Understanding the prevalence and manifestation of the anxiety and social difficulties experienced by children with Developmental Language Disorder.

doi:10.21203/rs.3.rs-2484292/v1

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Research Article

Understanding the prevalence and manifestation of the anxiety and social difficulties experienced by children with Developmental Language Disorder.

https://doi.org/10.21203/rs.3.rs-2484292/v1

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Journal Publication

published 15 Jun, 2023

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Background

It is well-documented that children with Developmental Language Disorder (DLD) experience socio-emotional difficulties. Despite this, there is little consensus as to how these difficulties manifest. This study aims to understand their prevalence, and inform intervention development by understanding the relationships between them.

Methods

A mixed-methods, case-control study was conducted. First, an online survey was completed by 107 parents of either children with DLD (‘DLD sample’; n = 57), or typically developing children (‘typical sample’; n = 50), aged 6–12 years old. The online survey comprised of standardised psychosocial measures, binary psychosocial statements (generated from previous qualitative work) and both family stress and coping mechanisms. Two separate mediation models were run to understand the underlying mechanisms behind (1) anxiety, and (2) social frustration; separate correlation analyses were used to determine the relationships between other psychosocial and familial variables. Qualitative interviews were then carried out with a small subset of the survey respondents (n = 4).

Results

The DLD sample scored significantly higher on all psychosocial statements than the typical sample. Experiencing anxiety (80.7%, p < 0.05), requiring routine and sameness (75.4%, p < 0.001) and emotional dysregulation (75.4%; p < 0.001) were the most common difficulties for children with DLD. Family stress and coping mechanisms only correlated with the manifestation of psychosocial difficulties in the typical group, not the DLD group. ‘Intolerance of uncertainty’ was found to fully mediate the relationship between DLD diagnosis and symptoms of anxiety. Emotion regulation was found to moderately mediate the relationship between DLD diagnosis and social frustration.

Conclusions

Parents appear to cope well with their children’s complex psychosocial needs. Intervention focussing on intolerance of uncertainty and emotion dysregulation may help the management of psychosocial difficulties. Further research is needed to understand the children’s preference for routine.

Developmental language disorder

specific language impairment

parents

children

psychosocial difficulties

anxiety

Developmental language disorder (DLD) is characterised by difficulties with expressive and receptive language, impacting individuals’ everyday lives and social interactions (1). It is estimated to affect 7.6% of children (2). As with other neurodevelopmental disorders (NDDs), their difficulties are well documented to extend to a wide array of psychosocial difficulties, however they are often omitted from psychosocial intervention (e.g. 3; 4).

Children with DLD are estimated to experience six times the rate of anxiety and twice the rate of depression than their typically developing peers (5), as well as problems with self-esteem (6) and peer difficulties (7). These psychosocial difficulties are not inevitable for children with DLD however (Social Adaptation Model; 8); their language profiles do not explain all psychosocial difficulties (e.g.9) and individuals with DLD experience these difficulties at different times and to varying extents (e.g.10,11). Understanding the manifestation of psychosocial difficulties in children with DLD is key to developing psychosocial support programmes to prevent the escalation of these difficulties.

A recent study identified two key difficulties expressed by parents of children with DLD: childhood anxiety and social frustration (12). These difficulties were described as having a symbiotic relationship which was maintained through additional psychosocial difficulties, specifically, emotion dysregulation, sleep disruption and low self-esteem. More research is required to understand the association between these difficulties in children with DLD.

Emotion regulation as a mediator

Research on children with other NDDs (e.g. autism spectrum disorder; ASD) has identified emotion dysregulation in explaining both the manifestation of anxiety (e.g. Conner et al., 2020) and the exacerbation of social frustrations (e.g. 14). Emotion regulation (ER) refers to the ability to exert control over one’s emotional experience (15), and has been long identified as dysregulated amongst children with DLD (e.g. 16). Regulation strategies typically involve cognitive restructuring to reduce an angry or stressed response, or refocussing on stimuli that evoke fewer unpleasant emotions (17). Both of these strategies require a level of ‘inner speech’ (18), which requires intact language skills and has therefore unsurprisingly been shown to be limited in children with DLD (19). Furthermore, the difficulties with vocabulary and both use and understanding of grammatical structure in those with DLD can limit their ability to discuss emotions and learn regulation strategies from their parents (20).

ER has an inherent relationship with anxiety; a limited ability to regulate one’s thoughts and emotions can lead to the maladaptive ‘worry loops’ characteristic of anxiety (21). Longitudinal studies of neurotypical children have shown a predictive effect of emotion dysregulation on the later development of other, broader anxiety symptoms (22, 23), such as hyperactivation of the sympathetic nervous system, catastrophic thoughts and uncontrollable worry (24). There is not yet a clear understanding of the direction of this relationship amongst those with DLD.

ER is also thought to be associated with social skills both in neurotypical children (25), as well as those with DLD (26–28). In children with DLD, social withdrawal is suggested to have particular links to emotion dysregulation (e.g. 26), where children find it easier to remove themselves from situations in response to feeling overwhelmed. Conversely, emotional competence has been shown to mediate the relationship between DLD and oppositional and defiant social behaviour in other children (28). Amongst children with other NDDs, enhanced ER skills were found to contribute to increased prosocial behaviours and decreased peer problems (29–31). Morozova et al. (32) proposed that ER skills enable children to navigate social situations with greater success, through using more adaptive coping strategies.

Intolerance of uncertainty as a mediator

Intolerance of uncertainty (IU) is a trait characterised by preference for predictability and reacting with emotional distress when presented with the unknown or unfamiliar (33). It is recognised as a transdiagnostic risk factor in the formulation of a number of anxiety disorders (34–36). Children with DLD could be suggested to have further vulnerability to IU, as their difficulties in understanding verbal language render instructions and cues difficult to understand, thus increasing the likelihood of experiencing uncertainty in everyday situations. The specific presence of IU, however, has only recently been identified amongst children with DLD (12). In this sample, children with DLD were found to require additional preparation for unfamiliar situations, and experienced emotional distress at unexpected changes in routine (12).

Far more research has been conducted amongst children with other NDDs, who often share similar difficulties in inferring meaning from interactions as those with DLD (e.g. ASD and Williams Syndrome; 37). As a result, IU has been identified more consistently as a co-occurring experience amongst these populations (36, 38). Moreover, it has been suggested to contribute to the manifestation of their symptoms of anxiety (39–41), prompting the development of tailored interventions (e.g. 42). It is possible that IU could also explain much of the variance in children with DLD’s psychosocial difficulties.

Anxiety as a mediator

Anxiety itself has been suggested to contribute to social frustration. In children with other NDDs, anxiety has been suggested to contribute to a shift away from direct eye-contact when processing emotions (43). As such, children may miss meaningful social information and connections, impacting their awareness of others (43) and overall social reciprocity (44). Characteristically, anxiety can also contribute to negative interpretations of other people’s behaviours in social situations (45), particularly in the presence of ambiguity (46), such as that created by disordered language. Suggestions have been made that such negative interpretation bias could exist amongst children with DLD when engaging in social interaction (47), perhaps fuelled by the anxiety of not understanding what is being said and resulting in unnecessary conflict. These connections, however, have yet to be explicitly tested.

Social frustration and the behavioural symptoms of anxiety have a long-recognised reciprocal relationship: prior negative social experiences have been shown to increase the likelihood of experiencing anxiety (e.g. 48), whilst anxiety itself contributes to social behaviours such as withdrawal (e.g. 49), or even hostile or aggressive interpersonal behaviour (e.g. 50). Not only are children with DLD more likely to be subjected to social exclusion and peer victimisation (51, 52), but they have also been suggested to demonstrate more withdrawal (53, 54) and aggressive behaviours (55). Investigating the direction of the relationship between anxiety and social frustration is important in understanding the support children with DLD may need when navigating social contexts.

