatment for public speaking anxiety in students. advancements and results in personalized medicine .  J Pers Med . 2020;10(1):14. doi:10.3390/jpm10010014

Steenen SA, van Wijk AJ, van der Heijden GJ, van Westrhenen R, de Lange J, de Jongh A. Propranolol for the treatment of anxiety disorders: Systematic review and meta-analysis . J Psychopharmacol (Oxford). 2016;30(2):128-39. doi:10.1177/0269881115612236

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

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Overcoming Speech Impediment: Symptoms to Treatment

There are many causes and solutions for impaired speech

• Types and Symptoms
• Speech Therapy
• Building Confidence

Speech impediments are conditions that can cause a variety of symptoms, such as an inability to understand language or speak with a stable sense of tone, speed, or fluidity. There are many different types of speech impediments, and they can begin during childhood or develop during adulthood.

Common causes include physical trauma, neurological disorders, or anxiety. If you or your child is experiencing signs of a speech impediment, you need to know that these conditions can be diagnosed and treated with professional speech therapy.

This article will discuss what you can do if you are concerned about a speech impediment and what you can expect during your diagnostic process and therapy.

FG Trade / Getty Images

Types and Symptoms of Speech Impediment

People can have speech problems due to developmental conditions that begin to show symptoms during early childhood or as a result of conditions that may occur during adulthood. 

The main classifications of speech impairment are aphasia (difficulty understanding or producing the correct words or phrases) or dysarthria (difficulty enunciating words).

Often, speech problems can be part of neurological or neurodevelopmental disorders that also cause other symptoms, such as multiple sclerosis (MS) or autism spectrum disorder .

There are several different symptoms of speech impediments, and you may experience one or more.

Can Symptoms Worsen?

Most speech disorders cause persistent symptoms and can temporarily get worse when you are tired, anxious, or sick.

Symptoms of dysarthria can include:

• Slurred speech
• Slow speech
• Choppy speech
• Hesitant speech
• Inability to control the volume of your speech
• Shaking or tremulous speech pattern
• Inability to pronounce certain sounds

Symptoms of aphasia may involve:

• Speech apraxia (difficulty coordinating speech)
• Difficulty understanding the meaning of what other people are saying
• Inability to use the correct words
• Inability to repeat words or phases
• Speech that has an irregular rhythm

You can have one or more of these speech patterns as part of your speech impediment, and their combination and frequency will help determine the type and cause of your speech problem.

Causes of Speech Impediment

The conditions that cause speech impediments can include developmental problems that are present from birth, neurological diseases such as Parkinson’s disease , or sudden neurological events, such as a stroke .

Some people can also experience temporary speech impairment due to anxiety, intoxication, medication side effects, postictal state (the time immediately after a seizure), or a change of consciousness.

Speech Impairment in Children

Children can have speech disorders associated with neurodevelopmental problems, which can interfere with speech development. Some childhood neurological or neurodevelopmental disorders may cause a regression (backsliding) of speech skills.

Common causes of childhood speech impediments include:

• Autism spectrum disorder : A neurodevelopmental disorder that affects social and interactive development
• Cerebral palsy :  A congenital (from birth) disorder that affects learning and control of physical movement
• Hearing loss : Can affect the way children hear and imitate speech
• Rett syndrome : A genetic neurodevelopmental condition that causes regression of physical and social skills beginning during the early school-age years.
• Adrenoleukodystrophy : A genetic disorder that causes a decline in motor and cognitive skills beginning during early childhood
• Childhood metabolic disorders : A group of conditions that affects the way children break down nutrients, often resulting in toxic damage to organs
• Brain tumor : A growth that may damage areas of the brain, including those that control speech or language
• Encephalitis : Brain inflammation or infection that may affect the way regions in the brain function
• Hydrocephalus : Excess fluid within the skull, which may develop after brain surgery and can cause brain damage

Do Childhood Speech Disorders Persist?

Speech disorders during childhood can have persistent effects throughout life. Therapy can often help improve speech skills.

Speech Impairment in Adulthood

Adult speech disorders develop due to conditions that damage the speech areas of the brain.

Common causes of adult speech impairment include:

• Head trauma 
• Nerve injury
• Throat tumor
• Stroke 
• Parkinson’s disease 
• Essential tremor
• Brain tumor
• Brain infection

Additionally, people may develop changes in speech with advancing age, even without a specific neurological cause. This can happen due to presbyphonia , which is a change in the volume and control of speech due to declining hormone levels and reduced elasticity and movement of the vocal cords.

Do Speech Disorders Resolve on Their Own?

Children and adults who have persistent speech disorders are unlikely to experience spontaneous improvement without therapy and should seek professional attention.

Steps to Treating Speech Impediment 

If you or your child has a speech impediment, your healthcare providers will work to diagnose the type of speech impediment as well as the underlying condition that caused it. Defining the cause and type of speech impediment will help determine your prognosis and treatment plan.

Sometimes the cause is known before symptoms begin, as is the case with trauma or MS. Impaired speech may first be a symptom of a condition, such as a stroke that causes aphasia as the primary symptom.

The diagnosis will include a comprehensive medical history, physical examination, and a thorough evaluation of speech and language. Diagnostic testing is directed by the medical history and clinical evaluation.

Diagnostic testing may include:

• Brain imaging , such as brain computerized tomography (CT) or magnetic residence imaging (MRI), if there’s concern about a disease process in the brain
• Swallowing evaluation if there’s concern about dysfunction of the muscles in the throat
• Electromyography (EMG) and nerve conduction studies (aka nerve conduction velocity, or NCV) if there’s concern about nerve and muscle damage
• Blood tests, which can help in diagnosing inflammatory disorders or infections

Your diagnostic tests will help pinpoint the cause of your speech problem. Your treatment will include specific therapy to help improve your speech, as well as medication or other interventions to treat the underlying disorder.

For example, if you are diagnosed with MS, you would likely receive disease-modifying therapy to help prevent MS progression. And if you are diagnosed with a brain tumor, you may need surgery, chemotherapy, or radiation to treat the tumor.

Therapy to Address Speech Impediment

Therapy for speech impairment is interactive and directed by a specialist who is experienced in treating speech problems . Sometimes, children receive speech therapy as part of a specialized learning program at school.

The duration and frequency of your speech therapy program depend on the underlying cause of your impediment, your improvement, and approval from your health insurance.

If you or your child has a serious speech problem, you may qualify for speech therapy. Working with your therapist can help you build confidence, particularly as you begin to see improvement.

Exercises during speech therapy may include:

• Pronouncing individual sounds, such as la la la or da da da
• Practicing pronunciation of words that you have trouble pronouncing
• Adjusting the rate or volume of your speech
• Mouth exercises
• Practicing language skills by naming objects or repeating what the therapist is saying

These therapies are meant to help achieve more fluent and understandable speech as well as an increased comfort level with speech and language.

Building Confidence With Speech Problems 

Some types of speech impairment might not qualify for therapy. If you have speech difficulties due to anxiety or a social phobia or if you don’t have access to therapy, you might benefit from activities that can help you practice your speech. 

You might consider one or more of the following for you or your child:

• Joining a local theater group
• Volunteering in a school or community activity that involves interaction with the public
• Signing up for a class that requires a significant amount of class participation
• Joining a support group for people who have problems with speech

Activities that you do on your own to improve your confidence with speaking can be most beneficial when you are in a non-judgmental and safe space.

Many different types of speech problems can affect children and adults. Some of these are congenital (present from birth), while others are acquired due to health conditions, medication side effects, substances, or mood and anxiety disorders. Because there are so many different types of speech problems, seeking a medical diagnosis so you can get the right therapy for your specific disorder is crucial.

Centers for Disease Control and Prevention. Language and speech disorders in children .

Han C, Tang J, Tang B, et al. The effectiveness and safety of noninvasive brain stimulation technology combined with speech training on aphasia after stroke: a systematic review and meta-analysis . Medicine (Baltimore). 2024;103(2):e36880. doi:10.1097/MD.0000000000036880

National Institute on Deafness and Other Communication Disorders. Quick statistics about voice, speech, language .

Mackey J, McCulloch H, Scheiner G, et al. Speech pathologists' perspectives on the use of augmentative and alternative communication devices with people with acquired brain injury and reflections from lived experience . Brain Impair. 2023;24(2):168-184. doi:10.1017/BrImp.2023.9

Allison KM, Doherty KM. Relation of speech-language profile and communication modality to participation of children with cerebral palsy . Am J Speech Lang Pathol . 2024:1-11. doi:10.1044/2023_AJSLP-23-00267

Saccente-Kennedy B, Gillies F, Desjardins M, et al. A systematic review of speech-language pathology interventions for presbyphonia using the rehabilitation treatment specification system . J Voice. 2024:S0892-1997(23)00396-X. doi:10.1016/j.jvoice.2023.12.010

By Heidi Moawad, MD Dr. Moawad is a neurologist and expert in brain health. She regularly writes and edits health content for medical books and publications.

Can Emotional Stress Cause Speech Problems?

Millions of Americans are affected by high-stress levels and anxiety disorders each year. Chronic stress and anxiety can result in many symptoms, such as fatigue, insomnia, and frequent headaches. Unfortunately, only a small number of those affected will receive proper support and treatment to improve their mental health and eliminate their symptoms. 

Although awareness and access to mental health resources have increased, there is still a stigma surrounding mental health challenges, and many people, as a result, suffer in silence and are unwilling to ask for help. This can be even more heightened when these challenges affect the ability to communicate. 

Significant levels of stress and anxiety can have many negative effects, including affecting our ability to use speech and language to express our thoughts, feelings, needs, and ideas. Speech therapy can help alleviate these symptoms, strengthen communication skills, and increase confidence. If you think you might benefit from speech therapy through Great Speech, get started today by scheduling your free introductory call ! 

Can Stress and Anxiety Cause Slurred Speech?

When the body experiences frequent bouts of stress or anxiety, some physical reactions can affect the fluency and clarity of speech. While this is not exactly the same as slurred speech caused by other factors, it can be quite similar. 

