Summary        Sommaire        Text in French
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Patricia M. Sims
Dyer’s Nethercott Braunton
EX33 1HT DEVON
Tél. 01271 813648

As speech and language therapists, we are in a unique situation in that (1) we regularly meet with, and treat, an extremely wide range of problems among children of all ages, on a one to one basis, and (2) we have abundant opportunities for discussion with parents. No other group of professionals has quite such a chance to obtain an overall view, and hence great insight, into children's difficulties, and so it is perhaps incumbent on us to lead the way in broadening the issues.

Tension and anxiety are normal attributes which are essential to us all, but people differ in the degree to which they possess them and the manner in which they exhibit them. I wish to show how this can give rise to variations in development. Throughout this paper I use the word anxiety broadly. At the one extreme I include great fear, worry or stress. Strong fears are common in childhood and we should bear in mind that the full range of adult depressive symptoms may be expressed by children by the age of six years (Angold, 1988). On the other hand, I intend anxiety to include mild states of tension which may result in excess excitement, slightly exaggerated intensity of feeling, restlessness or even a little seriousness. Tension and anxiety do not have to be out of the normal range to be associated with problems.

Inherent tension or anxiety (or inherent predisposition to it) must combine with environmental influences to affect a child's levels of tension. Moreover, there is increasing evidence that a pregnant woman's stress hormones can affect the fetus and have long-lasting effects on the child's behaviour and development (Van Reempts et al., 1996; Wadhwa et al., 1993; Weinstock, 1997). Prenatally stressed infants show a higher incidence of attention deficits, hyperanxiety and disturbed social behaviour; it also appears that they may be more prone to future psychiatric disorders (Weinstock).

It is necessary to make an enquiry into a child's personality traits through an appropriate and sensitive discussion with a parent, who receives no impression that anything abnormal is being considered. Indeed, it becomes clear that abnormality is frequently normal behaviour in an exaggerated form and that if we seek to properly understand problems, we must acknowledge the importance of fully comprehending normal behaviour.

A personality check list can be referred to whilst talking with a parent. I have found that most parents participate eagerly in the discussion and that children are often pleased to hear their fears and habits aired without censure, whilst they play.

It is recommended that possible interpretations and effects of traits are included in the training of therapists.

One very important trait to consider is that of switching off. Everyone indulges in this device which may have, initially, a protective function, and can be pleasurable. However, some children who have a tendency to feel tense or anxious, regularly switch off or experience shutdowns in thinking in the classroom, often when being instructed. If this behaviour becomes, or has already become in the preschool years, habitual (programmed or conditioned), the switch-offs can be essentially involuntary – and no longer necessarily anxiety-triggered. The child may find himself unable to absorb, retain, retrieve or connect information. Problems with connection appear to be common to both dyslexia and autism. Uta Frith and colleagues' research with positron emission tomography is supportive of dyslexia being a problem of disconnection (Paulesu et al., 1996). Where switched off states occur in infancy on a more global scale, we see a range of social and cognitive difficulties, with the voluntary and involuntary shutdowns and inability to connect and process for meaning described by Donna Williams, who suffers from autism (Williams, 1996).

Evidence of switching off has been obtained from direct observation, first-hand written and verbal accounts and from accounts of parents and carers.

Avoidance is another initially protective trait which we all share. When it is taken to extremes, however, it can be obsessional and compulsive. In describing children with such marked avoidance problems, Elizabeth Newson refers to a Pathological Demand Avoidance Syndrome where the children are obsessive in their avoidance, very manipulative, superficially sociable and have a poor sense of personal identity. It is not primarily the task that is being avoided, but the demand itself (Newson, 1989; Newson, 1996). I have certainly encountered such children, and it seems to me that the condition can sometimes hide emotional hypersensitivity and a fear of social situations. Superficial sociability may falsely reassure people that all is well. As with other abnormal behaviour, the symptoms appear to lie on a continuum.

While one child charms his way out of meeting demands, another distracts the adult's attention, talks nineteen to the dozen or keeps interrupting. He may cry, waste time, ignore the adult, be 'tired', have a headache, be 'busy' or he will 'do it in a minute'. He may start giggling, be disruptive, or say the task is boring or silly. He may reply 'I don't know' to everything asked and pretend to be quite inept. He may employ a diversity of tactics. It is the degree and consistency of the avoidance which mark it as abnormal, rather than the form it takes.