Influence of the family environment

Child temperament has long been linked to the family environment (e.g. 56): the socio-emotional context of each family unit, as influenced by the behaviour and quality of the interpersonal relationships within the household (Bowen Family Systems Theory; 57). Raising a child with DLD has been shown to increase family stress (58, 59), which has been linked to an increase in the child’s experience of anxiety (59). This could be explained through Sameroff’s unified theory of development (60), where it is proposed that much of a child’s ER is directed by the behaviour of those around them. As a result, when those in the family system display psychosocial difficulties, the child may internalise these and learn less adaptive ways of managing their own emotions (61). This could only be further exacerbated by the recognised heterogeneity of DLD (62).

More specifically, family communication styles have been shown to be key in adaptive psychosocial development of children, particularly for those with developmental disorders (63). A focus on open communication and affirmation in adverse circumstances has been shown to increase psychosocial resilience (63, 64). However, increased family stress is suggested to impact the different parenting practices and coping strategies used within the household. For example, stressed parents have been suggested to model more ‘anxiety-enhancing’ coping styles, such as avoidance and control (e.g. 65); maladaptive coping styles that are then modelled to the child. Should family factors such as these be conclusively linked with child psychosocial development, it suggests a focus for a whole-family intervention (e.g. Triple P: 66).

Aims of current study

Whilst anxiety, social frustration and emotion dysregulation have all been previously identified in children with DLD, the relationship between them has yet to be fully understood. Elements like IU and family context may help explain both the manifestation of these difficulties, as well as the direction of the relationship between them. The aims of the current study are therefore (1) to test the hypothesis that children with DLD report higher rates of all stated psychosocial difficulties than those of typically developing children; and (2) to then understand the association between these psychosocial difficulties, and identify possible mediating factors, including ER, IU and anxiety using a mixed-methods approach. The association between different psychosocial factors and the manifestation of anxiety will be explored through correlational and mediation models, as well as through qualitative interviews of parents of children with DLD.

Design

This study used a mixed-methods, explanatory sequential design (67). This is due to the relatively unexplored nature of the topic area, as well as the recognised demographic biases in quantitative data sampling (e.g. 68). This method supports an inclusive research approach, whereby the participants themselves are consulted regarding interpretations (e.g. 39).

A case-control quantitative survey study was used to explore the prevalence of psychosocial difficulties and the relationships between them. On finalising this stage of data collection and analysis, any demographic sampling biases were identified (e.g. over-recruitment of white, high income participants; 69), as well as any additional questions that emerged from the findings. Phenomenological qualitative interviews were then held with a small and separate sample of parents of children with DLD. Purposeful recruitment was used to ensure a range of life contexts was captured (including race, income and relationship status), and the quantitative findings were discussed with them individually. A joint display has been used when reporting results (70); qualitative findings are integrated throughout the quantitative analysis, to provide additional insight and context.

Participants

Participants who completed the online survey (‘survey sample’) were recruited between January and April 2022, those who completed the interview (‘interview sample’) were recruited between June and July 2022. The survey sample was recruited through convenience sampling, and the interview sample through purposeful sampling. Convenience sampling was chosen for the survey sample due to the expected difficulty in recruiting, given the low level of awareness of DLD (71). Purposeful sampling was chosen as a way to recruit parents from populations that were demographically underrepresented in the survey sample, to ensure representation of a range of family contexts and increase the validity of the results (72). Participants were first recruited through advertising to the Engage with DLD database (E-DLD; Engage with DLD), an online network connecting families with DLD with researchers. Research adverts were also circulated via Twitter, Mumsnet and relevant parenting groups on Facebook. Parents from the interview sample had not completed the survey, but were recruited purposively from previous research (12).

The survey sample comprised a total of 107 parents of children with DLD (‘DLD sample’; n = 57; Male children n = 29) and typically developing children (‘Typical sample’; n = 50; Male children n = 27). To be eligible, children had to be aged between 6- and 12-years-old (M = 8.92; SD = 1.76); participants were excluded if they failed to complete the first ‘psychosocial statements’ question. Participants in the DLD sample were also required to confirm their child’s DLD diagnosis through self-report. Due to the expected range of both nationalities and services accessed to receive a diagnosis, no uniform diagnostic report was required. Parents responded to the following questions: “Do you have a child that has difficulties either using spoken language or understanding spoken language?” (answer response “Yes” was required for the DLD sample); “Is there a known explanation for this language difficulty (that is NOT DLD/specific language impairment)?” (answer response “No” was required for the DLD sample).

Child and parent age, as well as child sex and parent’s self-reported gender was collected. Country of residence, parent’s ethnicity and number of children in household were also confirmed. To provide an indication of socioeconomic class, participants’ postcodes, monthly income and the occupation of main income earners were also asked. Characteristics of the survey sample can be found in Table 1; participants were predominantly white, mothers, and had above average monthly income (c.2,650 GBP in March 2022; 74). The only significant difference between the DLD and typical samples was for parent self-reported gender; nearly all parents who completed the survey for the DLD sample were mothers (92.7%) whereas statistically more fathers completed the survey for typically developing children (36.7%; p < 0.001).

Table 1

Demographic characteristics of the DLD sample and typically developing sample who completed the online survey.
		Typical sample (n = 50)		DLD sample (n = 57)
Child gender, % (N)	Male	58.7	(27)	51.8	(29)
Child gender, % (N)	Female	41.3	(19)	48.2	(27)
Child age, M (SD)		8.9	(1.7)	9.0	(1.8)
Parent gender, % (N)	Male	36.7*	(18)	5.5*	(3)
Parent gender, % (N)	Female	63.3*	(31)	92.7*	(51)
Ethnicity, % (N)	Black	2.0	(1)	-	(0)
	Hispanic	-	(0)	1.8	(1)
	South Asian	6.0	(3)	1.8	(1)
	White	90.0	(45)	96.5	(55)
	Other	2.0	(1)	-	(0)
Monthly income (GBP), M (SD)		3,332.9	(1,387.5)	3096.9	(1,314.9)
Number of children, M (SD)		2.1	(0.7)	2.2	(1.0)
*significant difference between groups at p < .008 (Bonferroni adjustment).

[Insert Table 1 here]

The interview sample comprised of four parents of children with DLD: two mothers were white British, one white European (first generation immigrant to the UK; bilingual family), and one Black British. Their incomes ranged from low income (£20,000 per annum) to high income (above £60,000 per annum), and lived across England, Scotland and the Isle of Wight. Three of the parents were cohabiting and one was a single-parent household, without support from the father. Their children were six, seven, ten and eleven (see Table 2). All information gathered was self-report, including diagnosis.

Table 2

Characteristics of the mothers interviewed and their children with developmental language disorder.
Parent Pseudonym	Child Pseudonym	Age of child	Child gender	Income ^a	Ethnicity	Number of siblings	Known comorbidities	Relationship
Josephine	Femi	6	Male	Low	Black British	0	-	Single
Liz	Ali	7	Female	ND	White British	2	-	Co-habiting
Iris	Dimo	10	Male	ND	White European	1	-	Co-habiting
Helen	Joe	11	Male	High	White British	1	Dyslexia, APD, PDA traits^b	Co-habiting
PDA = pathological demand avoidance; APD = auditory processing disorder; ND = not disclosed. ^a Income groups are defined as ‘Low’ = below £30,000 per annum; ‘Middle’ = £30,000-£60,000 per annum; ‘High’ = above £60,000 per annum .^b No Autism Spectrum Disorders.

[Insert Table 2 here]

Measures

Psychosocial statements. Eleven statements were derived from previous work according to the psychosocial difficulties described to be bothering parents of children with DLD the most (75). These were presented to parents at the beginning of the survey; they were asked “Is it true that your child…” and were required to choose between “true” or “false” to each statement. The full list of statements can be found in Fig. 1 (e.g. “…struggles to understand their emotions”). A continuous variable ‘social frustration’ was calculated from the composite score of answers to ‘often removes themselves from social situations’, ‘struggles to understand the intentions of others’, ‘lacks awareness of others’ and ‘is often excluded from social situations’ (“true” = 1, “false” = 0). This method was chosen as it captures a range of experiences proposed to be characteristic of children with DLD (12); other social scales were deemed too specific to difficulties experienced in other populations (e.g. 76), or underdeveloped (77). Due to the small number of items in the variable ‘social frustration’, inter-item correlations were used to measure reliability (78). Correlations were strong between all items (Range = 0.38–0.68, M = 0.50); for all statements, a higher score indicates experiencing more difficulties.

