4Stigma stuttering

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JSLHR

Article

Assessment of Stigma Associated With

Stuttering: Development and Evaluation of

the Self-Stigma of Stuttering Scale (4S)

Michael P. Boylea

Purpose:To create a psychometrically sound scale thatmeasures different levels of internalized stigma (i.e., self-stigma) among adults who stutter and to analyze factorstructure, reliability, and initial construct validity of the scale.Method:Two-hundred ninety-one adults who stutter wererecruited from Board Recognized Specialists in FluencyDisorders and the National Stuttering Association. Participantscompleted a web-based survey including an experimentalscale called the Self-Stigma of Stuttering Scale (4S), designedto measure different levels of self-stigma in people whostutter, along with a series of established measures of self-esteem, self-efficacy, and life satisfaction.Results:The experimental scale demonstrated adequatereliability in internal consistency and temporal stability. Factor

analysis revealed underlying components supportive of amultidimensional model of stigma. Stigma self-concurrenceand, to a lesser extent, stereotype agreement and stigmaawareness were negatively correlated with self-esteem,self-efficacy, and life satisfaction, supporting initial constructvalidity of the scale.Conclusion: Speech-language pathologists can identify thepresence of self-stigma in their adult clients who stutter andhelp them to alter these beliefs. The 4S can be a means forresearchers and clinicians to achieve these goals.

Key Words: stuttering, stigma, assessment, stereotypes,psychosocial issues, fluency disorders, psychosocial issues

The physical and motoric aspects of stuttering include

involuntary speech disruptions that can make oralcommunication challenging and frustrating. In addi-tion to the more visible physical aspects of stuttering, social,cognitive, and affective dimensions are critical to consider.Many recent studies have shown that many people who stutter(PWS) experience shame and self-consciousness (Ginsberg,2000); heightened risk for development of many mental healthproblems, including social and generalized anxiety disorders,social phobia, and negative affect (Blumgart, Tran, & Craig,2010; Iverach, OBrian, et al., 2009; Iverach et al., 2010);and reduced overall quality of life, including lower socialand emotional functioning (Craig, Blumgart, & Tran,2009) compared with fluent controls. Importantly, it is clearthat most researchers agree that these findings are likely the

result of living with a chronic communication disorder thatelicits social penalties, including negative listener reactions

and stereotypes, bullying and teasing, and social harm and

rejection, as stuttering does (Craig et al., 2009; Iverach et al.,2011), rather than reflecting the underlying cause of stut-tering. In essence, what these authors describe as socialpenalties reflects the concept of stuttering being a stigma-tized disorder. Because it appears possible that stigma maybe relevant to many of the negative psychological conse-quences experienced by PWS, and because addressing theseissues is important for speech-language pathologists (SLPs),it seems important to discuss stigma in detail as it relatesto stuttering.

Public Stigma

A stigma is a trait, attribute, signal, or mark that is

devalued among a particular social group. Stigma is alsothe outcome of possessing the devalued trait in which thenegative social meanings associated with that trait becomelinked to the individual in certain social contexts (Goffman,1963; Shelton, Alegre, & Son, 2010). Current theoreticalmodels of stigma identify both public stigma and self-stigma.Public stigma involves the negative cognitive, affective, andbehavioral reactions of members of the public to individ-uals with stigmatized conditions in the form of stereotypes,prejudice, and discrimination (Corrigan & Watson, 2002).Link and Phelan (2006) described public stigma as involvinga person being labeled, stereotyped, excluded from the non-stigmatized group, being discriminated against, and losing

aThe Pennsylvania State University, University Park, PA

Correspondence to Michael P. Boyle, who is now at Oklahoma State

University, Stillwater: [email protected]

Editor: Jody Kreiman

Associate Editor: Hans-Georg Bosshardt

Received September 1, 2012

Revision received November 28, 2012

Accepted February 4, 2013

DOI: 10.1044/1092-4388(2013/12-0280)

Journal of Speech, Language, and Hearing Research Vol. 56 15171529 October 2013 AAmerican Speech-Language-Hearing Association 1517


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status. Importantly, this process happens in the context of apower imbalance, with the beliefs of the more powerfulgroup prevailing. Public stigma has negative consequencesfor stigmatized individuals, including diminished quality oflife and mental health, as well as restricted opportunities inemployment, education, housing, relationships, and commu-

nity functions (Corrigan, Larson, & Kuwabara, 2010; Major& OBrien, 2005; Steele, 1997; Steele & Aronson, 1995).

There is an abundance of research that has looked atpublic stigma related to stuttering. PWS are often believed topossess several negative or undesirable personality charac-teristics, including being introverted, shy, anxious, nervous,quiet, tense, guarded, fearful, embarrassed, and frustrated(Kalinowski, Stuart, & Armson, 1996). With a few excep-tions, these beliefs have been observed in a variety of popu-lations, including laypeople (Schlagheck, Gabel, & Hughes,2009), teachers (Lass et al., 1994), employers (Hurst &Cooper, 1983), college students (Hughes, Gabel, Irani, &Schlagheck, 2010), and SLPs (Cooper & Cooper, 1996). PWS

are also perceived to be less competent or intelligent than theirfluent counterparts (Silverman & Bongey, 1997; Silverman& Paynter, 1990), and many members of the public believethat jobs requiring frequent oral communication are inap-propriate for PWS (Gabel, Blood, Tellis, & Althouse, 2004).Historically, PWS have been characterized negatively in filmsand television (G. F. Johnson, 1987; J. K. Johnson, 2008)and in childrens literature (Bushey & Martin, 1988; Logan,Mullins, & Jones, 2008). PWS are more likely to be bulliedand teased (Blood et al., 2011; Evans, Healey, Kawai, &Rowland, 2008; Langevin & Prasad, 2012) and less likely tobe perceived by the other sex as attractive and worthy ofa romantic relationship, compared with fluent individuals

(Van Borsel, Brepoels, & De Coene, 2011). In summary, itappears that there is a public stigma related to stuttering thatmay impact vocational, educational, and social dimensionsof life.