Where anxiety or tension levels are high, there is often ritualistic or repetitive behaviour, adherence to routines, order and sameness, and fussiness and obsessional activity (compare this with the somewhat compulsive behaviour of many celebrities before going on stage, of professional tennis players during difficult matches, etc.).

These traits are exhibited in a variety of ways. There may be a slight resistance to change on the one hand, and demands for sameness so extreme on the other that an entire family's day is organised around the child, for the sake of peace and quiet. Whilst we tend to be aware of such behaviour when it is extreme, routine enquiries into personality traits show how common it is, in lesser and perhaps normal forms, among children.

Examples: Every bed-time (which is always the same time) Heather leads her mother upstairs, empties some cupboards and spreads their contents around the room. Then she looks out of the window and says exactly what she said the night before, and the nights before that. Gerard will not allow his mother to help out at playgroup; she does not normally stay so she must never stay – it would break the rule. James is distressed if routes to places are changed. Tim wears the same clothes day in, day out, and he walks on his toes. Shashida always turns all the baked bean tins around to face exactly the same way in the supermarket.

Other important traits which help to gauge tension or anxiety levels include restlessness and hyperactivity (indicators of heightened tension and excitability), fearfulness, worrying, sensitivity to criticism, wetting and soiling, habits in relation to eating, sleeping and walking, temper tantrums, the degree of reliance on comforters (including thumb-sucking), sensory and emotional hypersensitivity and hyposensitivity, retarded or arrested development, and regression. Being switched off to a degree might result in inactivity, aloofness, a poor sense of danger or of identity, dressing difficulties, ‘selfishness’, apparent poor hearing, self-directed abuse or even some extraordinary ability. It might also contribute to undetermined handedness and possibly therefore to left-handedness. K.M. Cornish and I.C. McManus (1996) have found normal control children to be more lateralised and more consistent in their hand preference than children with autism or learning disabilities. (A left-handed preference was shown by 23% of children with autism, 11.5% of children with learning disability and 4.4% of normal control children. This incidence of left-handedness was found to be consistent with that reported elsewhere.)

Possible interpretations of the way in which traits are expressing tension or anxiety are aided by the manner in which they combine. While, for example, a child's very dependent behaviour might have originated from fearfulness, his other behaviour might suggest that it has become ritualistic.

Whilst physical explanations may sometimes be valid, they might be erroneously attributed to traits. It cannot be assumed, for instance, that a child's dribbling or clumsiness does not have its origins in a lack of awareness or attention, or that impulsiveness or a state of tension is not in some cases at least a contributory factor in the origin of clumsiness. Unrefined or dyspraxic motor responses might then be liable to persist because they have been programmed early in life – rather as squinting (strabismus), treated late, can persist if the child's brain is allowed to become fixed in its behaviour.

It is important to be aware that convulsions can be psychogenic in nature (Lancman et al., 1994), as may be strabismus (Douche et al.,1990), and allergy is related to heightened sensitivity and is an overreaction which can have an emotional origin. We should also be open-minded about chemical imbalances, since these, too, can have a psychological basis. Moreover, it is problematic that a switched off condition can mimic a hearing loss.

When a therapist is aware of and understands a child's traits, she or he is able to see that many speech and language problems are in fact traits themselves (or secondary traits):