Anxiety. Anxiety was measured using the parent-report version of the Spence Children’s Anxiety Scale (SCAS-P; 79). To minimise the length of the survey, only the statements relating to subscales of interest were used (also regrouped in prior literature; e.g. 80). These were determined from anxiety disorder symptoms found to be common in children with DLD (e.g. 11): generalised, social and separation anxiety, as well as obsessive compulsive disorder (OCD; e.g. “my child worries that something bad will happen to them”, “my child worries what other people will think of them”, “my child worries about being away from us/me”, “my child has to keep checking that they have done things right”, respectively). Questions use a 5-point Likert scale, with answers ranging from “Never” to “Always”. Higher scores indicate an increased experience of anxiety. The scale has well-established reliability in both neurotypical children (e.g. 81) and those with NDDs (e.g. 82). Using Cronbach’s α, internal reliability was very strong for both case-control samples (DLD group α = 0.94; typical group α = 0.92), and acceptable across all subscales (DLD group α = 0.72–0.89; typical group α = 0.75–0.84).

Intolerance of Uncertainty. The short form of the intolerance of uncertainty scale was used (IUS-12; 33). It is a refined version of the 27-item scale, and requires parents to indicate how characteristic 12 separate statements are of their child (e.g. “unforeseen events upset my child greatly” and “a small unforeseen event can spoil everything, even with the best of planning”). Response options are provided along a 5-point Likert scale, from “Not at all characteristic of my child” to “Entirely characteristic of my child”. Higher scores indicate higher levels of IU. In neurotypical samples, the scale has been found to have a good test-retest reliability, as well as construct validity against other symptom measures of anxiety (e.g. 83). Internal reliability was very high for both case-control samples (DLD group α = 0.99; typical group α = 1.00).

Insistence on sameness. The 15-item ‘Insistence on Sameness’ subscale (ISS) of the Repetitive Behaviour Questionnaire (RBQ) was used (84). Items are rated on either a 4-point scale or a 3-point scale, depending on the behaviour, for example “Are there any aspects of routine that your child insists must remain the same?” would be answered “No”, “Mild problem” or “Serious problem”; “How do they react if any changes are made to their surroundings at home?” would be answered “May comment on”, “Accepts the change”, “Will accept the change, but shows extreme anxiety” or “Will not accept the change”. There are two subdomains: ‘inhibitory’ which refers to avoidance of uncertainty and paralysis in the face of it; and ‘prospective’ which refers to desire for predictability and the active seeking of information to increase certainty of future events. Higher scores indicate a higher level of intolerance of uncertainty. Although most widely used in populations with ASD, showing good construct validity (e.g. 85), the scale has also been used in both neurotypical samples (e.g. 86), as well as samples with language difficulties (that include DLD; e.g. 87). Internal reliability was high for both case-control samples in this study (DLD group α = 1.00; typical group α = 1.00).

Emotion Regulation. A total score was derived from five items taken from the Child Social Behavioural Questionnaire (see 88): “shows mood swings”, “gets over excited”, “gets easily frustrated”, “gets over being upset quickly” and “acts impulsively”. Each of these items were rated on a scale from “Almost never” to “Almost always”. Higher scores indicate a higher level of emotion dysregulation. Reliability and construct validity has been demonstrated in previous psychometric work (89). Due to the small number of items in the scale, inter-item correlations were used to measure reliability (78). Correlations were high between all items (Range = 0.90-1.00, M = 0.96).

Parenting stress. The Parenting Stress Scale (PSS; 90) was used, for which parents are required to indicate how much they agree with 18 statements along a 5-point Likert scale (from “Strongly disagree” to “Strongly agree”). Examples of these statements include “I sometimes worry whether I am doing enough for my children” and “It is difficult to balance different responsibilities because of my children”. Higher scores indicate a higher level of experienced parenting stress. The scale is widely used and has been validated in populations from Hong Kong (91) to Spain (92). Internal reliability was excellent for both case-control samples in this study (DLD group α = 1.00; typical group α = 1.00).

Family communication style. The Family Problem Solving Communication Index (FPSC; 93) was used as a way of measuring communication styles. It is a 10-item instrument, for which the parent is required to indicate to what extent the item reflects their family’s pattern of communication on a 4-point Likert scale ranging from “False” to “True”. There are two subscales: ‘Affirming communication’, for example “we take the time to hear what each other has to say or feel”; and ‘Incendiary communication’, for example “we walk away from conflicts without much satisfaction”. These subscales have good convergent validity (93) and the internal reliability was high for both ‘affirming’ (DLD group α = 1.00; typical group α = 1.00) and ‘incendiary’ subscales (DLD group α = 1.00; typical group α = 1.00).

Family coping mechanisms. The Brief-Coping Orientation to Problems Experienced (Brief-COPE) is a shortened version of the original 60-item scale (94). Participants are required to respond to 28 items on a 4-point Likert scale, from “I haven’t been doing this at all” to “I’ve been doing this a lot”. The measure has been widely validated in both clinical populations and cross-culturally (e.g.95,96). Items are traditionally grouped into three categories of coping styles: ‘Problem-focussed’, ‘Emotion-focussed’ and ‘Avoidant coping’ (97). However, for the sample in this study, internal validity was low for certain subscales (emotion-focussed, DLD group α = 0.001; problem-focussed, DLD group α = 0.14, Typical group α = 0.07). As such, a factor analysis was run to re-define three new subscales: ‘adaptive coping’ was characterised by items concerning acceptance, positive reframing and problem-oriented action (e.g. “I’ve been taking action to try to make the situation better”); ‘maladaptive coping’ was characterised by avoidance and negative reframing (e.g. “I’ve been criticizing myself”); ‘alternative coping’ was characterised by drug taking and spirituality (e.g. “I’ve been praying” or “I’ve been using alcohol to make myself feel better”). Higher scores for each subscale indicate use of that coping mechanism; each coping style is not mutually exclusive. Statements that were excluded from these groups due to low correlation values included: “I’ve been expressing my negative emotions”, “I’ve been getting help and advice from other people” and “I’ve been making fun of the situation”. As a result, the validity of the final subscales was high for both DLD (α = 0.68–0.81) and typical groups (α = 0.65–0.83).

Procedure

Ethical approval for the study was granted by the Psychology Research Ethics Committee at the University of Bath (Ref:21–215). An online survey was used as the method for data collection. Participants were invited to take part through an online advert, which included a weblink to the consent form and survey. In the advert they were also given the option to contact the research team by email to ask any questions. Questions took 15–20 minutes to complete. Statements within each question were randomised, whilst the questions themselves were in a fixed order, appearing in the same order in which they are listed below. Parents were entered into a prize draw to win a £50 voucher to compensate them for their time.

Interviews were conducted online using Microsoft Teams, lasting up to 40 minutes each. Conversation began with an overview from the parents of their child’s key psychosocial difficulties, to provide the researcher with context for further discussion. Then. parents were presented with the results from the survey (Figs. 1, 2 and 3). Discussion topics included (1) whether they personally identified with the results, (2) whether they were surprised by any of the findings, and (3) provided them with an opportunity to share lived experiences that either expanded on the results or conflicted with them.