Self-Stigma

Whereas public stigma is what the public does to stig-matized individuals, self-stigma is what stigmatized individualsdo to themselves by internalizing the stereotypes, prejudice,and discrimination they are exposed to from the public(Corrigan, Larson, & Rsch, 2009). Stereotypes becomenegative beliefs about the self, and prejudice is experienced as

a negative emotional reaction to internalized negative atti-tudes. These negative cognitive and affective reactions canlead to self-discriminating behavior in which individuals failto pursue work, independent living, meaningful relationships,or other social opportunities (Corrigan & Watson, 2002).Corrigan et al. (2009) labeled this lack of confidence in theability to achieve life goals the why tryeffect (e.g., Whyshould I try to get work? Someone like me will not be ableto handle a job like that). Self-stigma has been associatedwith reduced self-esteem and self-efficacy (Corrigan, Watson,& Barr, 2006), quality of life (Jacoby & Austin, 2007), socialinteraction and adaptation (Berger, Ferrans, & Lashley,2001), and overall psychological well-being (Kellison, Bussing,

Bell, & Gravan, 2010). Self-stigma is also associated withincreased mental health problems, including helplessness,depression, and anxiety (Mak, Poon, Pun, & Cheung, 2007;Yen et al., 2005); impaired physical health status (Barreto& Ellemers, 2010); and decreased utilization of and adher-ence to clinical services and treatment (Corrigan, 2004;

Sirey et al., 2001).Research has shown that PWS are afraid that others

will view them as mentally defective, stupid, strange,not good enough, a fool, incompetent, freak ofnature, not a whole person, mentally retarded, infe-rior, socially crippled, not normal, an imbecile, anidiot,or crazybecause of their stuttering (Bricker-Katz,Lincoln, & McCabe, 2010, Corcoran & Stewart, 1998;Klompass & Ross, 2004; Plexico, Manning, & Levitt, 2009;Whaley & Parker, 2000). Beyond mere fear of what othersmay think, it has also been demonstrated that some PWSinternalize these negative attitudes and integrate them as part

of their self-concepts, as illustrated by the following quotes:Absolutely, stuttering has affected my self-esteem, self-image, self-identity, and the way I see and value myself(Klompass & Ross, 2004, p. 295), and well, because Istutter, I dont deserve to say what I was going to say. I thinkit kinda brings down my self-worth at times. When I have,like, when looking for a job, that oh, Im not worthy of that(Plexico et al., 2009, p. 98). It is also known that a consid-erable number of PWS have turned down jobs or promotionsbecause of their stuttering (Hayhow, Cray, & Enderby,2002; Klein & Hood, 2004) and that many restrict theirparticipation in any desired activity that involves speaking,indicating general patterns of participation restriction forsome PWS (Bricker-Katz et al., 2010; Daniels, Hagstrom, &

Gabel, 2006). From this research, it appears clear that stigmacan be internalized among PWS.

A Multidimensional Model of Stigma

Corrigan and colleagues have developed a theoreticalmodel of self-stigma that is composed of four progressivelevels (Corrigan & Watson, 2002; Corrigan et al., 2010,2012; Corrigan, Rafacz, & Rsch, 2011; Corrigan et al., 2006).The first level is called stereotype awareness,in which stig-matized individuals become aware of the negative stereotypesassociated with their condition that are held by the public(e.g., I believe that the public thinks that PWS are less

competent

). The second level is calledstereotype agreement,in which individuals with a stigmatized condition agree withand express the same stereotypes about other members ofthe stigmatized group that are held by the general public(e.g., I agree with the public, most people who stutter are lesscompetent and they make me uncomfortable). The third levelis calledself-concurrence,orapplication,in which individualsinternalize and apply the negative beliefs found in the publicto themselves personally (e.g., Because I stutter, I am lesscompetent). The final stage isharm,which is represented bydecrements in well-being, including lower self-esteem.

Importantly, Corrigan and colleagues believe thisis a progressive stigma model in which the first two levels

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(awareness and agreement) are necessary but not the mostimportant factors associated with decrements in well-being.Rather, the model proposes that self-concurrence has thestrongest implications for lower psychological well-being,including self-esteem and self-efficacy (Corrigan et al., 2006,2010, 2011). It would be expected that proximal stages (e.g.,

self-concurrence and harm) have greater associations thandistal stages (e.g., awareness and harm). This progressivemodel can be described as trickle-down in nature, such thatawareness would be expected to be higher than agreement,which would be expected to be higher than self-concurrence.

This multidimensional model of stigma can be appliedto PWS. There is evidence that PWS are aware of the factthat they may be perceived negatively by the public; thisdemonstrates stereotype awareness (Bricker-Katz et al.,2010; Plexico et al., 2009). There is also evidence that somePWS hold the same negative views about other PWS thatare held among the general public (Craig, Tran, & Craig,2003; Kalinowski, Lerman, & Watt, 1987); this indicates

stereotype agreement. However, although PWS may agreewith negative stereotypes about other PWS, or a hypotheticalperson who stutters, some studies have shown that manyPWS rate themselves personally in a more positive, non-stereotypical manner (Fransella, 1968; Kalinowski et al.,1987) and believe that stuttering is significantly more handi-capping for the average person who stuttersthan forthemselves (Klein & Hood, 2004). However, no research todate has analyzed these components of stigma simultaneouslyin PWS.