1. Delayed, arrested or regressed speech and language. A child who is feeling anxious or resisting change may not be ready to begin speaking or he may not be ready to change his speech – whether one is considering his phonology, vocabulary or his syntax; sometimes speech reverts to an earlier stage. We need to have an awareness of the situation to avoid inappropriate advice or therapy. Jargon (which tends to increase with tension and excitement) may be retained, sometimes only to be used at certain times of the day, rather like a comforter. Many children have their own preferred words for things and refuse to change them; they can even show discomposure if they allow the correct version of a word to ‘slip out’.
2. Pedantic or literal comprehension and expression of language can result from a child liking sameness and adhering to firm rules, often of his own making (possibly as a result of limited comprehension).
3. Limited Comprehension can result from switch-offs or states of shutdown (voluntary or involuntary, specific or more global, partial or entire, temporary or customary). Auditory and visual information may be attended to in parts or out of context. The child may only pay attention to key or impersonal words. He may not process the meaning of intonation.
4. Limited or poorly organised language can result from degrees of shutdown (including depression). Thoughts may be sluggish, triggered or difficult to connect or sequence, and information may be hard to retrieve. The child may not ask questions, since they tend to necessitate involvement as well as a connection of ideas.
5. Mumbling can result from ambivalent feelings and fear of self-exposure or failure, and it may become habitual.
6. Mutism can result from emotional hypersensitivity, avoidance, and retention of the status quo; it can become heavily conditioned – making it physically difficult to speak.
7. Vocal quality can be affected by tension and anxiety which may result in dysphonia or idiosyncratic pitch and intonation (particularly when there is ritualistic behaviour or a poor sense of identity).
8. Repetitive Speech and Language. Repetitive, ritualistic, obsessional or compulsive speech and behaviour increase with increased levels of tension or anxiety. We are all aware that a child may keep talking on the same subject. We may not be aware that he may ask questions repetitively to receive predictable answers. He may do or say things (often of a negative nature) repetitively, in order to see or hear predictable patterns of responses. It is easier for him to manipulate for reproof than for praise; sometimes his pleasure during a rebuke is obvious and is misinterpreted as mischievous. If the 'correct' responses are not forthcoming, he may provide them himself. This may result in him talking to himself or perhaps smacking his own bottom.
9. Dyspraxia of speech is associated with early anxiety-related traits and often exists with other problems which can be related to tension or anxiety.
10. Stammering arising from traits. I have found that children who stammer or clutter their speech have, or have had, noteworthy personality traits related to anxiety or tension. It is appropriate to consider a relationship between repetitive and compulsive behaviour and early stammering (Sims, 1997). Stammering is habitual, conditioned, repetitive and spasmodic behaviour, with some aspects reminiscent of tics and their compulsive qualities. It begins with simple repetitions of sounds and syllables which, I suggest, become habitual and compulsive in some children. When the child attempts to pass on to the next syllable or word, he is at the same time programmed or needing to continue the repetitions – his brain is receiving conflicting messages and he therefore experiences blocks followed by struggles. The behaviour becomes conditioned to, or triggered by, certain feelings or circumstances (compare blushing) and the stammering patterns reinforce themselves, perhaps to the extent that they require negligible triggering. Some adults who stammer have retained compulsive feelings and feel an urge to do it in spite of wishing to rid themselves of the affliction; the release of tension after each struggle can be addictive. In such cases the stammer would not be being maintained by conditioning alone. Thus, according to my findings, stammering appears to originate in commonplace childhood anxiety or tension which is often within normal limits – it is simply the case that habitually repeating words and syllables has more scope for complications than do most other personality traits (e.g., repetitive thumb-sucking). In the light of this, it is not difficult to see how the Lidcombe Programme might be effective, with its emphasis on special attention and positive support for the child, and early correction of repetitions (Onslow et al., 1997).

In Table 1 I have listed some traits and problems experienced by twelve children who were taken from the clinical waiting list in the order in which they were referred or re-referred; no selection was made. The table demonstrates the prevalence of anxiety-related personality traits and their association with developmental difficulties.

The traits overlap throughout the various conditions and syndromes, showing that the conditions do not exist as entities. Tables 2, 3, 4 and 5 illustrate that symptoms listed by societies, support groups and professional individuals are related to traits:

Dyslexia: Common signs listed by the British Dyslexia Association (Table 2) can be related to tension or anxiety (note in particular the symptoms which suggest switching off in the early preschool or pre-reading years).