Typically, when we experience stress, we have a tendency to clench the jaw and teeth. When this is combined with the other symptoms of stress, such as a dry mouth, a mind that is racing, or the experience of a panic attack, speech can become more complex and less clear. 

Stress and anxiety can affect the whole body, and while it may not always be the direct cause of speech disruptions, it can reveal speech problems that already exist. 

What are the Signs of Speech Anxiety?

It is common for many individuals to experience some degree of speech anxiety when they are required to speak publicly, usually at work, in a social situation, or in the classroom. Public speaking is one of the most common fears among children and grown-ups. The symptoms of speech anxiety can range from simply feeling slightly nervous to experiencing a level of fear that is almost incapacitating. Some of the most common signs of speech anxiety include:

• Shaking Hands 
• Butterflies in the Stomach
• Racing or Rapid Heartbeat 
• Squeaky, Shaky, or Broken Speaking Voice 

How Do Anxiety and Stress Affect the Voice and Speech Patterns?

Experiencing severe stress and/or anxiety can be incredibly overwhelming, so it’s not surprising that it can affect our ability to communicate. 

Speech and language can be affected in the following ways: 

Shaky Voice: This symptom is perhaps the most common or well-known symptom relating to speech. In times of extreme stress and anxiety, it is common for the whole body to shake, including the mouth, jaw, and voice box. This can make the voice sound as though it is vibrating or crackling during speech.

Quiet Voice: Those who experience anxiety – especially social anxiety – commonly find that they have difficulty speaking up when in public. This kind of vocal quietness is quite common, and it can make your voice and the manner in which you speak sound different to others. While this may simply be related to volume, it can also be the result of looking at our feet while we speak.  

Dry Mouth or Throat: Dry mouth or throat is a common symptom of stress and anxiety, and some people may feel like they are losing their voice. One potential reason for this is that anxious feelings can exacerbate acid reflux symptoms, and individuals with acid reflux have a tendency to wake frequently with a sore throat and a loss of voice. Anxiety also increases nervous system activity by activating the flight or fight response; this can cause the mouth to produce less saliva. 

Stuttering: Feelings of stress and anxiety can disrupt the flow of speech and cause stuttering . While stuttering itself is a different disorder, it can be made worse by anxiety or can appear in those who don’t usually stutter. Anxiety can also cause a tendency to overthink word choice and sentences, which in turn can make it easy to stumble over our words or stutter a fair amount. 

These are only a handful of the challenges that anxiety can cause with speech and voice. Everyone experiences anxiety differently, and the body can present symptoms in a wide variety of ways. If you are struggling with your communication due to stress and anxiety, speech therapy can help. Get started by scheduling your free introductory call today! 

Can Stress Cause You to Say the Wrong Words?

While we’ve explored how stress and anxiety can affect our ability to produce clear and fluent speech, it is also important to discuss how it can affect our cognition, as not all symptoms of anxiety are physical. Anxiety and stress can affect our ability to think and put our thoughts and feelings into the right words. It is common for people with anxiety to forget certain words, replace words with other incorrect ones, lose their train of thought, and more. 

How Can Speech Therapy Help?

By now, we’ve answered the question, “Can stress mess with your speech?” and can now look at possible solutions. If you are struggling with your mental health, it is important to speak to your primary medical caregiver about the correct course of action; after all, speech therapy may not be the full answer. They may suggest other therapies that are better suited to your situation, medications, or a combination of both. 

Experienced speech and language pathologists can help improve the clarity of your speech, as well as work on your cognition and confidence. While it is most important to take care of your mental health, improving your speech and language skills can give you the boost you need to succeed professionally and socially for years to come.

Don’t wait to get started; schedule your free introductory call today! 

Can Speech Therapy Help With Anxiety?

Table of Contents

Is your child more nervous than their peers?

Does their nervousness make them stutter, or do they have trouble speaking out loud in certain social situations?

Did you know that there is a link between anxiety and speech and language disorders?

If you are finding out about the connection between anxiety and speech and language disorders for the first time, don’t be afraid.

It’s true that there’s an overlap between anxiety and speech disorders, but help is available.

Keep reading to learn more about the connection between anxiety and language disorders, and how speech and language therapy can help your child.

What Is Anxiety?

Anxiety is your body’s natural response to stress.

Anxiety is characterized as a feeling of fear or apprehension about what’s to come.

Certain events, such as the first day of school, meeting a new teacher, or being in a large group of new people might cause your child to feel nervous.

But if their feelings of anxiety are excessive or severe, last for longer than six months, and are interfering with their life, your child may have an anxiety disorder.

An anxiety disorder is when you feel this apprehension and nervousness all the time, even when there is no immediately obvious reason for it.

The anxiety disorder can be intense and prevent your child from doing things that they would otherwise be able to do.

This type of anxiety may cause them to stop doing things they enjoy.

If left untreated, the anxiety can worsen.

Speech And Language Disorders Linked With Anxiety

There are a number of speech and language disorders linked with anxiety.

You may have heard of some of them.

It’s important to note, however, that speech therapists do not treat anxiety directly.

That’s the realm of a mental health professional like a psychotherapist.

However, if your anxiety is linked with a speech or language disorder, speech therapy for adults can help alleviate that disorder.

Likewise with speech therapy for children .

However, it’s interesting to note that in some cases an anxiety disorder can hold somebody back from receiving the very treatment that can help alleviate it.

In that case, we can help as well.

We offer virtual speech therapy sessions as well, which can not only be more convenient, they can alleviate your anxiety as you go through the course of treatment in the comfort of your own home.

Without further ado, let’s take a look at speech disorders linked with anxiety below.

1. Dyslexia

Dyslexia is a speech and language disorder with a link to anxiety.

Dyslexia is characterized by a difficulty identifying words, understanding written and spoken language, and literacy problems.

It’s common for kids with dyslexia to experience anxiety.

Kids with dyslexia may feel anxious because they don’t understand why reading is so hard for them.

And reading-related anxiety can affect how kids feel about learning in general.

Kids with dyslexia might feel anxious about having to read “easier” books or being called on to read a passage in class and mispronouncing the words in front of everyone.

While dyslexia doesn’t lead to an anxiety disorder, the two conditions often co-occur.

If your child has both, it can help to know you’re not alone.

According to one study, nearly 30 percent of kids with dyslexia also have an anxiety disorder.

Be sure to monitor your child for symptoms of anxiety and dyslexia.

By reassuring them that their dyslexia doesn’t mean that they are unintelligent or lazy, and that they can succeed in life with dyslexia, you may be able to help lessen their anxiety about it.

Speech therapy for dyslexia can also help to build their language skills.

2. Stuttering

Stuttering is a complex speech issue.

People who stutter may become socially anxious, fear public speaking, or worry their stuttering will undermine their performance at work or school.

Research shows that stuttering is not a mental health diagnosis, and anxiety is not the root cause of stuttering.

Anxiety can, however, make stuttering worse.

Stuttering often presents in childhood.

Common among children ages 2-6 who are learning to speak, it sometimes goes away on its own.

Five to 10 percent of children stutter at some point, and at least 75% outgrow it.

For the remaining 25%, however, stuttering may continue to be a problem in adulthood.

Stuttering is often much worse when a child is anxious.

To support your child with their stutter, make sure that you create a relaxed environment around speech and communication.

Don’t talk over your child, correct their speech, or ask them to speak more quickly.

Attentively listen to your child while they speak.

Children who stutter may worry the person to whom they are speaking is annoyed or bored.

Don’t correct your child’s stutter or give them the word they appear to be looking for.

Speech therapy for stuttering can help them strengthen their speaking skills and build confidence at their own pace.

And if you notice they’re stuttering at a young age, seek early intervention speech therapy , as it’s been shown early treatment has much better results than taking the “wait and see” approach.

3. Selective Mutism

Selective mutism is an anxiety disorder that often emerges in childhood.

Selective mutism is diagnosed when a child consistently doesn’t speak in some situations but speaks comfortably in other situations.

These children are unable to speak in certain social situations where there is a demand to speak, such as at school, at dance class, at soccer practice, or at the corner store.

In other situations, these same children may speak openly with others and may even be considered to be chatty.

Selective mutism causes significant impairment in children’s lives and can interfere with performance at school and with friends.

It can often prevent them from having fun and engaging in regular childhood experiences.

It also can keep them from having their personal or school needs met, as they are unable to ask for help.

If you think your child has selective mutism, talk to a speech therapist.

They can give you tips for helping your child, as well as strategies to begin incorporating at home.

Book Your Appointment With Sol Speech And Language Therapy Today

If you’re ready to take the first steps towards alleviating your child’s anxiety and improving their speech and language skills, schedule your appointment at a clinic location today.

Our licensed speech pathologists have experience working with anxiety in relation to speech disorders.

During your appointment, you’ll have the chance to share your child’s medical history and discuss goals for your child’s speech and language development.

Following an evaluation, your speech therapist will design a treatment plan tailored for your child’s unique needs.

Book your appointment with Sol Speech And Language Therapy today.

Sol Speech & Language Therapy offers personalized skilled intervention to those struggling with their speech and language skills. Services offered include screening, consultation, and comprehensive evaluation. We also provide one-on-one and/or group therapy for speech sound disorders, receptive/expressive language delay/disorder, stuttering/cluttering, accent reduction, and much more.

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Speech, language and communication needs and mental health: the experiences of speech and language therapists and mental health professionals

Annabel hancock.

1 Division of Psychology and Language Sciences, University College London, London UK

Sarah Northcott

2 Division of Language and Communication Science, City University of London, London UK

Hannah Hobson

3 Department of Psychology, University of York, York UK

Michael Clarke

Associated data.

Data are available on request due to privacy/ethical restrictions. The data are not publicly available due to privacy or ethical restrictions.

While the relationship between speech, language and communication needs (SLCN) and mental health difficulties has been recognized, speech and language therapists (SLTs), and mental health professionals face challenges in assessing and treating children with these co‐occurring needs. There exists a gap in the evidence base for best practice for professionals working with children and young people (CYP) who experience difficulties in both areas.