Purpose of the Current Study

PWS are likely to experience public stigma and may beat risk for self-stigma. This may be related to many of therecent troubling findings concerning lower levels of well-being and quality of life in PWS. It seems important to beable to measure self-stigma in PWS and determine whetherassociations do exist between stigma and important elementsof well-being and, if so, at what levels of stigma. To measurethe stigma associated with stuttering, it was necessary tocreate and tailor a scale specifically related to individualswho stutter, rather than use a more general measure of stigma.There have been many scales developed to measure percep-tions, attitudes, and feelings of adults who stutter (e.g.,Andrews & Cutler, 1974; Darley & Spriesterbach, 1978;

Erickson, 1969; Ornstein & Manning, 1985; Riley, Riley, &Maguire, 2004; Woolf, 1967; Yaruss & Quesal, 2006). Despitethe several scales available to measure cognitive and affec-tive dimensions of stuttering, a validated scale does not yetexist that measures the self-stigma associated specificallywith stuttering, particularly within the context of the progres-sive, multidimensional model of stigma presented by Corriganand Watson (2002).

The purpose of this study was to create a scale thatmeasures stuttering within the multidimensional model ofstigma proposed by Corrigan and colleagues (Corrigan et al.,2011; Corrigan & Watson, 2002) and analyze its psycho-metric properties in terms of (a) factor structure, (b) internal

consistency, (c) temporal stability, (d) content validity, and(e) initial construct validity. It was hypothesized that thescale would demonstrate sound psychometric properties,including good internal consistency and temporal stability,and would be composed of three main factors: awareness,agreement, and self-concurrence. In addition, it was hypoth-

esized that initial construct validity would be supportedthrough negative correlations between the different dimensionsof self-stigma (i.e., awareness, agreement, and self-concurrence)and self-esteem, self-efficacy, and life satisfaction. Morespecifically, in accordance with the progressive nature of theself-stigma model, it was hypothesized that self-concurrencewould be most negatively associated with measures of well-being, with agreement having a smaller association andawareness having an even smaller association (Corrigan et al.,2011; Corrigan & Watson, 2002).

It should be noted that the fourth stage of Corriganand colleagues(2011) model, harm, was represented by

measuring self-esteem, self-efficacy, and life satisfaction.

These constructs were evaluated using previously validatedmeasures, rather than creating new items. These constructswere measured because they are known to be crucial com-ponents of mental health and well-being (Bandura, 1997;Crocker, 1999; Pavot & Diener, 1993). Improving well-beingand quality of life is considered by many to be a critical aspectof working with PWS (Craig et al., 2009; Tran, Blumgart, &Craig, 2011; Yaruss, 2010). This idea has been reinforcedwith the recent findings that reduced mental health amongPWS is associated with avoidance of speaking situationsand failure to maintain benefits of speech modification aftertherapy has ended (Iverach, Jones, et al., 2009). The Self-Stigma of Stuttering Scale (4S) would provide a different way

of measuring the hidden dimensions of the stuttering disorderthat are relevant to well-being and quality of life in PWS.

Method

Participants and Procedure

Participants in this study were 291 adults who stutter(ages 1883 years), recruited from the National StutteringAssociation (NSA) as well as Board Recognized Specialistsin Fluency Disorders. The survey mode was web based.Web-based surveys have some advantages over traditionalmail surveys in that they are more efficient in distribution

and data management (Kaplowitz, Hadlock, & Levine,2004), they are perceived by many survey respondents to beeasier to fill out and less likely to be misplaced, and they canoften reach a larger number of potential respondents(Kiernan, Kiernan, Oyler, & Gilles, 2005). One drawbackof the web survey is that response rates are not ableto be determined, as the total number of PWS who hadaccess to the survey is unknown. The web survey used inthis study was created using Qualtrics Survey Research Suitesoftware Version 28, 206. After approval for the researchwas obtained from the NSA Research Committee and theInstitutional Review Board at The Pennsylvania StateUniversity, a series of e-mails was sent to individuals listed

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on the NSA database describing the survey with a link to takethe survey online. In addition, Board Recognized Specialistsin Fluency Disorders were contacted with the request to for-ward the e-mail to any clients or acquaintances who stutter.The Dillman (2008) method was used for determining thenumber of requests sent to potential respondents as well as

the amount of time between requests. Personalized e-mailsfor prenotification, second, third, and final contacts weresent to the participants. There were 2 days between preno-tification and the second e-mail containing the survey, ap-proximately 3 weeks between the second and third contact,and approximately 1 month between third and final contacts.Forty-one individuals, who were obtained by conveniencesampling, completed the survey twice, approximately 2 weeksapart, in order for us to obtain temporal stability results.The survey that participants completed was composed ofseveral different components, including the experimentalscale describedin this article (the 4S); three previously existingmeasures of self-esteem, self-efficacy, and life satisfaction;

and a section measuring demographic information.

Instruments

The 4S.The general format of the scale was adaptedfrom the Self-Stigma of Mental Illness Scale (Corrigan et al.,2006), with the content changed to be relevant for PWSrather than for individuals with mental illness. The 4S wasdesigned to assess three major components of self-stigma,including stereotype awareness (e.g., I think the public be-lieves that most people who stutter are insecure), stereotypeagreement (e.g., I believe that most people who stutter areinsecure), and self-concurrence (e.g., Because I stutter, I

feel more insecure than people who dont stutter). Responseswere given on a 5-point agreement scale (1 =strongly disagree,

2 = somewhat agree, 3 =neither agree nor disagree, 4 =somewhat agree,5 = strongly agree). Scores on each subscalewere averaged, with higher scores representing higher self-stigma. Positively worded items were reverse scored. TheAppendix shows all 73 items that were included in the firstversion of the 4S.