Signs of Dyslexia

Before School

• History of slow speech development.
• Difficulty learning nursery rhymes.
• Finds phonological difficulty with the selection of the odd one out, e.g., cat; mat; pig; fat.
• Slow in name finding.
• Some dyslexic children enjoy being read to, but show no interest in letters or words. Others have no patience for sitting and listening.
• Often accused of not listening or ‘not paying attention’.
• Poor understanding of prepositions.
• Difficulty with two or more instructions at one time, but well able to carry out tasks when presented in smaller units.
• Difficulty keeping simple rhythm.
• May not crawl – but walks early.
• Persistent difficulty in dressing.
• Difficulty with shoe laces, buttons, clothes the right way round.
• Difficulty with catching, kicking or throwing a ball.
• Difficulty with hopping and/or skipping.
• Excessive tripping, bumping into things and falling over things.
• Obvious ‘good’ and ‘bad’ days, for no apparent reason.

At Primary School

• Personal organisation poor.
• Poor time keeping and awareness.
• Difficulty in remembering what day of the week it is, his birth date, seasons of the year, months of the year.
• Difficulty in learning to tell the time.
• Difficulty remembering anything in a sequential order, e.g., days of the week, the alphabet, tables, foreign languages.
• Poor reading progress – particularly on look-and-say methods.
• Inability to blend letters together.
• Difficulty in establishing syllable division, beginnings and endings of words, synthesis and analysis of words.
• Hesitant and laboured reading especially when reading aloud, often misses out words or adds extra words or fails to recognise familiar words.
• Making anagrams of words, e.g., tired for tried, breaded for bearded.
• Undetermined hand preference.
• Confusion between left and right.
• Poor handwriting with many reversals and badly formed letters.
• Difficulty in picking out the most important points from a passage.
• Poor standards of written work in comparison with oral ability.
• Losing the point of the story being written or read.
• Messy work with many crossings out and words tried several times, e.g., wippe, wype, wiep, wipe.
• Persistent confusion with letters which look similar, particularly b/d, p/g, p/q, n/u, m/w.
• Confusion with number order, e.g., units, tens, hundreds.
• Confusion with symbols, e.g., + and x signs.
• A word spelt several different ways in one piece of writing.
• Badly set out written work; inability to stay close to the margin.
• Seems to ‘dream’ – does not seem to listen.
• Easily distracted.
• Limited understanding of non-verbal communication.
• Fine motor skills might be poor, leading to weaknesses in the speed, control and accuracy of the pencil.
• May become the class clown, disruptive or withdrawn.
• Employs work avoidance tactics (sharpening pencils, looking for books, etc.).
• Rests head on desk or right over to one side when colouring or writing.
• Performs unevenly day to day.
• Excessive tiredness.

Hyperactivity: The symptoms collated by the British Hyperactive Children's Support Group (Table 3) can all be related to tension or anxiety. The children seem to be in a state of tension which makes them keyed up to do things or have things done; they might be irritable or excited.

Some Symptoms of Hyperactivity

The group points out that there are degrees of the problem and that not every child will have all the symptoms.

In Infancy

• Crying, screaming, restlessness; some need little sleep.
• Colic; very difficult to feed, whether breast or bottle.
• Cannot be pacified or cuddled; spurn affection.
• Excessive dribbling; may be very thirsty.
• Headbanging, cot rocking, fits and tantrums.

In Older Children (in addition to symptoms in infancy)

• Clumsy, impulsive; often accident prone.
• Erratic, disruptive behaviour.
• Compulsive ‘touching’; constant motion.
• Disturb other children; may be aggressive.
• Lack concentration and may be withdrawn.
• Normal or high IQ but fail at school.
• Poor appetite; poor hand and eye co-ordination.
• Unco-operative behaviour.
• Self-abusive (pulling hair, picking skin, etc.).
• Continued problems with sleep.

The Support Group also refers to obsessions, social problems, speech and language difficulties, fidgeting, distractibility, ability to create havoc, high pain thresholds and hypersensitivity leading to allergies. Other observers refer to disorganisation, boredom, excitability, insatiability, egocentricity, low self-esteem and depression.

Autism: I include Dr Mildred Creek's working party's nine points (Creek et al., 1961) to portray symptoms of severe autism (Table 4) because they draw attention to the acute anxiety frequently suffered by the children (point 6). It can be seen that the nine points feature within the personality traits I have been describing. The difference between youngsters with autism and other children is in the degree of those traits which interfere with normal social relationships and communication (in particular those associated with a withdrawn state and repetitive and compulsive activity).