To explore the views of SLTs and mental health clinicians about their experiences of working with CYP exhibiting co‐occurring SLCN and mental health difficulties.

Methods & Procedures

Semi‐structured interviews were conducted with eight SLTs and six mental health professionals, including psychotherapists, clinical psychologists, play therapists and counsellors, with experience working with CYP with SLCN. Interviews were analysed using reflexive thematic analysis and themes were identified from the data.

Outcomes & Results

Participants felt that SLCN and mental health difficulties frequently co‐occur. Participants described how CYP with SLCN and mental health issues commonly experience difficulties across and between the domains of language and cognition, emotional well‐being and challenging behaviour. Findings suggest that there are organizational limitations in the fields of SLT and mental health that have implications for the efficacy of assessment and treatment of CYP with SLCN and mental health difficulties. Traditional talking therapies were perceived to be inaccessible and ineffective for CYP with SLCN and mental health difficulties. Interventions blending behaviour and emotion programmes with language and communication interventions were considered potentially beneficial.

Conclusions & Implications

Future research should explore and evaluate current services and service set‐up in SLT and mental health. The findings from this study have important implications for the efficacy of treatments provided to this population suggesting that more research needs to be done into effective diagnosis and interventions for this population.

WHAT THIS PAPER ADDS

What is already known on the subject.

• Research suggests that CYP with SLCN, such as developmental language disorder (DLD), are likely to experience mental health difficulties including depression, anxiety and poor emotional well‐being. CYP who experience difficulties with SLCN and poor mental health are not well understood and this area remains under‐researched. This has implications for clinician knowledge and therefore the effective diagnosis and treatment of children and adolescents experiencing SLCN and mental health difficulties. In addition, little is known about the accessibility of talking therapies to CYP presenting with SLCN and mental health difficulties.

What this paper adds to existing knowledge

• SLCN issues are understood by SLTs and mental health issues are understood by mental health professionals, but where these co‐occur difficulties exist for the diagnostic process, with professionals perceiving that CYP in this category are often undiagnosed or misdiagnosed. Organizational boundaries between SLT and mental health were perceived to contribute to a lack of understanding of SLCN and mental health needs, which has implications for effective diagnosis and treatment. Traditional talking therapies were thought to be inaccessible for CYP with SLCN and mental health difficulties. Interventions used in both SLT and psychotherapy were perceived as clinically useful if combined.

What are the potential or actual clinical implications of this work?

• This paper highlights implications for the accessibility and efficacy of the assessment and treatment provided to this population and to the organization of services currently treating this group of CYP. A direction for future research would be to undertake service evaluations and intervention‐based studies.

INTRODUCTION

The relationship between speech, language and communication needs (SLCN) and mental health is interwoven and highly complex and often poses real problems for speech and language therapists (SLTs) and mental health professionals to understand, diagnose and treat. SLCN is a broad category that covers a wide range of conditions affecting speech, language and communication (Bishop et al., 2017 ). For simplicity and consistency, the term ‘mental health’ or ‘mental health difficulties’ will be used to refer to children and young people (CYP) with social–emotional and mental health needs, anxiety and depression.

The aim of this study was to explore the views of SLTs and mental health clinicians about their experiences of working with CYP with SLCN and mental health difficulties and, if identified by participants, to explore issues around language and social communication disorders. We begin by first reviewing the existing evidence on the links between language, communication and mental health.

Language, social communication and mental health

There is extensive evidence that language and communication problems co‐occur with mental health problems, although the mechanisms behind this relationship remain unclear. Poor language skills are common in CYP with emotional–behavioural disorders. A 2014 systematic review reported that four out of five children with emotional–behavioural disorders had at least mild language difficulties that had not been previously identified (Hollo et al., 2014 ). Poor mental health can present as challenging behaviour, and is associated with disorders of social communication and language (Georgiades et al., 2010 ). In addition to externalizing problems, children with social communication difficulties (SCDs) are likely to experience anxiety (Moree & Davis, 2010 ). Cohen et al. ( 2013 ) and Wadman et al. ( 2011 ) reported that anxiety symptoms frequently occur in individuals with DLD in young adulthood. DLD can severely impact on mental health, and an increased risk for depressive symptoms has been consistently reported in this group. For example, clinical levels of depression range from 20% to 39% in children and adolescents with DLD compared with 14–18% in peers without DLD (Conti‐Ramsden & Botting, 2008 ). Difficulties with language and communication can affect daily living and extend across the lifespan to affect life outcomes. For instance, young offenders with language impairment are at a higher risk for mental health problems (Snow & Powell, 2004 ) and one of the biggest predictors of reoffending is unrecognized DLD (Winstanley et al., 2019 ).

It is possible that certain aspects of language and communication hold particular relevance for mental health. Van den Bedem et al. ( 2018 ) reported specifically more semantic problems in individuals with DLD and the contribution of this to the prediction of depressive symptoms. Children with pragmatic language difficulties also appear prone to emotional and psychosocial difficulties (Cohen et al., 2013 ). For example, in a community‐based longitudinal study, Sullivan et al. ( 2016 ) reported an association between poor pragmatic language in childhood and adolescent psychotic experiences, and that poor pragmatic language skills preceded early adolescent depression. Some children with pragmatic language impairments also show difficulties recognizing facial emotions (Merkenschlager et al., 2012 ), which may impact on their ability to respond appropriately to others and to form close relationships with those around them (Merkenschlager et al., 2012 ). Van den Bedem et al. ( 2018 ) suggested that children with social communication problems are more likely to adopt maladaptive emotional regulation strategies. These maladaptive strategies may contribute to the prediction of higher levels of depressive symptoms. Children with SLCN are also more likely to be the target of bullying and to experience emotional difficulties compared with their typically developing peers (Lloyd‐Esenkaya et al., 2021 ). SCDs are thought to predict social anxiety, and those who experience peer victimization are likely to present with SCDs (Pickard et al., 2018 ).

In clinical practice, those commonly diagnosed with SCDs and/or autism spectrum disorder (ASD) may also present with pragmatic problems. Research shows that CYP with ASD and SCDs meet the diagnostic criteria for co‐morbid diagnoses of depression and anxiety disorders (Hofvander et al., 2009 ). The prevalence of mental health disorders in ASD is high. For example, in an interview study of 54 young adults with Asperger syndrome, 70% reported experiencing one major episode of depression and 56% reported experiencing anxiety disorders (Lugnegard et al., 2011 ). Furthermore, children with SCDs as part of ASD experience attention and challenging behaviour disorders (Moree & Davis, 2010 ; Georgiades et al., 2010 ) and this may lead to poor mental health.

Another factor that may link language, communication and mental health is the role of emotions and the impact of language and communication upon emotional processes. The ability to effectively vocalize feelings and thoughts relies heavily upon robust language skills, especially in relation to gaining a sense of self‐expression, self‐control and emotional insight (Unsworth & Engle, 2007 ). Neuropsychological evidence also highlights that damage to classic language areas in the brain affects emotion processing. Computerised tomography (CT) scans of patients who had sustained a traumatic brain injury found that damage to the inferior frontal gyrus (i.e., Broca's area) was associated with increased alexithymia scores (difficulties identifying and describing one's own emotions) (Hobson et al., 2018 ). Similarly, communication problems of people who have had a stroke are associated with high alexithymia scores, even after accounting for depression and anxiety (Hobson et al., 2020 ). Such research has led to the proposal that the link between language and identifying emotions is intrinsic, and that language impairment could contribute to alexithymia and/or vice versa. This has been coined as the alexithymia language hypothesis (Hobson et al., 2020 ). While these studies reflect data from acquired language disorders (i.e., following traumatic brain injury or stroke), Hobson et al. ( 2020 ) suggests that individuals with developmental language problems are also likely to experience difficulties with alexithymia. Indeed, initial examinations of levels of alexithymia in DLD suggest that, at least according to children's parents, children with DLD have higher alexithymic traits and problems with recognizing and expressing their own emotions (Hobson & van den Bedem, 2021 ). If language problems lead to greater alexithymic traits, it would be expected that such emotional problems will increase the risk for mental health problems and impact on treatment.

Interventions for mental health and SLCN

There are clear links between language and communication problems and mental health, and plausible models for how these two domains interact. It is thus pertinent to ask: What can interventions do to help and are current interventions suitable for CYP with SLCN? The use of appropriately modified talking therapies for CYP with language and SCDs is lacking evidence. Nonetheless, deficits in speech, language and communication would be expected to negatively impact the effect of talking therapies as CYP with SLCN would have difficulties with understanding pragmatic and inferential language, understanding and using narrative language, and understanding and interpreting emotions. Furthermore, difficulties communicating abstract concepts in verbal and non‐verbal children have been identified as limiting factors to effectively access psychological therapies (Lang et al., 2010 ). Thus, social communication and language difficulties may reduce the accessibility and therefore efficacy of traditional talking therapies.

There appears little acknowledgement about the role of language and communication in modifications of talking therapies. The National Institute for Health and Care Excellence (NICE) guidelines for the use of psychosocial interventions with adults with ASD (NICE, 2013 ) recommend using plain English during therapy sessions and avoiding the use of metaphors. In addition, much of the research in this area has focused largely on the use of cognitive behavioural therapy (CBT) in children and adolescents and often with overt SLCN such as voice disorders, stammering and selective mutism (Bercow et al., 2016 ; Menzies et al., 2008 ). There is also a growing body of research on the use of adapted talking therapies for adults with SLCN. For instance, the Solution Focused Brief Therapy (SFBT) in Poststroke Aphasia SOFIA trial (Northcott et al., 2021 ) applied modified SFBT so that it was accessible to language‐impaired stoke survivors. There is no direct evidence for the use of adapted talking therapies in CYP with DLD or language impairments.

Without knowledge about the nature of the SLCN, suitable access to a talking therapy may be ineffective. For instance, individuals with ASD have more trouble understanding psychotherapy concepts than non‐autistic controls (Hall et al., 2015 ). Furthermore, differences in social communication may mean a lack of social chat, difficulties initiating and maintaining conversations and interpreting language literally, all of which would significantly impact upon effective accessibility to talking therapies (Bliss & Edmonds, 2008 ).