Many strategies were used in order to increase contentvalidity of the scale as it related specifically to stigma ex-perienced by PWS. First, potential items were generated onthe basis of an in-depth review of the literature of self-stigmaand psychosocial aspects of stuttering. Potential items were

assigned to bins,

or areas, corresponding to differentelements of stigma, and some items were systematicallyremoved due to redundancy, confusing language, or limitedapplicability to PWS (DeWalt, Rothrock, Yount, & Stone,2007). Second, the inclusion of interviews and discussionswith members of target populations for scale developmenthas been used extensively (Rao et al., 2009; Sayles et al.,2008). Eighteen PWS who were attending an annual con-vention of the NSA were approached and were askedwhether they would be interested in participating in aresearch project by answering what they believe people inthe public think about person who stutters, and how theythought most people in the public felt when talking to a

person who stutters. The content of these discussions wasrecorded through handwritten notes taken during the discus-sion. This was an important step in developing a survey thatwas anchored in the experiences of PWS.

Utilizing experts as content reviewers is common insurvey development (Berger et al., 2001; Vogel, Wade, &

Haake, 2006). A potential list of items was submitted to threeexperts for review. Expert status was based on (a) publicationrecords in peer-reviewed journals regarding survey develop-ment in psychosocial aspects of stuttering (e.g., social stigmarelated to stuttering; cognitive and affective dimensions ofstuttering) as well as (b) being a person who stutters or aperson who has recovered from stuttering. The experts servedas content reviewers to evaluate how well each item tappedthe concept of self-stigma related to stuttering in terms ofclarity and relevance, and they gave suggestions for potentialchanges. Then, a pilot study was conducted with 22 PWS.Pilot testing and obtaining feedback on a new survey is com-

monly done in the refinement stage of survey development

(Rao et al., 2009; Sayles et al., 2008). Participants were self-selected members of the NSA. These participants were queriedon the language, comprehensibility, format, and relevance ofitems. They then provided written feedback to the author viae-mail regarding their thoughts about the survey, and revi-sions were made on the basis of that feedback.

The Rosenberg Self-Esteem Scale (RSES). The RSES(Rosenberg, 1965) was used to measure self-esteem. Thisscale has 10 items measuring overall self-worth. Five itemsare positively worded (e.g., I feel I have a number of goodqualities), and five items are negatively worded and reversescored (e.g., I feel I do not have much to be proud of).Responses are measured on a 4-point scale (4 =strongly agree,

3 = agree; 2 =disagree; 1 = strongly disagree), and the scoreis the sum of the responses, which can range from 10 to 40,with higher scores representing higher self-esteem. The RSEShas been shown to be a reliable (a= .88), unidimensional,and valid scale that is frequently used in self-esteem research(Corrigan et al., 2006; Rsch et al., 2006).

The General Self-Efficacy Scale (GSES). The GSES(Schwarzer & Jerusalem, 1995) was designed to assess gen-eral feelings of self-efficacy, or belief in the ability to copewith daily hassles and adapt to stressful life experiences. Thescale contains 10 items (e.g., I am confident that I could dealefficiently with unexpected events) and is measured on a4-point response scale (1 =not at all true,2 = hardly true,3 =

moderately true,4 = exactly true). The final score is obtainedby adding the response to each item, with a range from 10to 40, with higher scores indicating higher levels of generalself-efficacy. The GSES demonstrates adequate psycho-metric properties, including unidimensionality, internalconsistency (Cronbachs coefficient alphas [as] ranged from.76 to .90 in a series of studies), and construct validity, andhas been used extensively in research measuring self-efficacy(Luszczynska, Gutierrez-Dona, & Schwarzer, 2004).

The Satisfaction With Life Scale (SWLS). The SWLSis a cognitively driven measure of global life satisfactioncontaining five items (e.g., In most ways my life is closeto ideal). Responses are measured on a 7-point scale



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(1 =strongly disagree, 2 =disagree, 3 = slightly disagree,4 = neither agree nor disagree, 5 =slightly agree,6 =agree,

7 =strongly agree). Scores are calculated by summing theresponses for each item and range from 5 to 35, with higherscores representing higher life satisfaction. The SWLS hasbeen shown to demonstrate unidimensionality, good reli-

ability (a= .87), and construct validity (Pavot & Diener,1993) and has been used frequently in research measuring lifesatisfaction (Pavot & Diener, 2008).

Data Analysis

Statistical analyses were conducted to evaluate thepsychometric properties of the 4S. To determine the under-lying factor structure of the 4S, exploratory factor analysisusing the principal components method of extraction wasconducted. Principal components analysis was used as thefactor extraction method because it is an optimal approachfor reducing data, especially from a scale with many items

(Floyd & Widaman, 1995). Decisions regarding how manyfactors to retain were guided by the widely used criteria ofthe Kaiser (1960) method in conjunction with scree plotanalysis (Cattell, 1966). Several rounds of factor analysis wereconducted for each of the theoretical subcomponents (i.e.,

awareness, agreement, and self-concurrence) of the scaleand for the overall scale. A range of different factors wasextracted in each analysis to examine the interpretabilityof each factor. Orthogonal analysis and varimax rotationwere used because the goal was to detect a clear pattern offactor loadings, and the factors were believed to be inde-pendent. Although the first version of the 4S contained73 items, more than half of these items were eliminated from

the scale following factor analysis, yielding a 33-item scale.Internal consistency was assessed using a. Temporal stabilitywas assessed with Pearson productmoment correlationsbetween participant scores on the original administration ofthe survey and scores obtained during a retest that occurredapproximately 2 weeks later. Initial construct validity wasmeasured by performing multiple regression analyses andobserving correlations between the different levels of self-stigma and self-esteem, self-efficacy, and life satisfaction.