Nine Points for Autism

1. Gross and sustained impairment of emotional relationships with people. This includes the more usual aloofness and the empty clinging (so-called symbiosis); also abnormal behaviour towards other people as persons, such as using them, or parts of them, impersonally. Difficulty in mixing and playing with other children is often outstanding and long-lasting.
2. Apparent unawareness of his own personal identity to a degree inappropriate to his age. This may be seen in abnormal behaviour towards himself, such as posturing or exploration and scrutiny of parts of his body. Repeated self-directed aggression, sometimes resulting in actual damage, may be another aspect of his lack of integration (see also point 5), as may be the confusion of personal pronouns (see point 7).
3. Pathological preoccupation with particular objects or certain characteristics of them, without regard to their accepted functions.
4. Sustained resistance to change in the environment and a striving to maintain or restore sameness. In some instances behaviour appears to aim at producing a state of perceptual monotony.
5. Abnormal perceptual experience (in the absence of discernible organic abnormality) is implied by excessive, diminished or unpredictable response to sensory stimuli – for example, visual and auditory avoidance, insensitivity to pain and temperature.
6. Acute, excessive and seemingly illogical anxiety is a frequent phenomenon. This tends to be precipitated by change, whether in material environment or in routine, as well as by temporary interruption of a symbiotic attachment to persons or things. (Apparently commonplace phenomena or objects seem to become invested with terrifying qualities. On the other hand, an appropriate sense of fear in the face of real danger may be lacking.)
7. Speech may have been lost or never acquired, or may have failed to develop beyond a level appropriate to an earlier stage. There may be confusion of personal pronouns, echolalia, or other mannerisms of use and diction. Though words or phrases may be uttered, they may convey no sense of ordinary communication.
8. Distortion in mobility patterns, for example, (a) excess as in hyperkinesis, (b) immobility as in catatonia, (c) bizarre postures, or ritualistic mannerisms, such as rocking and spinning (themselves or objects).
9. A background of serious retardation in which islets of normal, near-normal or exceptional intellectual function or skill may appear.

Tourette syndrome: Table 5 illustrates that there is considerable overlap between this syndrome and other conditions; the symptoms can all be tension/anxiety-related.

Symptoms and associated behaviours in Tourette syndrome, as listed by the

Tourette Syndrome (UK) Association

Essential signs:

Motor and/or vocal tics

Additional problems of many sufferers:

Obsessive-Compulsive and ritualistic behaviours

Hyperactivity/Attention Deficit Hyperactivity Disorder

Learning difficulties

Difficulties with impulse control, possibly resulting in aggressive or socially inappropriate acts; defiant and angry behaviours

Sleep disorders, including frequent awakenings or walking or talking in one’s sleep

 

 

Schizophrenia: A French study by M. Bourgeois and J.J. Etchepare (1986) compared the early behaviour of 35 adults suffering from schizophrenia with 35 controls (Table 6). We can see that problems associated with anxiety tended to be more common in the children who went on to develop schizophrenia.

Early Behaviour of People who became Schizophrenic

The information was gained by questioning parents.

0 – 5 years

6 – 12 years

It can be seen that the traits themselves form symptoms of dyslexia, hyperactive states, autism and Tourette syndrome. The actual labelling of a condition depends upon the prominence of some traits over others.

These facts explain why attempting to describe a typical example of a condition and making clear-cut diagnoses are activities which tend to be fraught with problems.

Factors which can give rise to confusion are:

1. Masking. The root of the problem may be missed if tension or anxiety is masked by switching off or avoidance or if there is some compensatory behaviour or superficial sociability.
2. Early programming or conditioning of behaviour can have the effect of maintaining a problem in a child who is no longer experiencing his former levels of anxiety or tension.
3. We may limit our understanding if we take it for granted that conditions such as stammering, dyslexia and autism are inherited per se; it may rather be that we inherit our levels of, or potential for, tension or anxiety and the ways in which we express it.
4. Since conditions such as stammering, dyslexia and autism create anxiety for the suffering individual, there has been a tendency to view all anxiety as an outcome rather than consider that a measure of it might have precipitated the fundamental behaviour.