In summary, despite the evidence for a relationship between SLCN and mental health needs, there are considerable knowledge gaps in understanding the impact of SLCN on the efficacy and accessibility of treatments, and the role of SLCN in traditional talking therapies has been largely unexplored. Little is known about clinicians’ perspectives of SLCN and mental health difficulties. Therefore, to inform and build the evidence base, the current study explored the views and experiences of clinicians assessing and treating CYP with SLCN and mental health difficulties. The aim of the study was to explore clinicians’ experiences of working with CYP with SLCN and mental health difficulties. The study addressed the following research questions:

• With what difficulties do CYP with SLCN and mental health needs typically present?
• How do clinicians experience assessing and delivering therapies to CYP with SLCN and mental health difficulties?
• What treatments are thought to be clinically useful for CYP with SLCN and mental health difficulties?

Research design

A qualitative research design using reflexive thematic analysis (TA) was chosen for this study in order to obtain a richness and depth to the data set that would appropriately answer the research questions. This approach facilitated an exploration of clinician experiences, observations and knowledge. A reflexive approach to TA was chosen due to the emphasis placed on the importance of the researcher's subjectivity as an analytic resource, and the reflexive engagement with theory, data and interpretation (Braun & Clarke, 2020 ). A reflexive approach is compatible with experiential qualitative research and was fundamental to the research questions. The approach adopted was an active and flexible process with the acknowledgement of theory. This process ensured a quality demonstrated in gold standard TA (Braun & Clarke, 2020 ). Interview questions were semi‐structured in nature; an interview guide and questions were constructed (see in the additional supporting information ) and followed from a flexible and dynamic perspective. The questions were designed to be open‐ended to facilitate flow of conversation with the aim to build rapport and encourage participants to talk about issues pertinent to the research questions.

Participants and recruitment

This study received ethical approval from University College London (LCD‐2020‐10). This study involved 14 clinicians: eight SLTs and six mental health professionals (Table  1 ). Inclusion criteria were that participants should be qualified allied health professionals in the field of speech and language therapy or mental health. Participants had to have sufficient professional experience (at least one year post‐qualification) working with CYP. Participants were provided with an information sheet written in plain English regarding the research area, interview procedure and research aims. Informed consent was obtained before each interview and participants were given the opportunity to ask questions.

Participant characteristics

Data collection

Interviews lasted for up to one hour and were conducted by the first author online via Microsoft Teams video conferencing software. Video‐audio data were collected. Online interviews were chosen for participant convenience and to ensure that the research could take place despite COVID‐19 pandemic restrictions. Each interview was recorded and transcribed verbatim by the first author and field notes were taken. Personally identifying information such as names and places of work were not transcribed to ensure participant anonymity. Video recordings were securely stored under encryption and deleted after analysis.

Data analysis

The transcribed interviews were subjected to an inductive thematic analysis. An inductive approach to thematic analysis was chosen due to the acknowledgement that epistemological assumptions would inevitably inform the analytic process (Braun & Clarke, 2020 ). However, the recognition that thematic analysis is a theoretically flexible approach was accepted and informed the analytic process. Therefore, the approach was descriptive but not wholly atheoretical. A flexible, active and interactive approach was central to the data analysis to support the process of theme generation, as opposed to theme emergence which could be deemed as not reflective of the data and the positionality of the researchers (Braun & Clarke, 2020 ).

NVivo 20 software was used to support line‐by‐line coding of all transcripts. A reflective diary was used to support the identification of themes from codes. Online team coding was conducted with two postgraduate research students and three senior researchers to support the process of reflexivity and refinement of theme generation. The first author presented raw data, identified codes and initial generated themes to the coding group; these were discussed, challenged and refined.

Reflexivity

As reflexive TA captures the skills the researcher brings to the process (Braun & Clarke, 2020 : 6), it is necessary to consider the researcher's perspective. The lead author is a female clinical academic SLT specializing in paediatric ASD, DLD and challenging behaviour. She is also a solution‐focused therapist and practices hypnotherapy with children and adults. The current project formed part of the lead researcher's pre‐doctoral clinical fellowship funded by The National Institute of Health Research. The co‐authors are senior researchers with experience in the fields of speech and language therapy and psychology with research in aphasia and solution‐focused brief therapy, alexithymia and SLCN. Participants were informed about the lead researcher's occupation, background and research aims. The lead researcher's interests and aims were not shared with the participants, and the researcher attempted to maintain a neutral stance throughout the interviews in order to obtain a true picture of clinicians’ experiences and understanding of specific subtypes of SLCN and their relationship to mental health.

Four main themes were generated from the data: (1) boundaries around professional relationships, (2) knowledge of SLCN and mental health, (3) being misunderstood: how CYP are perceived by others and (4) blended interventions. These are summarized in Figure  1 . We unpack each theme and its subthemes below.

Summary of the main themes and subthemes [Colour figure can be viewed at wileyonlinelibrary.com ]

Note: SLT, speech and language therapy; MH, mental health; MDT, multidisciplinary team.

In addition, data were gathered regarding how participants characterize this population. SLCN and difficulties with mental health were identified by participants as frequently co‐occurring. These data are presented following a discussion of the four themes under Figure  2 : SLCN and mental health difficulties: typical difficulties reported in this population.

Speech, language and communication needs (SLCN) and mental health difficulties: typical difficulties reported in this population [Colour figure can be viewed at wileyonlinelibrary.com ]

Theme 1: Boundaries around professional relationships

This theme describes observed discrepancies in the identification of children with SLCN and mental health difficulties, and discrepancies in approaches to working with this population between mental health professional participants and SLT participants. Differences in service provision, professional practice and lack of multidisciplinary team working were cited by participants as contributing factors to the observed discrepancies.

One subtheme concerned marked differences in the organization of SLT and mental health services. SLT and mental health services were not only considered differently organized but also highly variable depending upon postcode, funding and service set‐up. How services were set‐up was construed to play a large part in the appropriate management, or perceived mismanagement, of children with SLCN and mental health difficulties. Service boundaries were identified as contributing to a range of difficulties working across and between disciplines. For example, SLTs discussed difficulties referring to services such as child and adolescent mental health services (CAMHS), often receiving referral rejections from CAMHS with limited or no feedback. Other examples cited by participants were related to limited feedback or acknowledgement to receiving patient reports, a physical distance between services, and difficulties identifying appropriate treatment pathways for CYP with SLCN and mental health difficulties, particularly in mental health services. ‘Lots of referrals get rejected, so many referrals that we really feel as a team need CAMHS support’ (participant (P)5: SLT).

Participants described how services are often entirely separate and working in respective isolation. This was interpreted to contribute to a limited or total absence of joint working, resulting in a lack of knowledge of each profession's discipline and of discipline protocols, for example, referral systems, use of screening for appropriate referrals and confidentiality policies. Service level differences were also cited as causing difficulties identifying which discipline should assess and manage CYP. ‘It was sort of, oh no, that has to be CAMHS, CAMHS has to deal with them, and if they were under seven, then CAMHS would say, oh no, that has to be speech therapy, speech therapy is dealing with them’ (P3: SLT).

A second subtheme was limited multidisciplinary team (MDT) working. An MDT is a group of health or social care workers and professionals who are members of different disciplines, each of which provides a specific service to service users (Hodder Education, 2021 ). Differences in service provision and service funding resulting in a separation of professionals, both at a geographic and organization level, was construed as a contributing factor to limited MDT working between mental health and speech and language therapy. Participants described how SLTs and mental health professionals are often not part of the same MDT and therefore have fewer opportunities to provide integrated care. SLT participants commented that their profession is often unaccounted for within acute mental health services, and one mental health professional considered her role under the safeguarding team as being cut‐off from the SLT's role which was under the SEN team. In addition, some participants attributed limited MDT working to policy level differences such as psychological services not sharing information with SLT due to confidentiality policies and differences in patient note systems:

‘we're often funded by different streams and funded by different people, we work in different health trusts quite often, and that actually has massive implications for the fact a) that you're not physically in the same building, so you don't get to see these people very often, but that even things about how we collect data, our electronic patient systems, we often use very different data technology that, that can make things very difficult in terms of information sharing’. (P13: mental health professional)

SLT participants also described a lack of approachability from mental health professionals which was seen as alienating and limiting from a diagnostic and therapeutic perspective, further contributing to limited MDT working, collaboration and cohesion between these professional groups.

‘because you've talked about an incident or challenging behaviour or something like that, certain psychology colleagues see that as inappropriate or you've overstepped a boundary because you're talking about a kind of emotion when that's something that they do, or they perceive themselves as doing quite exclusively’. (P7: SLT)

Theme 2: Knowledge of SLCN and mental health difficulties

The first theme ‘Boundaries around professional relationships’ directly interacts with the second theme ‘Knowledge of SLCN and mental health difficulties’. A perceived lack of shared knowledge was seen to be related to limited opportunities for multidisciplinary experiences and the clinical service set‐up overall.

The first subtheme concerned the ‘visibility’ of SLCN. It was construed that potentially less immediately obvious SLCN, such as DLD, are less likely to be identified by mental health professionals than more visible SLCN, such as stammering and selective mutism. Visible SLCNs discussed more frequently by mental health professionals as opposed to invisible SLCNs. This discrepancy was described by participants as potentially contributing to unidentified SLCN and mental health difficulties within mental health services, and the lack of knowledge universally with assessment and treatment of this population.