Results

Participant Characteristics

Four hundred forty-six people opened the link tothe online survey that was conducted after the pilot study.However, many responses could not be included in the finalanalysis, including 64 responses from people who did notstutter, 11 from people under age 18, and 80 from people whodid not complete any section of the survey beyond the firstfew screening questions. Therefore, the total number ofresponses from PWS age 18 or older included for data anal-ysis was 291. The sample consisted of 178 males (61%),97 females (33%), and 16 individuals (6%) who did notspecify. The average age was 39.70 (SD = 15.89), with a rangefrom 18 to 83. Participants consisted of 33 (12%) AfricanAmericans; six (2%) Asian Americans; 11 (4%) Hispanic

Americans; 207 (74%) White, non-Hispanics; and 20 (7%)participants who specified otherfor ethnicity. Two hun-dred forty-seven (88%) of the participants had received orwere currently receiving speech therapy, 32 (11%) had not,and 13 (1%) did not answer.1

Factor Structure

Item elimination. Significant loadings were consideredto be .40 or above in the initial stages of analysis (Clark &Watson, 1995). Items 6, 12, 13, 14, 19, 24, 25, 26, 42, 49, 50,63, and 64 were eliminated because of questionable relevanceto theoretical constructs of interest; Items 9, 18, 23, 33,and 51 were eliminated because they loaded highly onmultiple and less relevant factors; Items 31 and 32 did notload highly on any factor items; and Items 7, 17, 27, 43, 54,56, 59, 66, 69, and 70 were eliminated due to redundancywith other items in their section of the scale. In addition, twopairs of items37 and 38, as well as 35 and 36appeared

to be doublet factors, which are considered conceptuallyweak (Chesney, Neilands, Chambers, Taylor, & Folkman,2006) and were thus eliminated. Item 71 was eliminatedbecause it was believed that this item would be poor in dis-criminating PWS from people who do not stutter. Finally,Item 1 was eliminated because it was heavily skewed, with85% of the respondents giving the same response.

Reanalysis post initial item elimination. A factor anal-ysis was conducted on the entire 4S after elimination of theitems described in the previous paragraph. Power for thisanalysis was sufficient because the minimum number of casesneeded was exceeded, based on the recommendation ofhaving more responses than 5 times the number of items

being analyzed (Floyd & Widaman, 1995). Because analyzingthe total 4S measures a more general construct, includingmany more items than any of the preceding analyses, acriterion of .35 was used in determining factor loadings. It is

justified to move loading criteria slightly downward foranalyses with more items measuring wider constructs (Clark& Watson, 1995). Using this criterion, only Items 2 and 57did not load on any factor, and these items were eliminated.

Final factor analysis. A final factor analysis was con-ducted on the remaining 33 items. Scree plot analysis incombination with the Kaiser (1960) method indicated thata three-factor solution was the most parsimonious, witheigenvalues 6.59, 4.06, and 2.72 accounting for 40.5% of the

total variance. After varimax rotation, 12 items loaded ontothe first factor labeled stigma self-concurrence,14 itemsloaded onto the second factor labeled stigma awareness,and seven items loaded onto the third factor labeled stereo-type agreement.Factor loadings for the revised version ofthe scale are shown in Table 1.

Most of the items had their highest loading on theexpected factor and much lower loadings on the other factors.All items except 53 and 62 loaded higher than any other ontheir respective factors. Items 52 and 58 loaded significantlyon two factors, which is a common occurrence in factor

1Percentages are rounded.



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analysis. These items were retained because there was a strongtheoretical justification for keeping them within a certainfactor based on the existing literature and the stigma modelused in this study. The results suggested that most items on

the 4S were capturing unique aspects of stigma related tostuttering in the domains of stigma awareness, stereotypeagreement, and stigma self-concurrence. Note that two of thefactor labels are different from the labels given by Corriganet al. (2006), which specified stereotypes only. The factorsin this study related to awareness and self-concurrence con-tained more than stereotypes, making the more general termstigmaa more appropriate label.

Correlations were small between factors of awarenessand agreement (r = .03), awareness and self-concurrence(r= .06), and agreement and self-concurrence (r = .12).DeVellis (2012) recommended that cross-factor correlationssmaller than .15 should be considered orthogonal to main-

tain the simplicity of uncorrelated factors. This justifies theuse of principal components extraction and varimax rotationon the factors. Raw scores on stigma self-concurrence weresignificantly correlated with stigma awareness scores (r= .20)

and stereotype agreement scores (r = .27); however, stigmaawareness scores were not significantly related to stereotypeagreement scores (r = .06).

Reliability: Internal Consistency and

Temporal Stability

Two different types of reliability measures, internalconsistency and temporal stability, were assessed in thisstudy. To assess internal consistency, coefficient alpha (a)values were calculated for the 4S and its subscales. Table 2contains a measures that provide evidence of internalconsistency reliability, as they are all between .70 and .89,

Table 1.Factor analysis of the final version of the Self-Stigma of Stuttering Scale (4S).