Data analysis

Analysis was completed using IBM SPSS Statistics for Windows Version 26.0. Full data (i.e. those that completed all measures; ‘complete sample’; n = 79), and incomplete data (i.e. those that omitted at least one measure; ‘incomplete sample’; n = 28) were compared to identify any potential biases created by missing data. Amongst the incomplete sample, those who completed the child anxiety symptom measure (n = 21) demonstrated significantly lower scores (M = 10.38, SD = 13.0) than those with full data (n = 79; M = 20.1, SD = 14.1; p = .003). This difference was most significant amongst the typical sample (full sample: M = 13.6, SD = 9.6; incomplete sample: M = 1.9, SD = 4.5; p < .001). There were no other significant differences on any demographic measures: income (p = .42), child sex (p = .60), child age (p = .87), parent gender (p = .59) and ethnicity (p = .12). DLD and typical samples were also compared across the demographic questions. A significantly higher proportion of fathers was found in the typical sample than the DLD sample (p < .001); no significant differences were found between samples for any other demographic characteristics (ps = .80-.34; see Table 1).

To estimate the prevalence of psychosocial difficulties in both children with DLD and typically developing children, the psychosocial statements were compared between-groups (typical vs. DLD), using chi-squared tests. Then, to quantify any differences in individual scores (e.g. anxiety, emotion regulation), the rest of the symptom and coping scales were compared between-groups using independent samples t tests, for all subscales as well as total scores. All tests were run with Bonferroni adjusted significance levels. If significant between-group differences were found for anxiety and social frustration, they were taken forward as dependent variables for mediation analyses.

The potential relationships between psychosocial characteristics were explored through Pearson correlations run between all demographic variables and psychosocial variables (with Bonferroni adjusted significance levels). To then determine the role of key psychosocial difficulties in underlying the manifestation of social frustration (psychosocial statements) and anxiety (SCAS-P), parallel mediation models were planned for each dependent variable that demonstrated a significant between-group difference (DLD vs. typical). All parallel mediation models were run using the PROCESS macro in SPSS (78). The dichotomous variable of sample group (i.e. typical or DLD sample) was used as the independent variable for both models. Model one was run with anxiety as the dependent variable; IU and ER were entered as potential continuous mediators. Model two was run with social frustration as the dependent variable; ER and anxiety were entered as potential continuous mediators. Bias-corrected and accelerated 95% confidence intervals were used, alongside 10,000 bootstrap resamples to adjust for measurement error. The Sobel test was used to identify the significance level of any mediation effect.

To explore any identified relationships further, the qualitative interviews were conducted and then analysed using Interpretative Phenomenological Analysis. This approach was chosen due to the participant-centred nature of the conversations, and the focus on the phenomenon of raising a child with DLD (98). Stories and quotes were used to either expand on or contrast with the quantitative data; pseudonyms were used throughout. Subsequently, data from the qualitative and quantitative phases were integrated. The result is a joint display under the key study aims, demonstrating how each methodology compliments one another 99).

Psychosocial difficulties

The DLD sample scored significantly higher on all psychosocial statements than the typical sample (ps < .05; see Fig. 1). The majority of both the DLD sample and typical sample reported their children ‘experiencing anxiety’ (DLD = 80.7%; typical = 58.0%). Only a minority of the typical sample reported their child experiencing any of the other psychosocial difficulties listed (12.0%-40.0%). In comparison, a majority of the DLD sample reported their child experiencing all but one of the psychosocial difficulties (54.4%-80.7%): ‘sleep problems’ (45.6%).

[Insert Fig. 1 here]

The largest differences between DLD and typically developing sample are ‘struggles to understand the intention of others’ (difference = 51.7%), ‘lacks awareness of others’ (difference = 45.6%), ‘is often excluded from social situations’ (difference = 44.1%) and ‘requires routine/sameness’ (difference = 43.4%).

Qualitative insights

All mothers agreed that anxiety, routined behaviours and emotion dysregulation were the most problematic for their child. Parents particularly described anxiety behaviourally, through incessant worrying, nail biting (Ali), as well as seeking reassurance and company:

“Even now if I’m making dinner in the kitchen [Femi] just has to come and stand beside me, as he feels like he hasn’t been around me that much, if he’s been playing in the living room or whatever… and then if I’m cleaning the kitchen afterwards, he’s just like ‘when are you going to come and sit with me, when are you coming’. So yeah he likes someone to be present with him and I would say that’s a bit of a part of anxiety for him – he doesn’t like being by himself.” (Josephine)

Iris described how Dimo has learnt to manage his worries through the counselling he has accessed over the last year:

He has learnt he can overcome situations, there is no need to be anxious all the time. [The worries] certainly have not gone. I think he always will be a worrier, but he has absolutely learnt to deal with them better… he tends to brood and to dwell on things, so he needs to be snapped out of it, either by himself, or if you tell him. So, he is really making that effort not to brood… since he has learnt that it’s okay to talk about it, he now increasingly comes to me when there is a worry. So he is not just bottling it up.

Preference for routine was experienced by all children of the mothers that were interviewed, however the reasons behind this appeared to differ. Josephine suggested ‘requires routine and sameness’ would come equal to ‘anxiety’ for her six-year-old, as she feels they are so inter-linked: “A lot of [Femi’s] routined behaviours can be a ‘worry’ thing”. Similarly, Liz noticed that when anything at school changes, or there’s a change to Ali’s routine, there’s huge upset, and she focusses on tidying her room and ordering her teddies to make her feel better:

Anything out of the norm that she’s not fully sure of what’s happening, or what it will look like… She’s started to worry about finishing this year and going back up to a new teacher in the year above… I know now if she’s organising her toys I just call school and say we’re going to be late. You can’t rush her or stop her, otherwise there’s a full-blown meltdown.

For Iris, she felt Dimo simply found routine easier. He didn’t have any emotional response to routine changing, but was simply more likely to forget what he was meant to be doing: “He’s happy to go along with whatever, but the think he struggles with is to remember a change in routine… it just goes over his head”.

Both Helen and Iris were surprised to see ‘lacks awareness of others’ on the list. They both described their children as “actually very empathetic”, describing how:

There was a new child that joined [school] during or after Covid, so a very tricky situation for that child, and it has been specifically pointed out that it was Dimo that was specifically going over to that child and making sure they were included and welcomed. I was over the moon.

Helen thought perhaps this lack of awareness of others was in fact lack of self-awareness:

He’s very aware of other people if they are sad, but he’s totally unaware of the impact he has on other people… for example, if I had a row with his sister, he would be completely able to observe that and understand what had happened and why we might be upset, but he basically has zero self-awareness… in a social situation with peers he makes odd noises and sort of talks to himself… he literally couldn’t care less that other people might think that’s a bit odd

Similarly, Iris and Josephine questioned whether or not the ‘struggle to understand the intention of others’ could be due to the relative immaturity of their children, when compared to their typically developing peers. Josephine described how its others’ deceit that Femi particularly struggles to understand:

At school he’s got in trouble before from doing something that he knows he’s not supposed to do it, but because other people are, and they’re his friends, he’s just like ‘yeah but my friends are doing it’, and the teacher says, ‘but is that right’, and he says ‘no, but my friends are doing it’… there’s no connection there at all…I know his friends know that that’s wrong and they’re trying to get him to follow, and he will just follow. He’s quite a sheep.

Helen was surprised to see that ‘is often excluded from social situations’ was so low down. She described how last summer she “invited every child possible for a playdate, and it just never gets reciprocated”. She also described how this has only become more challenging as Joe has become older; it is no longer up to the parents to organise playdates and the children invite who they want, meaning Joe is always left out.

The two mothers of the younger children (Josephine and Liz) mentioned being surprised that “sensory sensitivity” wasn’t on the list of psychosocial difficulties. Josephine described how Femi: “Always has to be touching things, I’ve had to get him a lot of fidget things for him to play with, to keep him occupied… it’s the physical touch, he’s always wanting to feel people”. He also appeared to prefer noise and loudness, for example loud crowds rather than quiet streets. Lack of auditory stimulation made Femi feel “uncertain”:

He likes constant noise, and something going on… he stomps around constantly… he always has to have some sort of noise, the volume control in his voice sometimes, I’m right beside him, I don’t know why, I find it so funny, he’s just like ‘AND THEN!’, I say ‘mummy can hear you, can we maybe bring it down a little bit… but then it goes down like 0.5%” You have to keep asking him.