‘I don't think that's typical for mental health practitioners (to consider language difficulties). No, I would definitely think I know my team, the teams that I've worked in, most people would not think about language, particularly language disorders in a young person as part of the part of their (psychology) assessment, unless a parent disclosed something like that, or unless they were very, it was very clear evidence that there were quite obvious difficulties’. (P13: mental health professional)

Difficulty teasing out SLCN from mental health issues (and vice versa) was also interpreted as contributing to a lack of knowledge regarding appropriate diagnosis of CYP with SLCN and mental health difficulties. It was construed that a lack of understanding of the relationship between SLCN and mental health often impacts upon which professional should and would assess and treat this population. Participants discussed how social skills historically have been explicitly taught by SLTs but that mental health professionals are increasingly using this approach as an intervention strategy. Participants discussed a general lack of clarity around role boundaries which could sometimes lead to perceptions of overstepping a professional role or boundary. ‘In my kind of experience, I find certain psychologists very much see emotion, or kinds of challenging behaviour as their domain and they don't like anyone stepping into it’ (P7: SLT).

Barriers to accessing talking therapies was the second subtheme. Knowledge around diagnosis was construed as relating directly to providing appropriate interventions for this population, particularly regarding talking therapies. Traditional talking therapies were interpreted as being potentially inaccessible and inflexible for individuals presenting with SLCN and mental health difficulties, particularly if language difficulties were unidentified. SLTs and some mental health professional participants viewed psychological therapies as language heavy, involving higher level language and concepts that CYP with SLCN would struggle to comprehend and verbalize.

‘I might go and observe a psychology session with them and then the language they're using is far too complex the, the psychological language, the therapy materials, they often use a metaphorical language, they're using kind of these images and symbolism, which is far too complex for the person in general and then they're not really understanding’ (P7: SLT).

Due to a perceived lack of knowledge, identification of CYP with less visible SLCN might be missed by mental health professionals and unaccounted for within traditional psychological therapies. SLT participants described how in such instances appropriate accessibility and efficacy of talking therapies for CYP with SLCN may be compromised. ‘I'm not sure how much they know about these particular children's language needs and like how therefore their intervention with DEAF‐CAMHS‐H [CAMHS for the hearing impaired] is delivered effectively’ (P2: SLT).

Theme 3: Being misunderstood/labelled as naughty

Both SLT and mental health professional participants construed CYP presenting with SLCN and mental health difficulties as misunderstood and often perceived negatively by staff, carers, parents and the wider environment. In particular, difficulties with challenging behaviour, dysregulation and disengagement were interpreted by participants as being misunderstood and perceived as ‘naughty’. Participants considered the high prevalence of behaviours such as disengagement, a distrust of professionals and school refusal as contributing to this perception. Participants interpreted this population as commonly using non‐typical social communication skills that may result in difficulties building and maintaining relationships with peers, staff, parents and carers, further contributing to a negative perception. Difficulties with understanding and expressing language were seen to be related directly to instances of challenging behaviour.

‘We tend to get a lot of young people who are presenting at school, with quite significant behavioural difficulties and we tend to find that being viewed as a behavioural child, rather than a child that's got underlying language needs that have been un‐diagnosed’ (P5: SLT).

Theme 4: Blended interventions

The final theme concerns blended interventions. This theme describes participants’ descriptions of optimum interventions for CYP with SLCN and mental health difficulties. It was construed that working with the systems and environment around CYP is clinically useful for this population.

The first subtheme concerns working with the environment. The use of positive behavioural support systems, emotional regulation strategies and programmes, staff training, and the involvement of parents within interventions were deemed as clinically useful interventions for CYP experiencing SLCN and mental health issues. Parent–child interaction therapy (PCIT) is used by SLTs with the aim of improving interactions between children and their parents/carers (Falkus et al., 2016 ). Theraplay is used by psychotherapists to support healthy child/caregiver attachments (Institute of Theraplay, 2021 ). Both PCIT and Theraplay offer similar programmes where parents are involved as part of the intervention process. Participants discussed the potential of combining or utilizing such approaches in a more joined‐up manner for future targeted interventions. A functional approach to mitigating SLCN was also construed as beneficial for this population. Participants discussed how targeting specific aspects of SLCN may not be as beneficial as focusing on increasing overall functioning and well‐being of CYP.

‘So, I think in terms of delivering therapy, lots of it is about that environmental to therapeutics, so sort of, let's see if we can normalize the environment as much as we can in this environment and support behaviour through communication’ (P3: SLT).

The second subtheme concerned supports for communication. This theme was discussed universally by participants. The need to adapt language and consider therapist delivery within all diagnostic and therapeutic processes was seen as paramount for CYP experiencing SLCN and mental health difficulties. Using simple or no language to take the pressure off a requirement for verbal communication was interpreted as being necessary within any intervention for this population. Other visual supports, such as talking mats (Murphy et al., 2013 ) and communication systems, such as visual timetables and ‘now and next’ boards, were considered useful.

‘The use visuals, the use of visuals full stop. Whether that's visual or written timetable, even if the child has literacy so implementing a sort of routine on a timetable and consistent use of that across the day, I think works well’ (P4: SLT).

Play therapy or the use of play as a vehicle for access to psychological therapy for CYP with SLCN and mental health difficulties was considered a potentially useful psychological approach for this population due to the lack of emphasis upon verbal communication:

‘So, I think the use of toys and play can help bring their outer world about what's going on when, what they see inside and speech doesn't need to be, it doesn't need to be a part of that’ (P12: mental health professional). ‘I think the therapy it's different because I'm not expecting, they don't have to talk’ (P11: mental health professional).

Explicitly teaching higher level language was deemed an important intervention strategy, particularly in relation to comprehending and expressing emotions. One SLT participant described how they had combined a cognitive developmental theory of emotion and a psychotherapy model, with a vocabulary intervention directed through talking mats (Murphy et al., 2013 ) to facilitate communication. This was discussed and explored as a potentially useful way to develop emotion vocabulary comprehension and processing with this population.

‘You give people labels to understand what they're feeling physically, and then you move it onto more cognitive levels where that's the more kind of established sort of CBT, that kind of approach where they're thinking about their emotions and their thoughts … then you move on to the word level stage (of the vocabulary intervention) and that's very much around introducing kind of very basic semantic understanding of the word of the meaning and then you're building in the syntax and you're trying to get a really deep, you're trying to get there because they often have a vague notion of what certain words mean, but their understanding is very poor so you're trying to really reinforce a particular meaning or understanding of an emotion word’ (P7: SLT).

Merging interventions drawing upon practices from speech and language therapy and mental health was discussed. For instance, an SLT talked about how they had successfully combined shape coding (Ebbels, 2021 ), which is an established intervention used by SLTs, with social communication, emotional regulation, and transactional support (SCERTS), which is a behaviour intervention (Prizant et al., 2006 ). Participants also interpreted the use of relatable, non‐hypothetical language, and teaching how emotions look and feel in the body as being clinically necessary for this population. Participants advocated for the need to modify and adapt traditional talking therapies such as cognitive behavioural therapy and using an individualized approach. ‘Lots of more sort of explicit ways of doing things and using lots of examples from his own his own life and things that he would bring to the session rather than me coming up with example’ (P13: mental health professional).

Common difficulties reported by interviewees to be seen in CYP with SLCN and poor mental health

In addition to the themes described above, participants generated discussion regarding how they characterize this population. In answer to the question ‘can you tell me about some of the difficulties these CYP experience?’, participants described a range of difficulties this population typically present with. This is not a diagnostic criterion; it is a set of descriptions used by participants to describe their experience of this population (Figure  2 ).

Participants felt that characterizing the overall presentation of this population is often problematic. Participants reported that it is difficult to determine what is specifically a SLCN and what is a mental health need. SLCN and difficulties with mental health were identified by participants as frequently co‐occurring. Key aspects of development were identified by participants as being typically delayed or disordered with CYP experiencing SLCN and mental health difficulties. Participants reported that CYP in this population would commonly experience difficulties across these areas. The first area identified was emotional well‐being. Participants felt that this population significantly struggle with feelings of self‐consciousness, low self‐esteem, and anxiety, often about the presence of a communication impairment, and the impact of their communication difficulty on their experiences with the world around them. Participants felt that difficulties with self‐esteem and anxiety could sometimes result in poor emotional resilience. One participant described how young offenders are at particular risk of developing low self‐esteem because of multiple exclusions from education and therefore a sense of rejection that they may experience throughout life. Another participant described how difficulties with SLCN could impact on their well‐being and levels of anxiety and distress and behaviour. ‘We definitely see those children, they're often very anxious and there is definitely an impact of some of their difficulties on their well‐being, self‐esteem and their mental health’ (P5: SLT).

The second common characteristic was challenging behaviour. Participants described this population as typically experiencing difficulties with engagement, staying on task, and finding it hard to comply with work in the classroom or, with other professionals. Typical behavioural difficulties were problems with emotional regulation and the presence of anger or aggressive behaviours. Participants described how CYP can be disruptive or conversely appear withdrawn and isolated in social situations. Other reported difficulties in this area were with attention and listening and with building and maintaining relationships, particularly with peers.

‘We see quite a lot of, we describe it as anxiety for the children that, that I work with and dysregulation is a term that I've been using much more recently, so that can present as very elevated, it can present us physical aggression, some self‐harm and behaviours, yeah, sort of, socially inappropriate behaviours in terms of removing clothes and smearing and that sort of thing’ (P10: mental health professional).

The final area identified as characteristic of this population was language and cognition. Participants felt that this category of CYP experience difficulties with general language comprehension, processing of spoken language and with their expressive language. ‘Verbally he (a patient) appeared to understand things very well or he had a good, he had a good vocabulary, but actually his understanding was limited so he could be quite misleading’ (P13: mental health professional).

Difficulties with executive function was also discussed, often in relation to CYP being able to appropriately plan and organize themselves. One participant cited how it is common for CYP to arrive late to lessons, getting lost en‐route and forgetting school equipment. Difficulties with verbal reasoning were also described as commonly present with this population. ‘They're breaking their curfews and they end up in trouble with the police and things because they can't tell the time’ (P5: SLT).

Difficulties with metacognition (thinking about thinking) was also highlighted by participants as a typical difficulty seen in these CYP. Difficulties with insight, being able to monitor their communication and planning how to approach a learning task were all discussed as typical problems for this population. ‘They may not have insight into their own language use or behaviour’ (P2: SLT).