Variable

Factor 1:Stigma

self-concurrence

Factor 2:Stigma

awareness

Factor 3:Stereotypeagreement

52. Because I stutter, I feel more nervous than people who dont stutter. .484 .101 .436

53. Because I stutter, I feel just as confident as people who dont stutter. .443 .182 .55655. Because I stutter, I feel less capable than people who dont stutter. .490 .096 .33958. Because I stutter, I feel less sociable than people who dont stutter. .480 .070 .42962. Because I stutter, I feel less assertive than people who dont stutter. .379 .157 .38163. Because I stutter, I stop myself from taking jobs that require lots of talking. .702 .008 .12364. Because I stutter, I stop myself from accepting promotions at work. .772 .043 .09765. Because I stutter, I stop myself from selecting the career I really want. .773 .060 .08967. Because I stutter, I stop myself from going for higher education opportunities. .730 .112 .12368. Because I stutter, I stop myself from talking to people that I know well. .629 .011 .04272. Because I stutter, I stop myself from participating in social events. .772 .111 .08273. Because I stutter, I stop myself from taking part in discussions. .837 .087 .038

3. Most people in the public believe that people who stutter are insecure. .058 .470 .0574. Most people in the public believe that people who stutter are self-confident. .114 .445 .2965. Most people in the publ ic bel ieve that people who stutter are friendly. .071 .516 .1608. Most people in the publ ic bel ieve that people who stutter are capable. .001 .706 .073

10. Most people in the public believe that people who stutter are outgoing. .097 .463 .304

11. Most people in the public believe that people who stutter are mentally healthy. .058 .581 .12715. Whentalkingto a personwho stutters, mostpeople in the general publicfeel patient. .057 .613 .10716. When talking to a person who stutters, most people in the general public

feel annoyed..089 .502 .082

20. When talking to a person who stutters, most people in the general publicfeel comfortable.

.055 .576 .160

21. When talking to a person who stutters, most people in the general publicfeel anxious.

.002 .541 .071

22. When talking to a person who stutters, most people in the general publicfeel embarrassed.

.038 .535 .033

28. Most people in the general public believe that people who stutter should avoidspeaking in front of groups of people.

.052 .698 .020

29. Most people in the general public believe that people who stutter should have otherpeople speak for them.

.049 .657 .140

30. Most people in the general public believe that people who stutter should avoid jobsthat require lots of talking.

.050 .666 .068

40. I believe that most people who stutter are nervous. .007 .139 .63041. I believe that most people who stutter are self-confident. .005 .047 .64144. I believe that most people who stutter are capable. .113 .071 .39745. I believe that most people who stutter are incompetent. .071 .018 .41646. I believe that most people who stutter are insecure. .047 .043 .67747. I believe that most people who stutter are outgoing. .052 .021 .61348. I believe that most people who stutter are shy. .075 .124 .494

Note. Factor loadings after varimax rotation. Boldface values represent primary loadings associated with each factor.



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which are included in the acceptable to very good rangedescribed by Nunnally (1978).

To assess temporal stability, testretest correlationswere calculated between responses to the original question-naire and a follow-up questionnaire sent out 2 weeks later.Forty-one participants completed the scale a second time.Table 2 displays the testretest correlations for the 4S andits subscales. Testretest correlation for the overall 4S was

.80. Correlations for the subscales ranged from .55 to .82.It should be noted that testretest coefficients for the sub-sections of stereotype agreement and stigma awareness werebelow .70. Streiner and Norman (2003) stated that it is dif-ficult to determine a precise cutoff point for acceptable testretest reliability because it largely depends on what is beingmeasured and how long of a gap there is between test andretest. That said, those authors recommended comparing thecoefficient that was obtained with those obtained from otherinstruments measuring similar constructs. The testretestvalues obtained for the 4S are comparable to other stigmaquestionnaires taken 2 weeks apart by adults with a widevariety of disorders. These studies have revealed testretest

correlations for specific subscales in the range of .55.90and overall correlations for the total scale in the range of.71.92 (Berger et al., 2001; Boyd Ritsher, Otilingam, &Grajales, 2003; Corrigan et al., 2006; Kellison et al., 2010).

Construct Validity

Construct validity was evaluated by analyzing hypoth-esized relationships between measures representing certain

variables (DeVellis, 2012). In this study, stigma self-concurrencewas hypothesized to be negatively related to self-esteem, self-efficacy, and life satisfaction, with stereotype agreementhaving a smaller relationship to these measures and stigmaawareness having an even smaller relationship. Becausesome of the awareness, agreement, and self-concurrence

scores were significantly correlated, it was of interest to knowtheextent of theassociationsbetween these levels of stigmaandself-esteem, self-efficacy, and life satisfaction after sharedvariance was partialed out of the analysis. Table 3 showsmultiple regression analyses with self-esteem, self-efficacy, andlife satisfaction as dependent variables and stigma awareness,stereotype agreement, and stigma self-concurrence as inde-pendent variables. Scores on stereotype agreement andstigma self-concurrence were shown to be separately andsignificantly associated with self-esteem, self-efficacy, andlife satisfaction. However, stigma awareness was not asignificant predictor with agreement and self-concurrencein the model.

The correlations between these variables support thehypotheses and construct validity of the 4S. Effect sizes forcorrelations in this study use Cohens (1992) widely usedstandards (.1.3 = small,.3.5 = medium,>.5 =large). Witha= .05, and all levels of stigma included in the regressionmodel, stigma self-concurrence had a large negative corre-lation with self-esteem and had medium negative correlationswith self-efficacy and life satisfaction. Stereotype agreementhad smaller but statistically significant correlations withself-esteem, self-efficacy, and life satisfaction. Stigma aware-ness had small and nonsignificant relationships with self-esteem, self-efficacy, and life satisfaction. The notion thatself-stigma is a multilevel and progressive construct was

supported through mostly stronger correlations at prox-imal (e.g., self-concurrence and self-esteem decrement) ratherthan distal (e.g., stigma awareness and self-esteem decre-ment) stages.

Stigma Scores

To score the 4S and its subscales, the participants responses were averaged, yielding a number between 1 and 5.

Table 2.Reliability statistics for the 4S and subscales.