In contrast, Ali has become very selective with her clothing, and will now only wear soft tracksuit bottoms and tops, no socks and doesn’t like the feeling of her school shirt tucked into her skirt. These parents wondered whether it might be a “comfort thing” (Josephine), in response to feeling anxious or uneasy, though it was hard to pinpoint.

Psychosocial scores and coping mechanisms

Across the psychosocial scales, the DLD group had significantly higher rates of anxiety on all subscales compared to the typical sample. The largest significant difference was for social anxiety (p < 0.003, see Table 3) and separation anxiety p < 0.003), followed by generalised anxiety (p < 0.003). Similarly, the DLD group also had significantly higher rates of IUS on both subscales than the typically developing group (ps < 0.003) as well as emotion dysregulation (p < 0.003) and insistence on sameness (p < 0.003), all with large effect sizes (d = 1.00-1.18).

Table 3

Differences between groups on symptoms of anxiety, intolerance of uncertainty, emotion regulation, insistence on sameness, parent stress and family coping styles.
		Typical Sample		DLD Sample		Effect size
		M (SD)	Range	M (SD)	Range	Cohen’s d
SCAS-P	Total	11.7 (10.0)	0–50	23.9 (15.3)	0–54	0.94*
	GAD	3.2 (2.8)	0–12	6.1 (4.5)	0–16	0.76*
	SAD	3.6 (3.3)	0–13	8.0 (5.3)	0–18	0.98*
	OCD	1.5 (2.9)	0–14	2.8 (3.0)	0–13	0.43
	Separation	3.3 (3.1)	0–12	7.1 (5.2)	0–18	0.88*
IUS	Total	19.6 (6.7)	12–39	30.3 (10.8)	12–55	1.18*
	Prospective	11.8 (4.3)	7–24	17.9 (6.9)	7–32	1.05*
	Inhibitory	7.8 (3.1)	5–17	12.6 (4.8)	5–25	1.17*
EmReg	Total	10.9 (3.3)	7–21	15.1 (4.7)	7–24	1.05*
ISS	Total	2.3 (3.1)	0–18	7.2 (6.2)	0–24	1.00*
PSS	Total	37.3 (9.5)	21–63	37.9 (11.3)	18–61	0.06
FPSC	Affirming	11.7 (2.3)	5–15	12.2 (2.5)	5–15	0.21
FPSC	Incendiary	4.2 (2.7)	0–9	4.8 (2.9)	0–13	0.20
BCOPE	Adaptive	21.0 (4.7)	9–30	25.4 (5.6)	13–34	0.85*
	Maladaptive	13.2 (4.0)	8–28	14.2 (3.8)	8–29	0.24
	Alternative	6.7 (1.7)	5–11	6.4 (2.5)	2–16	-0.14
*Significant difference between groups at p < .003 (Bonferroni adjustment).
NB: the comparator group is the typical sample, meaning a positive d value indicates the DLD group displayed more of those symptoms.

[Insert Table 3 here]

There was no significant difference across groups for parenting stress (p = 0.40), communication styles (ps = 0.17–0.18) or either maladaptive (p = 0.13) or alternative coping (p = 0.27). Parents of the DLD group did, however, report significantly higher use of adaptive coping styles than those of typically developing children (p < 0.003).

Tables 4 and 5 present the Pearson’s correlations between age, income and psychosocial variables for the DLD sample and typical sample, respectively.

Table 4

Pearson correlations between study variables for children with DLD.
	Age	Income	GAD	SAD	OCD	Separation	Anxiety Total	IUS Total	Emotion Regulation	RBQ-ISS	PSS	FPSC Affirming	FPSC Incendiary	BCOPE Adaptive	BCOPE Maladaptive	BCOPE Passive
Age	--
Income	.08	--
GAD	.36*	− .10	--
SAD	.39*	− .13	.73*	--
OCD	.23	.09	.54*	.48*	--
Separation	.15	− .13	.69*	.70*	.47*	--
Anxiety Total	.34	− .10	.89*	.89*	.68*	.88*	--
IUS Total	.25	− .09	.56*	.70*	.59*	.63*	.74*	--
ER	− .08	− .21	.48*	.46*	.33	.63*	.59*	.63*	--
RBQ-ISS	.15	− .14	.49*	.55*	.61*	.56*	.65*	.79*	.62*	--
PSS	− .02	− .32	− .18	− .08	− .17	− .02	− .12	.04	.15	− .10	--
FPSC-A	− .04	.33	.11	.02	− .05	.09	.06	− .04	− .10	− .04	− .57*	--
FPSC-I	.13	− .30	− .04	.04	.10	− .07	− .01	.01	.14	.02	.53*	− .74*	--
BCOPE-Ad	.06	.37	.11	.14	.10	.10	.13	.11	.01	− .05	− .29	.42*	− .42	--
BCOPE-M	.24	− .27	.16	.06	.02	.02	.08	.02	.14	− .09	.54*	− .32	.45*	− .05	--
BCOPE-Al	− .16	− .13	− .24	− .25	− .26	− .14	− .25	− .28	− .10	− .20	.28	− .18	.20	− .12	.04	--
* Significant difference between groups at p < .003 (Bonferroni adjustment).
NB: GAD = Generalised Anxiety Disorder symptoms, SAD = Social Anxiety Disorder symptoms, OCD = Obsessive Compulsive Disorder symptoms, IUS = Intolerance of Uncertainty Scale, ER = Emotion Regulation, RBQ-ISS = Routined Behaviour Questionnaire- Insistence on Sameness Subscale, PSS = Parent Stress Scale, FPSC-A = Family Problem Solving Communication Index-Affirmatory, FPSC-I = Family Problem Solving Communication Index-Incendiary, BCOPE-Ad = Brief Coping Orientation to Problems Experienced-Adaptive, BCOPE-M = Brief Coping Orientation to Problems Experienced-Maladaptive, BCOPE-Al = Brief Coping Orientation to Problems Experienced-Alternative.

Table 5

Pearson correlations between study variables for typically developing children.
	Age	Income	GAD	SAD	OCD	Separation	Anxiety Total	IUS Total	Emotion Regulation	RBQ-ISS	PSS	FPSC Affirming	FPSC Incendiary	BCOPE Adaptive	BCOPE Maladaptive	BCOPE Passive
Age	--
Income	− .18	--
GAD	− .11	− .07	--
SAD	− .02	− .20	.68*	--
OCD	− .02	− .10	.77*	.47*	--
Separation	− .25	.11	.63*	.61*	.39*	--
Anxiety Total	− .12	− .09	.92*	.84*	.78*	.79*	--
IUS Total	.00	− .34	.60*	.68*	.50*	.48*	.70*	--
ER	− .03	− .35	.14	.36	.11	.12	.23	.34	--
RBQ-ISS	− .04	.17	.65*	.57*	.77*	.54*	.79*	.55*	.27	--
PSS	− .20	.07	.21	.29	.27	.11	.27	.11	.38	.45*	--
FPSC-A	.37	− .07	− .41*	− .40*	− .28	− .49*	− .49*	− .43*	− .33	− .53*	− .56*	--
FPSC-I	− .19	.03	.23	.17	.17	.25	.25	.37	.44*	.31	.45*	− .71*	--
BCOPE-Ad	− .17	− .05	.33	− .01	.24	.31	.27	.33	.11	.13	.05	− .22	.17	--
BCOPE-M	− .34	.00	.49*	.53*	.48*	.44*	.06*	.53*	.42*	.65*	.62*	− .67*	.52*	.30	--
BCOPE-Al	− .18	.18	− .01	− .05	− .02	.07	.00	− .03	− .04	.09	.20	.00	.08	.12	.36	--
*significant difference between groups at p < .003 (Bonferroni adjustment).
NB: GAD = Generalised Anxiety Disorder symptoms, SAD = Social Anxiety Disorder symptoms, OCD = Obsessive Compulsive Disorder symptoms, IUS = Intolerance of Uncertainty Scale, ER = Emotion Regulation, RBQ-ISS = Routined Behaviour Questionnaire- Insistence on Sameness Subscale, PSS = Parent Stress Scale, FPSC-A = Family Problem Solving Communication Index-Affirmatory, FPSC-I = Family Problem Solving Communication Index-Incendiary, BCOPE-Ad = Brief Coping Orientation to Problems Experienced-Adaptive, BCOPE-M = Brief Coping Orientation to Problems Experienced-Maladaptive, BCOPE-Al = Brief Coping Orientation to Problems Experienced-Alternative.