‘Difficulties with higher order language and the use of sophisticated, abstract and emotional language was also reported. Participants reported CYP in this population often experience difficulties understanding and using emotion language, particularly labelling emotions. They don't know what it means when somebody uses those words (emotional words), or is sarcastic’ (P5: SLT).

The misunderstanding of negative constructions was discussed as being a barrier to understanding emotions:

‘You might conceive that someone's doing something to you because you can't understand negative constructions, for instance, you just you assume everyone's just doing things to you but you're the one who's not quite understanding like the word no, or negative things’ (P7: SLT).

Difficulties with being able to understand abstract language and using language in a more abstract way to make predictions, use hypothetical language and humour was also cited as a typical difficulty in this population. ‘He would struggle with transferring that knowledge from a discussion about a hypothetical person to himself’ (P10: mental health professional).

The current study explored the experiences and views of SLTs and mental health professionals working with CYP with SLCN and mental health difficulties. Discussion around CYP with SCDs such as ASD, and developmental language disorder (DLD) was of particular interest. SLTs and mental health professionals in this study perceived certain subtypes of SLCN to commonly co‐occur with mental health difficulties. Findings suggest that there are organizational and service set‐up boundaries between SLTs and mental health clinicians, which has implications for the efficacy of assessment and treatment of this population. Findings also suggest that this population is often misunderstood and misidentified. The current research indicates that combined approaches in SLT and mental health may be beneficial for CYP who present with co‐occurring SLCN and mental health needs.

The current research has also identified that distinct barriers exist between mental health clinicians and SLTs which has led to boundaries between these professional groups. The most significant barrier was found to be around service organization and set‐up. Participants described how, as professionals, they felt organizational difficulties led to feelings of ‘failing’ this cohort. Findings suggest that mental health professionals and SLTs are often not in the same MDT and that SLT is often not a recognised professional group within children and adolescent mental health services. SLT and mental health services appear to be functioning in parallel, working under different teams, services, NHS trusts, local authorities, and sometimes entirely different organizations. Service set‐up and organization limitations were deemed to result in fewer opportunities for MDT working which has a negative impact on the knowledge professionals have of CYP with co‐occurring SLCN and mental health difficulties. Within the United Kingdom there is currently an ongoing consultation process with The Royal College of Speech and Language Therapists (RCSLT) and CAMHS to recognise the role of SLT within mental services and to increase SLT roles within core CAMHS services.

The current research highlights how a lack of understanding of this population is a clinical concern and has been described by participants in this study as having implications for effective diagnosis and treatment. The current study also illustrates that availability of joined up and multidisciplinary services for this population is scarce. This has resulted in a lack of shared knowledge about this population, leading to challenges with diagnosis, particularly with CYP who exhibit invisible SLCN and mental health difficulties such as DLD. The current research highlights that CYP with co‐occurring SLCN and mental health difficulties may be undiagnosed or misdiagnosed by professionals. This may mean CYP in this population fail to receive appropriately modified and evidence‐based treatment. The current findings resonate with other recent investigations of parents’ experiences concerning mental health support for their children with SLCN. Parents have reported concerns that mental health treatments were not accessible for their children and lacked adaptations necessary for them to work for children with conditions such as DLD (Hobson et al., 2021 ).

Typical behaviours and characteristics of CYP with co‐occurring SLCN and mental health needs are often misunderstood by parents, carers and professionals resulting in this population being misinterpreted and often labelled as ‘naughty’. Behaviours that are typically misunderstood include anger or emotional outbursts due to difficulties with emotional regulation, disengagement, language difficulties and problems with building and maintaining adult and peer relationships. Participants reported that children in this population are frequently ‘angry’ or show aggressive behaviours, and experience difficulties with friendships, can be distrusting of professionals, and are likely to show poor school attendance. Participants observed that CYP in this population are also likely to experience school expulsion, attendance to pupil referral units, and in some cases youth offending institutions/team (YOT).

A key finding was that interventions used in both speech and language therapy and psychotherapy are perceived as clinically useful if combined. Other research (Bercow et al., 2016 ; Menzies et al., 2018 ) has applied mental health interventions to specific subtypes of SLCN such as stammering, selective mutism and ASD, but little in relation to DLD. Participants discussed how they have successfully blended behaviour and emotion programmes with language and communication interventions. Similarly, participants discussed how combining traditional talking therapies, such as CBT, with modifications to account for communication difficulties, such as using visual supports, can be beneficial.

Hollo et al. ( 2014 ) has called for the development of interventions to ameliorate the effects of these dual deficits. Findings from the current study show that some existing or modified interventions are anecdotally effective. A good starting point for future research would be with the exploration of adapted traditional talking therapies and psychological therapies combined with SLT. A preliminary finding from the current research is that play therapy could also offer a potentially useful psychological therapy for CYP with co‐occurring SLCN and mental health difficulties due to its child‐led nature and lack of emphasis upon language and communication. Interestingly, play therapy was also raised by parents of children with DLD in the study by Hobson et al. ( 2021 ) as an approach that they felt would be worth pursuing. This has yet to be directly explored in individuals with SLCN but could offer further direction for future research into interventions for this population.

Findings from the current research show that it is not typical for mental health clinicians to consider language and communication skills within their assessment and treatment processes. The potential impact of this omission was described by participants as limiting CYP with co‐occurring SLCN and mental health needs to therapies that would likely be inaccessible. The current study has found that traditional talking therapies may not be modified for this population, unless the CYP have an obvious or diagnosed SLCN. This has implications for the efficacy of treatments provided, highlighting that traditional talking therapies, if not appropriately modified, are likely to be suboptimal for this cohort. Participants felt that traditional talking therapies could be reasonably adjusted to be accessible to individuals with SLCN. In a recent intervention study where aphasic adult patients received SFBT, Northcott et al. ( 2015 ) concluded that modifying question forms of therapy enabled greater accessibility.

Clinicians identified that CYP with SLCN and mental health difficulties most commonly experience difficulties across and between the domains of language and cognition, emotional well‐being and challenging behaviour. Fundamentally, participants considered that it is typical for CYP to present with co‐occurring SLCN and mental health difficulties, that is, difficulties across speech, language and communication and mental health. Previous research reports that children and adolescents with DLD and ASD are likely to experience difficulties with anxiety and depression (Cohen et al., 2013 ; Hofvander et al., 2009 ; Wadman et al., 2011 ). Results from the current study reflect this, indicating that difficulties with language and social communication are likely to interact with mental health difficulties. In addition, participants felt that SLCN can profoundly affect a person's social and emotional well‐being, and this can lead to poor mental health.

Participants described how CYP typically experiencing difficulties with higher level language are likely to find understanding and expressing emotions challenging. This supports existing frameworks such as the alexithymia language hypothesis (Hobson et al., 2020 ) which proposes that because of the intrinsic relationship between language and emotions, CYP with conditions such as ASD and DLD may be more likely to experience co‐occurring difficulties with mental health.

A limitation of the current study was that some of the participants were recruited from the researcher's professional network. Thus, a convenience sample was used and therefore potential selection bias may have been present, resulting in a failure to capture important perspectives from hard‐to‐reach participants. However, it is important to note that the range of participant specialities, knowledge and skill set was heterogenous and diverse.

Clear directions for future research have been identified from the results of the current study. The service organization, set‐up and service provision for this population is problematic. Future studies could explore and evaluate current services, set‐up and structure across and between SLT and mental health. The findings from the current study have important implications for the efficacy of treatments provided to this population, suggesting that more research needs to be done in this area. There exists a large gap in the evidence base for intervention‐based studies with this population. Larger scale intervention studies could also provide evidence for the efficacy of psychological approaches with this population. Future studies could also explore the adaptability of traditional talking therapies, combining approaches drawn from SLT and psychological therapies and the exploration of play therapy. Intervention studies analysing the efficacy of psychological therapies in children and adolescents with SLCN should arguably be conducted in part with SLT to provide input regarding SLCN. Modifications to talking therapies in young people with SLCN are therefore necessary in order to reflect and treat the presence of SLCN and mental health difficulties. Research from Solution Focused Brief Therapy (SFBT) in Poststroke Aphasia SOFIA trial (Northcott et al., 2021 ) suggests that modifications to SFBT is a promising psychotherapy approach for adults with aphasia, and that it is possible to adapt a language‐based psychological intervention for people with language disorders. In addition, behavioural activation therapy has also been shown to be successfully modifiable for adults with aphasia (Thomas et al., 2013 ) but further evidence, especially in a paediatric population, is scarce.

The current study aimed to describe typical presentations of this population, clinician experiences treating this population and clinically useful treatment approaches. The findings present a picture of the problems CYP with SLCN and mental health needs commonly experience and has enabled the documentation of a range of clinician experiences and views to inform and build a limited evidence base. Findings suggest that there are distinct organizational and service set‐up limitations with implications for the assessment and treatment of CYP with SLCN and mental health difficulties. Interventions drawing upon SLT, and mental health approaches may be beneficial for this population.

Supporting information

Supporting Information

ACKNOWLEDGEMENTS

Annabel Hancock thanks The Owl Therapy Centre for their invaluable support and for making this project a reality. She also thanks her supervisors and The NIHR for funding this project as part of the Predoctoral Clinical Academic Fellowship. She is also grateful to the participants who took part in this project, without which this research would not have been possible.

Hancock, A. , Northcott, S. , Hobson, H. , & Clarke, M. (2023) Speech, language and communication needs and mental health: the experiences of speech and language therapists and mental health professionals . International Journal of Language & Communication Disorders , 58 , 52–66. 10.1111/1460-6984.12767 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

The NIHR funded this project as part of Annabel Hancock's Predoctoral Clinical Academic Fellowship.

DATA AVAILABILITY STATEMENT

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May 14, 2024

Adolescent Anxiety Is Hard to Treat. New Drug-Free Approaches May Help

Research on the developing brain points to new ways to help young people with anxiety disorders

By BJ Casey & Heidi Meyer

Ellen Weinstein

A dolescence is a remarkable period of development and learning, a time when youths explore and adapt to changes in their social worlds and begin to form a sense of who they are and hope to be. It is a time when they first demonstrate a dramatic adaptability to the unique cognitive, emotional, physical, social and sexual demands placed on them as they transition from dependence on their parents or caregivers to relative independence. It is also, unfortunately, a time when the emergence of most mental health problems peaks.