Variable Cronbachs Testretest correlation

Overall 4S .87 .80Stigma awareness .84 .62Stereotype agreement .70 .55

Stigma self-concurrence .89 .82

Note. The time between test and retest was approximately 2 weeksfor 41 individuals who stutter.

Table 3.Multiple regression analysis with components of self-stigma predicting self-esteem, self-efficacy, and life satisfaction.

Dependent variable Independent variable B SE t p R2

Self-esteemStigma awareness .042 .048 .040 .879 .380 .45Stereotype agreement .170 .044 .179 3.833


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For statistical purposes, participants were considered to havehigh levels of self-stigma if their average score was above 3and low levels of self-stigma if average scores were below 3.This scoring was based on the observation that a score ofexactly 3 represented the theoretical midpoint of neitheragreeing nor disagreeing with stigma, scores higher than 3

represented agreeing with stigma, and scores lower than 3represented disagreeing with stigma. These average scoresshould be interpreted in terms of absolute self-stigma ratherthan relative self-stigma. The mean for stigma awareness was3.61 (SD= 0.54), with 86% of participants demonstratinghigh stigma awareness. The mean for stereotype agreementwas 2.56 (SD= 0.61), with 19% of participants agreeinghighly with these stigmatizing views as they apply to otherPWS. The mean for stigma self-concurrence was 2.70(SD= 0.92), with 39%of participants demonstrating high levelsof self-concurrence. It is important to note that the sample ofPWS in this study was limited, and so the scores presentedhere should not be interpreted as normative data for a rep-

resentative sample of all PWS. In summary, the results showthat a large proportion of the participants were highly awareof stigma related to stuttering, but a relatively small pro-portion agreed highly with negative stereotypes about otherPWS. Still, compared with participants who agreed highlywith negative stereotypes related to other PWS, a substan-tially larger proportion of participants applied highly nega-tive stigmatizing attitudes to themselves personally.

Discussion

This study focused on the development of the 4S, thefirst scale to measure the self-stigma associated with stut-

tering. Findings suggest that psychometric properties of thescale are adequate for research and clinical purposes. Spe-cifically, reliability measures indicate that the 4S has accept-able to very good internal consistency and acceptabletemporal stability. The scale is made up of three constructs:stigma awareness, stereotype agreement, and stigma self-concurrence. Initial construct validity was supported in thatself-stigma was negatively related to self-esteem, self-efficacy,and life satisfaction, with larger associations observed amonglater stages of stigma (e.g., stigma self-concurrence was morestrongly related to self-esteem than was mere awareness ofstigma), supporting the progressive model of stigma describedin this study (Corrigan et al., 2011). The 4S is relevant for SLPs

who work with PWS because it can be administered in a re-latively brief period of time (about 35 min) and can assessmultiple levels of stigma that appear to be valuable for under-standing the beliefs of PWS. It can also help in determiningthe need for client counseling on certain stigma-related issuespertaining to stuttering.

Clinicians may want to assess self-stigma during initialassessment and throughout the duration of treatment totrack whether clients possess altered self-stigmatizing atti-tudes. In addition, the awareness portion of the scale may behelpful in evaluating clientsperceptions of public attitudechange regarding PWS. It has been established that address-ing well-being and quality of life are relevant and important

goals for SLPs working with PWS through decreasingactivity limitations, participation restrictions, and barrierscreated by contextual factors (American Speech-Language-Hearing Association, 2007; Yaruss, 2010). PWS who self-concur or agree with stigmatizing attitudes about stutteringwill likely experience these problems (Klompass & Ross,

2004; Plexico et al., 2009). SLPs working with PWScan targetreducing these limitations, constrictions, and barriers byaddressing self-stigma with the assistance of the 4S. Forexample, the use of cognitive therapies and self-help andmutual aid programs may help clients decrease stereotypeagreement and stigma self-concurrence by challengingharmful beliefs that may limit their quality of life.

In general, the findings support previous researchdemonstrating negative associations between internalizedstigma and self-esteem (Berger et al., 2001; Corrigan et al.,2006), as well as self-efficacy (Rsch et al., 2006; Watson,Corrigan,Larson, & Sells, 2007), found in various populations

and extends these associations to PWS. Results support the

notion that self-stigma in PWS has multiple components (i.e.,awareness, agreement, self-concurrence) similar to what hasbeen proposed for individuals with mental illness (Corriganet al., 2006); however, the content of the stigma is differentbetween the groups. The findings (see Table 3) also partiallysupport the progressive model of self-stigma (Corrigan et al.,2011) and provide little support for the claim that mereawareness of negative perceptions of PWS from the publicmaybe functional in influencing stutterersself-concept aswell as their actual behavior (Turnbaugh, Guitar, & Hoffman,1979, p. 44). Assessing awareness of stigma alone is not suf-ficient to understand its impact. Of greater relevance is PWSagreeing with the stigma and, even more so, applying thestigma

and hurtful beliefs to themselves personally. When internaliza-tion of stigma extends beyond mere awareness into agreementand finally self-concurrence, PWS may be in danger of ex-periencing increasingly lower levels of well-being.

Results of the study partially supported the trickle-down expectation of the progressive model. Awarenessscores were higher than agreement scores; however, agree-ment scores were lower than self-concurrence scores. Itappears that PWS are harder on themselves than on otherPWS. These findings differ from previous research studiesthat suggested that PWS had more negative views aboutother PWS than they did about themselves (Fransella, 1968;

Kalinowski et al., 1987). A speculative explanation for these

discrepancies is that over recent years, many more PWS arecoming together through technologies, such as social mediaand online support networks, that were not previously available.This increased sense of community and access to other PWSmay be decreasing stereotype agreement among PWS. Thefindings that agreement scores were lower than self-concurrencescores and that awareness was more highly correlated with self-concurrence than agreement seem to imply that the progressivenature of self-stigma expressed by Corrigan et al. (2011)may not be generalized to PWS without some modification.Although it appears true that there are various levels of self-stigma in PWS, it does not appear that agreement withstereotypes for other stigmatized group members must be a



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prerequisite for applying that stigma to oneself personally.Additional research is needed to investigate the framework ofthe self-stigma model more deeply.