[Insert Tables 4 and 5 here]

Amongst the DLD sample, there was a moderate positive correlation between age and total anxiety symptoms (r = 0.34; older age indicated higher rate of anxiety), though none of the correlations reached the Bonferroni adjusted significance level (ps = 0.006–0.315). Higher IU had the strongest correlation with higher scores on the anxiety subscales (rs = 0.56–0.74, ps < 0.003), particularly between social anxiety and the inhibitory subscale of the IUS (r = 0.72, p < 0.003). Higher preference for insistence on sameness also had a strong correlation with higher IU (r = 0.79, p < 0.003), as well as a moderate to strong correlation with all anxiety subscales (rs = 0.49–0.61, ps < 0.003), particularly for social anxiety (r = 0.55), separation anxiety (r = 0.56) and OCD (r = 0.61). Higher emotion dysregulation had significant correlations with higher generalised anxiety (r = 0.48, p < 0.003), social anxiety (r = 0.46, p < 0.003), and, most strongly, separation anxiety scores (r = 0.63, p < 0.003), but not OCD (r = 0.33, p = 0.02). ER, insistence on sameness and IU all had strong, positive and significant correlations with one another (r = 0.62–0.79, ps < 0.003).

For the typical sample, there was no significant correlation between age and anxiety. Similar to the DLD sample, there was also a moderate to strong positive corelation between higher IU and higher anxiety across all subscales (r = 0.48–0.68, ps < 0.003). This relationship was particularly strong between inhibitory IU and total anxiety (r = 0.80, p < 0.003), as well as both generalised (r = 0.76, p < 0.003) and social anxiety subscales (r = 0.73, p < 0.003). Unlike the DLD sample, there was no significant correlation found between ER and either insistence on sameness (r = 0.27, p = 0.09) or IU (r = 0.34, p = 0.03), but there was a significant correlation between higher IU and increased preference for insistence on sameness (r = 0.55, p < 0.003).

There was no significant correlation between the anxiety scales and either parenting stress, or family communication styles within the DLD sample. Amongst the typical sample, however, both family communication styles and coping mechanisms had moderate to strong correlations with anxiety. An affirming communication style was significantly negatively correlated with separation anxiety (r=-0.49, p = 0.001) as well as total anxiety (r=-0.49, p = 0.001) and insistence on sameness (r=-0.53, p < 0.003); more affirming communication correlated with lower anxiety, and insistence on sameness. Conversely, maladaptive coping styles were significantly positively correlated with total anxiety (rs = 0.48–0.60, ps < 0.003); using more maladaptive coping strategies correlated with increased experiences of anxiety. Increased parent stress was also significantly positively correlated with increased insistence on sameness (r = 0.45, p = 0.003), as well as increased incendiary communication (r = 0.45, p < 0.003) and maladaptive coping styles (r = 0.62, p < 0.003).

The relationship between DLD and anxiety: Model 1

Following the identification of a significant relationship between anxiety and DLD diagnosis, the first mediation model set out to explore the potential contributors towards this relationship. As IU and ER were both found to have strong significant correlations with both variables, they were entered into the model as potential mediators.

There was a significant total effect of DLD diagnosis on anxiety symptoms (p < 0.001, β = 12.2, SE = 2.6, LLCI = 6.9, ULCI = 17.5). When IU and ER were kept constant, DLD diagnosis was able to account for 19.5% of the variance in anxiety symptoms. Nonetheless, when the potential mediators were included (IU and ER), the model’s predictive power increased to 63.6% (p < 0.001); as a result of entering these mediators into the model, DLD diagnosis lost all its predictive power (β = 0.7, p = 0.76). This final model, depicted in Fig. 2, demonstrates the strong mediating effect of IU in explaining the relationship between DLD diagnosis and anxiety (z = 4.46, p < 0.001). Although ER was significantly predicted by DLD diagnosis (β = 4.2, p < 0.001), it was not identified as a mediator due to its lack of significance in predicting anxiety (β = 0.4, p = 0.14).

[Insert Fig. 2 here]

Qualitative insights

When presented with this model, parents were very enthused by it: “That is just Femi, that should be the tagline beneath his name… 100% you’ve nailed it… that makes perfect sense, it’s nice to see because it’s what I perhaps can’t articulate, but it’s so obvious.” (Josephine). Helen described how:

“For children like Joe, there is so little that they are able to control in life… without knowing what is expected of them or what’s happening, the fear of overload… I mean it must be terrifying, it must be like being partially sighted and expected to walk your way through a city you’ve never been to”.

Helen went on to describe a pattern that Joe found himself in during the last year, “obsessing” over what happens in the afterlife, or what he refers to as “the spirit world”. She understood it as him trying to create some security, when the afterlife is perhaps the most unknown and uncontrollable phenomenon. She described how it almost drove her “nuts” as, for a year, “every evening he would have to rehearse a script with me around what will be in the spirit world… he had a whole written list of what he wanted…what it will look like”. Josephine and Liz also described how they believe their children’s intolerances of uncertainty also contribute to their routined behaviours and preferences for sameness.

For Iris, Model 1 made sense because she understood how Dimo’s DLD led to his feeling of uncertainty over day-to-day activities, an exhaustion of this uncertainty and thus resultant anxiety: “the fact that things go over his head, that is causing a certain level of uncertainty, because he can’t grasp it. And then of course it is only logical to slip into anxiety.” However, she also described how, for Dimo, this was experienced quite internally, and didn’t appear to drive his behaviours. For example, he never appears to seek out more information about upcoming situations in a proactive bid to feel more certain: “Not in a way of ‘if you don’t tell me what we’re doing tomorrow I am dreading tomorrow’”.

The relationship between DLD and social frustration: Model 2

On confirming that the DLD group experienced significantly higher levels of social frustration than typical group, the second mediation model set out to explore the potential effects of anxiety and ER on the relationship between DLD diagnosis and social frustration.

There was a significant total effect of DLD diagnosis on social frustration (p < 0.001, β = 1.98, SE = 2.5, LLCI = 1.5, ULCI = 2.5). When anxiety and ER were kept constant, DLD diagnosis was able to account for 40.4% of the variance in social frustration. When the potential mediators were included (anxiety and ER), the model’s predictive power increased to 60.0% (p < 0.001). Nonetheless, DLD diagnosis maintained much of its predictive power (β = 1.18, p < 0.001). This final model, depicted in Fig. 3, demonstrates the significant mediating effect of ER in explaining some of the relationship between DLD diagnosis and social frustration (z = 3.38, p < 0.001). Although anxiety was significantly predicted by DLD diagnosis (β = 12.05, p < 0.001), it was not identified as a mediator due to its lack of significance in predicting social frustration (β = 0.02, p = 0.09).

[Insert Fig. 3 here]

Qualitative insights

For Josephine and Helen, they understood the link between DLD, ER and social frustration to be cyclical. Josephine described it as being driven by Femi’s frustration “that he can’t explain how he’s feeling”. She described watching him in groups, where he gets embarrassed that his peers can’t understand him and loses control of his emotions, which impacts the interaction:

He finds it difficult to articulate his emotions, and within that his emotions can drastically change, so if I’m not understanding something, I’ll ask him to repeat it, and [he shouts angrily] “but I just said it! How dare you not understand me! Why don’t you understand me!” […] it makes sense that the social frustration would come from the emotion regulation, as opposed to anxiety. Especially as he has no anxiety within social situations.