The most common mental health concerns facing adolescents today are anxiety disorders, and their prevalence has been increasing for the past decade. A survey of tens of thousands of teens showed that this prevalence increased roughly 30 to 40 percent between 2012 and 2018, and based on evidence from teens from Germany, it rose another 70 percent during the first few years of the COVID pandemic. Yet anxiety disorders in young people are largely undertreated.

The only evidence-based behavioral treatments for anxiety are cognitive-behavioral therapies (CBTs). They involve identifying triggers of anxiety and then desensitizing the affected person to them through coping strategies such as positive thought reframing or breathing exercises, along with repeated exposure to the triggers in a safe environment. Although CBT is the most established treatment for adolescent anxiety, not all youths who try it experience relief. Among those who do, many fail to maintain improvements over time. A mere 20 to 50 percent of patients treated for anxiety without medication during adolescence remain in remission six years after initial CBT. The consequences can be long-lasting and severe. Left untreated, anxiety can lead to more serious chronic illnesses such as depression and substance use disorder later in life, greater susceptibility to physical illnesses and, in extreme cases, suicide.

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Fortunately, new discoveries about the adolescent brain are showing promising paths forward for the treatment of anxiety. Current research benefits from rapidly advancing imaging technologies that can reveal patterns of neural activity and exciting potential avenues for intervention. These modalities have already provided access to the inner workings of the developing brain in laboratory animals and teens, and scientists hope they will lead to new approaches in clinical practice that take into account the unique changes in the human brain during adolescence. By focusing on the developing brain and the behaviors it generates early on in life, we may be better able to alter anxiety-related memories, identify cues and situations that help to reduce symptoms, and mitigate the adverse effects of anxiety for young people before they become a more chronic affliction in adulthood.

In the past two decades we have learned that the adolescent brain undergoes notable changes in structure and function, and these changes are distinct from those observed during early childhood and adulthood. They are localized, meaning certain brain areas change earlier in development than others. Regions involved in emotions, such as the amygdala and the hippocampus, show peak structural and functional changes during the teen years. For example, during adolescence the amygdala’s volume increases (a structural change), and so does the way the amygdala is activated by certain emotional experiences (a functional change). In contrast, brain regions and circuitry associated with the regulation of emotions, thoughts and actions—the prefrontal cortex, for instance—change more gradually, with development continuing well into adulthood. These differences in developmental timing may lead to an imbalance in communication among brain regions, allowing one area to prevail over another in an adolescent’s decision-making. Accordingly, in emotionally charged or threatening situations, early-developing emotional areas “win out” over later-­devel­op­ing ones, driving some of the reactions and responses linked with the behaviors of anxious and volatile teens. These regional differences might have served an evolutionary purpose. They have been linked to heightened sensitivity to emotional and social information that may be essential for reproductive success and the survival of the human species. Unfortunately, these same imbalances have also been associated with increased reactivity to stress and greater susceptibility to anxiety disorders.

A core emotion associated with anxiety disorders is fear. Although fear is an adaptive response to threats and therefore essential for survival, persistent fear long after a threat has been removed can lead to a pathological state of anxiety. People with anxiety disorders have difficulty identifying when previously threatening situations have become safe, and they may overgeneralize by thinking that a negative experience in one situation will recur in other scenarios.

Decades of animal and human research have identified the basic brain circuitry for remembering an acquired fear in adults. The amygdala is key to developing a fear memory, and parts of the prefrontal cortex are involved in decreasing the strength of fear memories—a process known as extinction. Both the amygdala and the prefrontal cortex are highly interconnected with a third region, the hippocampus, which plays a role not only in fear extinction but also in determining how we experience fear in different situations. In particular, the hippocampus provides information about the surrounding environment to help an individual decide whether a given situation is more likely to present a threat (for example, a bear in the woods) or an absence thereof (a bear at the zoo). Much of this circuitry is conserved across different species, enabling the translation of basic animal research to treatments in humans.

Recently researchers have focused attention on fear memory and extinction during adolescence. These studies show that adolescents, like preadolescents and adults, are capable of acquiring a fear memory, but they are less able to extinguish those memories than people in other age groups. After being exposed to a few simple pairings of a neutral stimulus (a colored square) with an aversive stimulus (a loud noise), children, adolescents and adults alike show a fear response, measured by sweat gland activity, to the colored square even when the loud noise no longer happens. When preteen children and adults are then presented repeatedly with the colored square without the loud noise, they begin to see the square not as something predicting the threat of the loud noise but rather as a safe refuge from it—the fear memory is extinguished. Adolescents, however, continue to react fearfully to the colored square.

In cases when fear does get diminished for adolescents, it regularly returns with the passage of time. The finding that adolescents “learn” to extinguish fear less readily than younger or older people has been replicated in studies across species (mice, rats and humans). Most notably, during this developmental period, the amygdala is much more involved in sustaining the fear memory than the prefrontal cortex is in initiating the extinction process. A lower ability to initiate fear-­extinction learning is thought to confer a risk for anxiety. Thus, adolescents may innately be at higher risk.

Jen Christiansen

The discovery of differences in fear-extinction behavior and brain circuitry during adolescence has important implications not only for understanding the potential for increased susceptibility to anxiety disorders but also for choosing treatment options. Behavioral therapies such as CBT entail identifying triggers of anxiety, finding coping strategies and undergoing a process of desensitization built on the principles of fear extinction. But during adolescent fear extinction, the involvement of the prefrontal cortex, which is associated with the planning and control of behavior, is diminished—which implies that for adolescents, the effectiveness of conventional exposure-based CBT might also be diminished. Together, these facts raise the question of how we should tailor treatments for the developing brain. Specifically, how might we use what we know about the brain’s fear circuitry and the development of fear learning during adolescence to guide interventions that may be more successful in altering teens’ fear memories?

One strategy involves conceding the delayed maturation of the prefrontal cortex and circumventing the region in treatment. Rather than relying on prefrontal-based extinction learning, we have tested an alternative method called memory reconsolidation updating. Memory reconsolidation is based on the principle that memories are dynamic, not static. Every time a memory is retrieved, it gets modified. Reactivating a fear memory by presenting a reminder of the fear stimulus opens a time-limited window during which the memory itself becomes prone to disruption and change.

Studies in both humans and rodents suggest that fear-­memory updating is mediated by changes to the memory in the amygdala. Unlike the prefrontal circuitry, which continues to show developmental changes into young adulthood, the amygdala undergoes peak maturation during midadolescence.

These findings suggest that one way to help adolescents overcome pathological fear is to introduce what is called a reminder cue to retrieve the memory, followed by a delay before subsequently extinguishing it. In our lab, we tested this idea in both healthy adolescents and adults by comparing their retention of a fear memory after extinction with and without a preceding reminder cue. We found that even though adolescents typically show diminished fear extinction relative to adults, those who were prompted to retrieve the fearful memory several minutes before extinction learning showed a dramatic reduction in fear the next day compared with those who underwent only extinction learning. In fact, those adolescents’ fear memories diminished to the same degree as observed in adults.

Traditionally, extinction learning involves forming a new, competing, safe memory that leaves the original fear memory intact, meaning it is possible for those fearful thoughts to return later. The current findings, however, suggest that with memory reconsolidation updating, the original fear memory is altered. Thus, the reconsolidation approach has the potential to both reduce fear at the time of treatment and lessen the likelihood that it will return.

This research is exciting because it suggests a path to the clinical use of reconsolidation updating. Simple modifications to existing exposure-based CBT techniques might prove effective in reducing triggers of fear and anxiety in adolescent patients. This method could entail a step as simple as the therapist reminding patients why they are there when they arrive for their appointment—the equivalent of the reminder cue and fear-­memory retrieval in the lab setting. Then the therapist could spend several minutes establishing a safe rapport with the patient while waiting for the memory to enter a labile state during the reconsolidation-updating window. Desensitization with exposure therapy could then begin during the time in which the updating process takes place. The current variable efficacy of CBT in adolescents with anxiety disorders may be explained by the fact that some clinicians already use procedures that inadvertently tap into components of reconsolidation updating.

Recent attempts to incorporate reconsolidation-­updating approaches in treating adult patients with anxiety and trauma-related disorders have yielded some success, but to date they have not been used with adolescent patients. The studies in adults show short- and long-term reduction of symptoms, especially for patients with specific phobias and post-traumatic stress disorder. Although more basic and clinical research is needed, this method seems promising.

A nother strategy that may help adolescents extinguish a fear memory involves the use of safety cues that signal there is nothing to be afraid of. In an experimental setting, a safety cue can be a simple stimulus—a symbol or a sound—that is distinguishable from and repeatedly contrasted with a fear cue. Outside the lab, safety cues come in many forms and are likely to be a stimulus unique to the individual: a small personal object, a photograph of a loved one, a specific scent. We and others have shown that in humans and rodents alike, safety cues act by recruiting brain regions that show elevated activity during adolescence, including the amygdala and the hippocampus. The anterior part of the hippo­campus in particular shows a strong increase in activity when a safety cue is presented alongside a fear cue; the degree of activity corresponds to the reduction in fear. Furthermore, safety cues rely less on the prefrontal cortex than do other forms of fear regulation , such as extinction, highlighting the possible advantage of using a safety cue–based approach for anxiety during adolescence.

It is not feasible to avoid all triggers of excessive fear and anxiety, so it’s important that patients do not become overly reliant on safety cues to the detriment of learning other coping skills. Safety cues may be a valuable tool for increasing the tolerability of the early stages of treatment so that patients do not drop out. Early treatment sessions could include guidance from the clinician on how to identify and properly deploy a safety cue.

