Recommendations to "slow down", "take a breath", "say it again", etc., may increase the child’s anxiety and fear, leading to more difficulties with speaking and, in the "cycle of stuttering," to yet more fear, anxiety and expectation of stuttering.[49] With time secondary stuttering, including escape behaviours such as eye blinking and lip movements, may be used, as well as fear and avoidance of sounds, words, people, or speaking situations. Eventually, many become fully aware of their disorder and begin to identify themselves as stutterers. With this may come deeper frustration, embarrassment and shame.[50] Other, rarer patterns of stuttering development have been described, including sudden onset with the child being unable to speak, despite attempts to do so.[51] The child usually is unable to utter the first sound of a sentence, and shows high levels of awareness and frustration.