Emotion regulation, empathy, and theory of mind in children with childhood-onset fluency disorder: a multidimensional social-cognitive perspective

Stuttering is increasingly recognized as a neurodevelopmental condition extending beyond speech-motor disruptions to include socio-emotional and social-cognitive processes. This study examined emotion regulation, empathy, and theory of mind (ToM) in children who stutter (CWS) compared to typically developing peers. Eighty school-aged children (41 CWS, 39 children who do not stutter [CWNS]) were assessed using the Emotion Regulation Checklist (ERC), Bryant Index of Empathy (BIE), and Reading the Mind in the Eyes Test – Child Version (RMET-C). CWS demonstrated significantly greater emotion regulation difficulties (higher Lability/Negativity and total ERC scores; all p < 0.001), lower empathy (p < 0.001), and poorer ToM performance (p < 0.001) than CWNS. False Discovery Rate-corrected item-level analyses identified five RMET-C items on which CWS showed reduced accuracy, spanning affectively valenced states (worried, carefree, friendly) and cognitively complex mental states (thinking about something, certain). A sensitivity analysis excluding CWS with comorbid ADHD (n = 31) replicated all primary findings. Within the CWS group, female gender (p = 0.003) and higher maternal education (p = 0.001) predicted greater empathy, whereas psychiatric comorbidity predicted lower empathy (p = 0.022) and greater emotion regulation difficulties (p = 0.008). Stuttering severity was not associated with any socio-emotional outcome (all p > 0.05). These findings suggest that CWS experience significant socio-emotional and social-cognitive difficulties independent of disfluency severity. Multidimensional assessment and intervention addressing emotion regulation and social cognition alongside speech fluency may support optimal developmental outcomes.