Helen saw how social frustration could perhaps lead to anxiety, rather than the other way around: “It becomes very anxiety inducing being in a social situation when you don’t know how to behave”.

For Iris, she understood Dimo’s social anxiety to be totally hypothetical, rather than connected to actually experiencing social frustration. Although Dimo worries about other children bullying him (“what if they pick up on my struggles, they might make fun of me”), these worries haven’t materialised at all, and Dimo has a good group of friends. The only time she says she’s witnessed him socially withdraw she understood to be due to his language difficulties: “for him it is really that simple”.

This study aimed to estimate the prevalence of psychosocial difficulties amongst children with DLD, when compared to neurotypical children, and understand the mechanisms underlying two key psychosocial difficulties previously reported as frequently experienced by this population: anxiety and social frustration. Significantly more parents of children with DLD reported problems across all psychosocial difficulties than those of typically developing children; providing important context to previous qualitative findings (12). Anxiety was found to be the most prevalent of all specified psychosocial difficulties for children with DLD, alongside routined behaviours and emotion dysregulation; all of which shared significant correlations. Furthermore, the relationship between DLD diagnosis and anxiety was found to be fully explained by IU. The experience of social frustration amongst children with DLD was found to be partially explained by emotion dysregulation, and not by anxiety. The models used in this investigation provide preliminary evidence for the direction of the relationships between the many different psychosocial difficulties experienced by children with DLD.

The primary hypothesis of the study was that parents of children with DLD would report higher rates of all psychosocial difficulties than parents of typically developing children. Results supported this hypothesis and specified the difference to individual sub-domains. This study highlights social anxiety and separation anxiety as specific targets for intervention; also characteristic of typically developing children of this age, though at lower rates (100). Most other literature has focussed on ‘emotional difficulties’ (10, 11, 101) or, more recently, ‘internalising symptoms’ (e.g. 100), negating the distinct contributing factors to different symptoms. For example, a lack of ‘perceived controllability’ has been associated with the development of separation anxiety (103), whereas negative self-appraisal significantly predicts social anxiety (104).

In focussing on these subdomains of ‘emotional difficulties’, this study suggests a relationship between age and onset of anxiety; that symptoms of social anxiety begin earlier than late adolescence (105), as previously suggested (106). It also builds on previous work by suggesting that anxiety symptoms increase with age across childhood. For example, in typically developing populations, social communication difficulties have been found to significantly correlate with increases in social anxiety between ages 7- and 10-years-old (107). One suggestion for this pattern could be that anxiety increases as children become more aware of their differences (as in ASD; e.g. 106,107), for example as language requirements become more complex and their difficulties more obvious. Future studies should investigate possible links between self-awareness, social comparison and the manifestation of anxiety, and the role that language plays in these relationships longitudinally.

The literature on preference for sameness and routine amongst children with DLD is in its infancy, yet it was highlighted as a key characteristic for most of the children in the DLD sample. The parents in the current study understood this as an attempt to ‘control’ their environment, expanding on previous social findings (47). Lloyd-Esenkaya and colleagues described a ‘structure’ that children with DLD were observed to impose on their social interactions, illustrating a preference for sameness and routine within social activities (47). It is understandable that the communication difficulties characteristic of DLD may well lead to feeling out of control of one’s environment; for example, the increased difficulties with using self-talk could limit their ability to process information about their surroundings or prepare for activities (110, 111). Furthermore, speech and language therapists have described organisational and memory difficulties in many children with DLD (112); their language difficulties mean they may be less able to store additional information to help reassure them of upcoming uncertainty. Therefore, controlling their own environment through enforcing routine and sameness may be the most straightforward approach to managing their anxiety and frustration. More research is required to understand this preference amongst DLD populations more definitively.

Although omitted from the survey contents, the description of sensory sensitivity within our qualitative sample provides early context to other emerging work of children with DLD (113). In children with other, more well-researched, NDDs (71), heightened sensory sensitivity has been suggested to both exacerbate social and separation anxiety (114), as well as provide some relief through calming strategies (115). This chimes with what the parents in the current study described, where sensory stimuli either triggered anxiety (e.g. too much quietness), or provided comfort from their anxieties (e.g. soft clothing). Furthermore, sensory sensitivity has been used to explain children’s tendencies towards sameness and routine in ASD populations (39, 114), as also demonstrated in this population. The fluctuating states of hypo and hyper arousal influence the child’s motivation towards sameness as an attempt at anxiety regulation (116). More work needs to be done to investigate the manifestation of these behaviours amongst the DLD population.

In contrast to studies of other NDDs, sleep difficulties were relatively low, and emotional difficulties relatively high (117), emphasising the different needs of children with DLD, and requirement for novel intervention. The findings highlight the impact of internalising symptoms on families (e.g. ‘experiences anxiety’), in comparison to externalising symptoms (e.g. ‘has frequent tantrums’), and perhaps the need for more tailored intervention aimed at managing emotional difficulties (e.g. ‘Timid to Tiger’; 116, rather than social and behavioural difficulties (e.g. ‘Applied Behavioural Analysis’; 117).

The least prevalent psychosocial difficulties for the DLD sample included the ‘social frustration’ statements. This echoes the heterogeneity in social skills found amongst children with DLD (7) and was further demonstrated by two mothers of boys at a similar age who described very different levels of social success: one had many friends (Dimo) whilst the other struggled to receive an invite to any playdates at all (Joe). The most prevalent of the social statements, ‘Struggles to understand the intentions of others’, echoes the aforementioned emphasis given to the misinterpretation of social cues in qualitative work (12, 47). There may be an opportunity for interventions to focus on non-linguistic ways of interpreting interactions.

Manifestation of anxiety

The second aim of this study looked to understand the mechanisms underlying these key psychosocial difficulties. In terms of anxiety, families of typically developing children with symptoms of anxiety demonstrated more maladaptive coping mechanisms than families of children with DLD, as well as less affirming communication and higher parenting stress. All of these were significantly correlated with the child anxiety symptoms, supporting the wealth of literature linking these family characteristics with psychosocial development (e.g. 118–121). In comparison, families of children with DLD showed no such relationship. This is important, as it suggests that the manifestation of anxiety amongst children with DLD is less likely to be due to the parenting style or family factors. It is also remarkable, given the emotional strain that raising a child with NDDs can put on the family (124). Instead, their child’s emotional difficulties may be more likely to come more from cognitive differences, such as difficulties with ER due to their DLD; 123); this could increase a child’s likelihood of feeling overwhelmed and acting out behaviourally (e.g. 124). As such, traditional parenting programmes (e.g. ‘Incredible Years’; 125) may be inappropriate.

The relationship between DLD and anxiety was found to be fully mediated by IU. Parents described how they felt their children experienced an overload of uncertainty on a daily basis due to their language difficulties, which resulted in an acute intolerance of any additional uncertainty (e.g. change in routine). This supports recent work by Jones and Westermann, demonstrating that children with DLD perceive a greater level of uncertainty in their environment when processing stimuli, due to their lack of coherent internal speech (128). Worry, a behavioural characteristic of anxiety, has been identified as a cognitive strategy used to attempt to control the unknown (33, 129). Furthermore, IU has been used to explain the avoidance behaviours of individuals with panic disorder; contributing to a maintenance cycle where individuals avoid unfamiliar situations in fear of experiencing the physical sensations of ‘panic’ (130). Research should investigate the relationship IU may have with similar behaviours exhibited by children with DLD, such as social withdrawal (7). Similarly, if anxiety is truly exacerbated by fear of the unknown in this population, preference for routine and sameness should be investigated in relation to IU and anxiety; these preferences could be coping mechanisms, as suggested among children with other NDDs (e.g. 129).