The more fully the therapist and parents understand a child's personality traits, the more fully they will understand his problems, and the benefits to the child, parent, therapist and services are wide-ranging. (If the child is old enough and sufficiently able, it may be appropriate to help him gain insight into his condition, which can be confidence building.) Therapy becomes more efficient, creative, adaptable and rewarding for all concerned. Effective, involving treatment and preventative approaches are more easily devised (including more effective specific teaching strategies to tackle literacy difficulties, verbal dyspraxia, etc.). With increased empathy there is greater awareness of when a noninvasive approach is necessary and of what form it should take, of when and why praise might be counterproductive, or of when one might utilise repetitive streaks in therapy. The young preschool child whose reticence and need of the status quo has led to delay in his speech and language development may well require no direct intervention. Possibly some support will be all that is called for and conversations between the parents and their health visitor, playgroup leader and the child himself might help to remove or lessen any environmental factors which could be helping to raise levels of anxiety or tension; the parents are likely to be relieved that the child is not ‘slow’ and they are less likely to compare his development with that of other children in the neighbourhood.

Time does not permit an expansion on the comprehensive application to therapy, but I have detailed the approach's effects on it elsewhere (Sims, 2000).

The approach favours a greater awareness of when testing is appropriate and when it is not – or when it is perhaps even counterproductive because we are encouraging negative behaviour in the process, such as switch-offs, shutdowns or avoidance. It enables one to gain greater insight into test results. One becomes more aware, for example, when a certain child is unable to focus his mind properly during testing, or when a hyperactive child with an attention deficit might be performing unusually well because he is stimulated and focussed by the variety and the one-to-one attention provided by the situation. Another child might function better because the test is highly structured, factual and impersonal, with the administrator giving little eye contact; our knowledge of his traits will help us to appreciate this more quickly.

A glance at Table 7 shows that problems predominate in males. The remarkable agreement between the male:female ratios is indeed suggestive of common causal factors. It is interesting to speculate that since males evolved as the hunters and fighters they have needed to be more aggressive than females and hence to possess more inherent tension, which causes them more developmental problems.

Ratios of males to females for some conditions

(Information obtained from relevant associations)

The future may confirm an association between anxiety and a variety of syndromes and physical problems. Bulbena and colleagues in Spain (1992) have made a study of the association between joint hypermobility syndrome (JHS) and anxiety disorders. In particular, they found a high prevalence of panic and phobias among JHS cases. A British twin study by Bailey and his colleagues (1995) suggests that some aspects of abnormal development in autistic individuals occur early in gestation (e.g., minor congenital ones), and that autism is a very strongly genetic neuropsychiatric disorder. It is logical to consider, therefore, that anxiety could be a property of early genetic influences (as well as an effect of the mother’s stress hormones) and could affect fetal development and perinatal behaviour. Liley (1991) points out that the pregnant uterus is a very noisy place where the fetus is active and responsive; he asks for consideration and respect to be accorded to fetal personality and behaviour. Righetti (1996) concludes that the prenatal period is characterised by many emotional incidents for the fetus.

It is extremely likely that comprehensive research into children's personality traits would not only increase our knowledge of the development of speech and language but would have many wider implications. In our own field it might prove highly beneficial. It would be useful to know, for example, whether and to what extent some traits might be particularly associated with problems such as stammering. Are there patterns to the traits which are not easily discernible?

When children have learning, social and mental health problems it can generally be found that they had early personality traits related to tension and anxiety. These traits often seem to be present from early infancy or even from birth. Many speech and language difficulties, autism, Asperger’s syndrome, dyslexia, hyperactivity, Attention Deficit Hyperactivity Disorder, dyspraxia and conduct disorders are made up of or associated with anxiety/tension-related traits which are variable and overlap in an apparently haphazard manner with traits in other conditions. Each child’s condition is unique and whether we call him autistic, dyslexic, hyperactive or say he is suffering from specific language impairment or Tourette syndrome, etc., depends on his particular traits and the degree to which they are manifest or dominant. We must understand a child through his anxiety and tension linked traits in order to thoroughly understand his problems or condition. This will help us to ensure that the help we offer is entirely sensitive and appropriate and that our service is efficient.

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