As treatment progresses, cues can give patients a way to reduce their fear response long enough to evaluate the situation and use tools from CBT practice. Although research on integrating safety cues into treatment is in its earliest stages, the method shows great promise, particularly for adolescents. Our group recently demonstrated in mice that intermittently presenting a safety cue during an extinction protocol led to better fear extinction in adolescent mice than observed in either adolescent (28 to 50 days) or adult rodents trained without a safety cue.

The hope for these emerging therapeutic approaches is that we can tailor current anxiety treatments for young people by targeting the developing brain. It is important to be mindful of the fact that the magnitude and intensity of the fear response in people diagnosed with anxiety are probably much greater than the fear evoked by aversive stimuli in lab experiments, which are often mild, narrowly targeted and transient. It is also important to remember that CBT and antidepressants can treat anxiety effectively in many people. Unfortunately, though, for some, these solutions offer only limited or brief benefits. Therefore, the most effective forms of treatment may require a combination of approaches, including desensitization techniques modified to incorporate reconsolidation updating or safety cues, possibly in conjunction with antidepressants.

The ultimate aim is for us to optimize current treatments for youths with anxiety by targeting the brain during a period of development accompanied by intensive learning and, in so doing, improve the quality of life for adolescents both in the immediate future and later in life.

BJ Casey is Christina L. Williams Professor of Neuroscience at Barnard College.

Heidi Meyer is an assistant professor in psychological and brain sciences at Boston University’s Center for Systems Neuroscience.

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Selective mutism: symptoms, causes, and treatment

Posted: 15 May 2024 | Last updated: 15 May 2024

Selective mutism is best described as an anxiety disorder that causes a normally verbal person to be unable to speak when exposed to certain situations. While it is estimated to affect around one in 140 young children, awareness about selective mutism is relatively low. That said, there are certain misconceptions about the condition that have to be dispelled.

Check out this gallery to learn about selective mutism and what can be done about it.

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Introducing selective mutism

Selective mutism is a severe anxiety disorder that renders a person unable to speak in certain social situations, such as with schoolmates in the playground.

Early beginnings

Selective mutism normally develops during childhood, and in certain cases it can continue into adulthood.

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Common misconception

It is important to recognize that a person who suffers from selective mutism does not simply decide not to speak in certain situations.

The freeze response

Rather, a freeze response is triggered in them with feelings of panic, and this renders speaking quite literally impossible.

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Common reaction

In many cases of selective mutism, the sufferer will learn to recognize situations in which they freeze, and try to avoid these situations at all costs.

Not mute all the time

However, a person with selective mutism is able to converse normally in other situations where they feel comfortable.

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We are still learning about selective mutism, and in fact it is more common than you might think. It is estimated to affect about one in 140 young children.

Affected groups

It is also more common in people who are learning a second language, such as people who have migrated from their country of origin.

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The onset of selective mutism normally happens between the ages of two and four. Often it is first picked up upon when a child begins to interact with people outside their family, such as schoolmates.

The main symptom of selective mutism is a marked contrast in the way a child interacts with different people.

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Sudden stillness

When expected to speak with someone outside their comfort zone, the child may react with a sudden stillness and frozen facial expression.

Temper tantrums

A child with selective mutism may avoid eye contact and appear otherwise socially awkward. They may be stubborn or aggressive and more prone to temper tantrums.

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Other means of communication

In some cases, an otherwise confident child with selective mutism may use other means of communication, such as hand gestures or body language.

In the majority of cases, however, children are severely affected and tend to avoid communication altogether. They may manage to respond with a few words, or in a whisper.

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Phobia of talking

Experts think of selective mutism as a phobia of talking to certain people. The exact cause is unclear, but it has been associated with anxiety.

General anxiety

Children who suffer from selective mutism generally have a tendency towards anxiety and may find it difficult to take everyday events in their stride.

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Separation from parents

Some children find it so distressing being separated from their parents that they are unable to speak, and they become selectively mute with the adults who try to settle them.

Speech and language problems

Others might have a speech and language disorder or a hearing problem, which can increase levels of anxiety and make it even more difficult to speak.

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There is no evidence to suggest that children with selective mutism are more likely to have experienced trauma or abuse.

No connection

There is also no evidence of a link between selective mutism and autism, although it is perfectly possible for a child to have both.

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If left untreated, selective mutism can lead to a host of other problems down the line. Thankfully, it is possible for children to overcome selective mutism if it is caught early enough.

Diagnosing children

If you suspect your child may have selective mutism and there is no help available at their school, seek a formal diagnosis from a speech and language therapist.

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Your child may not be able to speak during the consultation, but a professional will be prepared for this and will have other ways to help your child communicate.

Diagnosing adults

It is also possible, although arguably more difficult, for adults to overcome selective mutism with the help of a mental health professional who has the support of a speech and language therapist.

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Treating selective mutism does not focus on the speaking itself, but rather on reducing or even eliminating the anxiety associated with speaking in certain situations.

Types of treatment

There are two key types of treatment often used to treat selective mutism: cognitive behavioral therapy (CBT) and behavioral therapy.

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CBT encourages a person to focus on how they think about themselves, others, and the world around them, and how their perceptions of these things affect the way they think and feel.

As a general rule, CBT is more suitable for older children and adults who struggle with selective mutism.

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Behavioral treatment

Behavioral therapy, by contrast, focuses on working towards and reinforcing desired behaviors, while replacing bad habits with good ones.

Selective mutism is a complicated and tricky disorder to live with. However, with the right help and support, things can get better.

Sources: (NHS)

See also: Understanding developmental language disorder

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Am Fam Physician. 2024;109(5):online

Related Putting Prevention Into Practice:  Screening for Anxiety Disorders in Adults

As published by the USPSTF.

The full recommendation statement is available at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/anxiety-adults-screening .

The USPSTF recommendations are independent of the U.S. government. They do not represent the views of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the U.S. Public Health Service.

This series is coordinated by Joanna Drowos, DO, contributing editor.

A collection of USPSTF recommendation statements published in AFP is available at https://www.aafp.org/afp/uspstf .

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Copyright © 2024 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions  for copyright questions and/or permission requests.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

Can a roller-skating goat help kids with speech problems?

Pediatric speech delay and disorder diagnoses more than doubled during the COVID-19 pandemic, according to a 2023 study .

A language delay occurs when a child's language skills lag behind peers their own age. A language disorder is characterized by atypical language acquisition that significantly disrupts communication.

Speech disorders in children are highly treatable, with some kids responding to different types of therapy better than others.

On Cincinnati Edition , we’ll discuss a new interactive approach that uses gaming technology. And we’ll talk about what parents and teachers should watch for when it comes to speech development.

• Suzanne Boyce, speech language pathologist, University of Cincinnati
• Desiree Rusch, speech language pathologist, Cincinnati Children’s

UC and Cincinnati Children’s are financial supporters of Cincinnati Public Radio.

Ways to listen to this show:

• Tune in live at noon ET M-F. Call 513-419-7100 or email [email protected] to have your voice heard on today’s topic.
• Catch the replay on 91.7 WVXU and 88.5 WMUB at 8 p.m. ET M-F.
• Listen on-demand. Audio for this segment will be uploaded to this page by 4 p.m. ET., or subscribe to our podcast .

• Addressing anxiety may aid walking problems in Parkinson’s

Study finds gait generally worse in patients with anxiety than without anxiety

by Marisa Wexler, MS | May 14, 2024

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People with Parkinson’s disease who have clinically significant anxiety tend to walk more slowly and with shorter steps than people with the disease who don’t have anxiety.

That’s according to the study, “ The impact of anxiety on gait impairments in Parkinson’s disease: insights from sensor-based gait analysis ,” which was published in the Journal of NeuroEngineering and Rehabilitation.

The changes in walking may make Parkinson’s patients who have anxiety more prone to falls and researchers said the finding suggests that helping patients deal with anxiety may help improve walking ability.

“Our findings imply a close relationship between anxiety and gait disturbances in [Parkinson’s] patients, with anxiety potentially impairing gait performance and negatively affecting patients’ quality of life,” the scientists wrote.

Abnormalities in walking, including unusually slow and small steps, are common with Parkinson’s disease. Anecdotally, some clinicians have observed that patients who are more anxious tend to have more walking issues, but there’s been little hard evidence for this idea.

Anxiety is common in Parkinson’s, linked to worse life quality: Study

Walking with anxiety.

Here, scientists in China used a computer-based sensor setup to analyze walking patterns in 144 Parkinson’s patients — 38 who reported clinically significant anxiety and 106 who didn’t — to get a more objective understanding of how anxiety affects gait in Parkinson’s patients.

“Our study adds new quantitative evidence to the existing knowledge of effect of anxiety on gait disturbances in patients with [Parkinson’s] and extends understanding of the details and extent of this effect,” the researchers wrote.

Walking patterns were analyzed in two setups. In one, patients simply walked in a straight line. Under it, those with anxiety showed dramatic changes for many parameters: they took shorter steps, had longer pauses between steps, walked slower overall, and even had differences in the angle at which their toes and heels hit the ground with each step.

In the second setup, patients walked in a straight line while simultaneously counting backwards from 100. Under this setup, which required cognitive attention to accompany the physical act of walking, patients with anxiety still had significantly shorter steps and were slower overall, but the difference wasn’t as dramatic and other parameters that were different in the first setup weren’t in the second.

Still, statistical analyses showed anxiety was an independent predictor of multiple gait parameters and, considering data from both setups, the researchers concluded that “gait performance was generally worse in patients with anxiety compared to those without anxiety in both … situations.”

The slower, shorter steps by patients with anxiety imply a more “ shuffling ” gait, which is a known risk factor for falls, the researchers said, who, for this reason, suggested “extra caution should be taken to prevent falls in patients who are experiencing anxiety.”

The findings underscore the importance of caring for patients’ holistically, including providing mental and emotional support as appropriate, when helping Parkinson’s patients dealing with walking problems.

“Addressing anxiety symptoms may not only help to improve a person’s overall mental health but also lead to better outcomes,” the researchers said. “By reducing anxiety, patients may be better able to focus on their physical therapy and rehabilitation and be more motivated to engage in activities that can improve their gait and overall mobility.”

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