This study also suggests that ER has a different association with anxiety than it does with depressive symptoms. The lack of mediation found here was in contrast to prior literature suggesting emotion dysregulation mediates the relationship between DLD and depressive symptoms in slightly older children (8–15 years old; 130). This supports what we know of neurotypical children; depressive symptoms that emerge later in childhood are due to their negative emotion processing styles (133).

Manifestation of social frustration

The relationship between DLD and social frustration was a little less clearly defined. ER explained some, but not all, of the variation in social frustration. As prior literature suggests there is no direct association between the language difficulties of the children and peer frustrations (e.g. 132), there must be other psychosocial factors influencing this relationship, such as prosociality (135). Alternatively, the concept of self-awareness has begun being linked to social frustration in other populations with NDDs (e.g. ASD; 134). In this study, parents felt their child’s social difficulties came not from lack of awareness of other people, but lack of self-awareness in social situations. In fact, they described their children as very empathetic and perceptive, but only when not personally involved in a situation. Instead, they described a limited ability to understand their behaviour’s impact on others; the children behave in a way that is annoying or ‘odd’ to others.

Recent studies have suggested that emotional and social difficulties develop in parallel for children and adolescents with a history of DLD (137), which could support the symbiotic and cyclical relationship also described by the parents. Additionally, the direction of the relationship between social frustration and psychosocial development may become more defined at an older age. In adolescents with DLD, peer problems have been found to mediate the relationship between DLD diagnosis and emotional problems (138). This is not dissimilar to the role social frustration plays in the development of psychosocial difficulties for children with other NDDs; in ASD, social frustration and emotion dysregulation predicted the later development of depression (e.g.137).

Clinical implications

This study has clear implications for the treatment of psychosocial difficulties in children with DLD. Firstly, it highlights the need for anxiety management in this younger age group (6- to 12-years-old), suggested through targeting an increase in children’s tolerance of uncertainty. Similarly, it suggests ER training could improve management of the children’s frustration in social situations. Finally, the study has implications for the usefulness of different modes of intervention. Both the lack of familial influence, as well as the low prevalence of behavioural problems, suggests the potential irrelevance of ‘parent training’ interventions (e.g. Cygnet: 138; Triple P: 66) and ‘behavioural training’ interventions (e.g. Positive Plus Programme: 139; Stop and Think: 140). Instead, it may be more beneficial to base interventions on emotionally and cognitively focussed treatments (e.g. CUES: 141) with clear awareness and consideration of the specific language needs of this population and adaptations thereof.

Limitations

The context within which the survey was taken must be accounted for. In 2022, families were still recovering from the challenges of the Covid-19 global pandemic, a context recognised to increase the levels of anxiety amongst all children, neurotypical and those with NDDs (e.g. 115,142). Although these figures could be seen as inflated by the pandemic, the elevated rate of anxiety amongst those with DLD still highlights them as a vulnerable group, and supports prior literature (5).

A further limitation is that confirmation of DLD diagnosis was parent-report only, without formal, independent assessment. Children were also not tested for their language abilities. The DLD population is recognised to be heterogenous (145), making it imperative that the individuals within any sample are confirmed to not just represent a specific subgroup. Nonetheless, it is this heterogeneity that renders uniform assessment challenging, with a general consensus lacking amongst professionals regarding the best method for assessing DLD (112). Nonetheless, this is still an improvement on much of the DLD literature, which cites ‘children with a history of DLD’ (e.g. 132) or ‘children at risk of DLD’ (e.g. 56); it is possible these children could meet the criteria for autism spectrum disorder when assessed further, (146). Other studies have used previous definitions of DLD that excluded those with low-IQ (e.g. 145); children with lower IQ have been shown to have a higher risk of mental health difficulties at adolescence (148). Relying on parent-report of formal diagnosis is therefore more likely to be an accurate representation of the current DLD population.

The analysis conducted here was cross-sectional, and therefore causal inferences must be drawn with caution. For example, it is possible that experiencing anxiety could contribute towards preference for sameness as a way of coping with uncertainty (39). Conversely, preference for sameness could either itself contribute to the manifestation of anxiety (149), or the relationship between the two could be bidirectional (150, 151). Nonetheless, the use of a mediation analysis suggests a direction between many of the variables, namely DLD diagnosis, anxiety, IU, ER and social frustration.

Finally, the ‘psychosocial difficulties’ measure used was not validated, but developed from statements provided by qualitative interviews of parents of children with DLD (12). It was designed to capture the broad range of psychosocial difficulties experienced by children with DLD (152), whilst minimising survey length. Although measures validated in typically developing populations can indicate psychosocial symptoms amongst children with DLD, they are less likely to capture the full range of symptoms experienced (153). Moreover, whilst the properties of psychosocial measures have been explored in children with other NDDs (154), there are no such explorations yet conducted for children with DLD. Future research should look to validate measures used amongst populations with DLD.

This study adds to the literature on the psychosocial difficulties of children with DLD by suggesting some directional relationships between these difficulties and highlighting new characteristics that have been previously under-represented. Two of these characteristics are (1) a preference for routine and sameness and (2) an IU, both of which were found to be associated with one another as well as with symptoms of anxiety. Furthermore, IU was found to fully mediate the relationship between DLD diagnosis and anxiety, offering a preliminary insight into the manifestation of anxiety amongst these children. Similarly, emotion regulation was found to partially mediate the relationship between DLD and social frustration. These two findings alone provide a focus for the development of much needed psychosocial intervention, preventing the escalation of these difficulties. It also suggests that there is a complex network of relationships between different psychosocial difficulties that exacerbate one another, that future work should look to disentangle.

ASD: Autism Spectrum Disorder

Brief-COPE: Brief-Coping Orientation to Problems Experienced

DLD: Developmental Language Disorder

E-DLD: Engage with Developmental Language Disorder

ER: Emotion Regulation

FPSC: Family Problem Solving Communication Index

GBP: Great British Pound

ISS: Insistence on Sameness subscale

IU: Intolerance of Uncertainty

IUS: Intolerance of Uncertainty Scale

NDD: Neurodevelopmental Disorders

PSS: Parenting Stress Scale

RBQ: Repetitive Behaviour Questionnaire

SCAS-P: Spence Children’s Anxiety Scale

UK: United Kingdom

Ethics approval and consent to participate

Ethical approval for the study was granted by the Psychology Research Ethics Committee at the University of Bath (Ref:21-215). Written consent was collected from all participants before any data collection began.

Consent for publication

All participants consented to have their anonymised data and quotes published.

Availability of data and material

Anonymised quantitative data analysed during the current study is available from the corresponding author upon reasonable request.

Competing interests

The authors have no competing interests to declare, including no financial nor non-financial interests.

Funding

The research was jointly funded by ARC West (National Institute of Health Research), and the University of Bath.

Authors’ contributions

AB conducted all data collection and qualitative interviews, as well as leading analysis and drafting of the manuscript. MSC, RB, YW and CD provided support to the design and interpretation of analysis, as well as critical review of the manuscript. As such, all authors contributed to written sections of the manuscript.

Acknowledgements

The authors would like to thank all parents who gave their time to participate in this research. In particular, thanks is given to the parents who were interviewed, for their generosity in sharing their stories and contributing to this project.

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Understanding the prevalence and manifestation of the anxiety and social difficulties experienced by children with Developmental Language Disorder.

Status:

Journal Publication

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Abstract

Background

Methods

Results

Conclusions

Figures

Background

Emotion regulation as a mediator

Intolerance of uncertainty as a mediator

Anxiety as a mediator

Influence of the family environment

Aims of current study

Methods

Design

Participants

Measures

Procedure

Data analysis

Results

Psychosocial difficulties

Qualitative insights

Psychosocial scores and coping mechanisms

The relationship between DLD and anxiety: Model 1

Qualitative insights

The relationship between DLD and social frustration: Model 2

Qualitative insights

Discussion

Manifestation of anxiety

Manifestation of social frustration

Clinical implications

Limitations

Conclusions

Abbreviations

Declarations

References

Status:

Journal Publication

Version 1