Limitations and Future Directions

There are some limitations to consider in this study.First, participants were recruited from either professionals

or self-help networks, meaning that most participants have

sought help or external support for their stuttering. It is

reasonable to believe that PWS with no history of treatment

or support groups may have responded differently to self-

stigma items. Also, even though many different ethnicities

were represented in this study, the majority of participants

were Caucasian; therefore, the 4S requires further evaluation

in larger populations of different ethnicities. Furthermore,

it is not known how responders differed from nonresponders

and whether those differences have implications for the

results found in this study.

An element of subjectivity is unavoidable in the in-terpretation of the results of factor analyses. Therefore, there

may be other ways of interpreting the factors that arose in

this study. Future research with different populations of

PWS will be helpful in confirming the factor structure found

in this study. It is also important to remember that the ob-

servational design of this study does not permit conclusions

of causal relationships. Although the results are suspected

to mean that self-stigma leads to diminished well-being as a

consequence, it is possible that there are mediating constructs

or that lower well-being leads to increased self-stigma. The

latter interpretation seems less likely, as it has been shown that

baseline self-esteem is not a long-term predictor of self-stigma,

but self-stigma is a long-term predictor of self-esteem (Link,Struening, Neese-Todd, Asmussen, & Phelan, 2001). Finally,

the theoretical model of self-stigma proposed by Corrigan

and Watson (2002) was used in this study as a guide for item

selection to answer the specific research questions posed.

Therefore, there may be other items related to the stigma as-

sociated with stuttering that could be relevant, depending on

different models or conceptualizations of stigma.

There are many new areas of research to be investi-

gated. First, it will be important to examine how self-stigma

varies with demographic information (e.g., age, gender) as

well as variables such as treatment experience and support

group involvement. Continued analysis of construct validity

of the 4S with measures related to shame, hope, and em-powerment will be important to consider. It will also be

important to look at the relationships between self-stigma

of stuttering and other important aspects of well-being in

PWS such as positive affect. The scale should also be ad-

ministered to PWS who are not part of treatment or support

groups to determine whether their stigma levels are higher

than those reported in this study. Tracking 4S score changes

across different treatment protocols for stuttering may also

be a valuable area for future research. Finally, most research

related to stigma and stuttering has used self-report mea-

sures. Future investigations may benefit from applying

other assessment methods to analyze connections between

well-being and stigma, including observational or behavioral

data, or physiological measures.

Conclusion

The 4S is a psychometrically sound measure of self-stigma in PWS. This scaletogether with other measures ofcognitive, affective, and social dimensions of stutteringislikely to provide information regarding clientsneed forcognitive change and the possibility of relapse followingtreatment. Looking at multiple layers of stigma throughinstruments such as the 4S can contribute to our understand-ing of processes that have implications for well-being andquality of life among PWS and can help to develop effectivetreatment strategies for altering negative beliefs. Regardlessof the negative reactions PWS may encounter from thepublic, which might be unavoidable at times, the extent towhich they agree with and internalize harmful self-stigmatizing

beliefs is modifiable and open to change. The 4S is intendedto be a tool used by researchers and service providers toidentify and document these types of changes in individuals

who stutter.

Acknowledgments

This research was conducted as part of the authors 2012

doctoral dissertation in the Department of Communication Sciences

and Disorders at The Pennsylvania State University. Parts of this

research were presented at the 2012 annual convention of the Amer-

ican Speech-Language-Hearing Association in Atlanta, GA. Special

thanks to my mentor and primary advisor, Gordon Blood, for all hissupport, reviews, helpful feedback, and suggestions throughout this

study. Thanks to committee members Ingrid Blood, Robert Prosek,

and James Herbert for their reviews, suggestions, and comments.Thank you to Rodney Gabel, Kenneth St. Louis, and Robert Quesal

for their reviews on an early version of the scale used in this study.

Thanks to Frank Germann and Daisy Phillips for their statistical

consulting. Thank you to the National Stuttering Association and

the Board Recognized Specialists in Fluency Disorders who helped

greatly with participant recruitment for this study. Thank you toall of the participants in this research.

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Appendix(p. 1 of 2)

Items in the first version of the Self-Stigma of Stuttering Scale (4S).

Most people in the general public believe that people who stutter areI1. nervous2. shy3. insecure4. self-confident5. friendly6. confused7. intelligent8. capable9. incompetent

10. outgoing11. mentally healthy12. embarrassed13. not trying hard enough to stop stuttering14. not concerned enough to stop stuttering

When talking to a person who stutters, most people in the general public feelI

15. patient16. annoyed17. frustrated18. confused19. surprised20. comfortable21. anxious22. embarrassed23. pity for the person who stutters24. unsure how to react to stuttering25. that they should help the person who stutters26. that they should give advice to the person who stutters27. not bothered by stuttering

Most people in the general public believe that people who stutterI

28. should avoid speaking in front of groups of people29. should have other people speak for them30. should avoid jobs that require lots of talking31. are likely to be hired for jobs that require lots of talking32. are likely to be promoted at work33. are able to do their job effectively

Most people in the general public would want toI34. avoid having a conversation with a person who stutters35. be friends with a person who stutters36. introduce a person who stutters to friends37. avoid dating a person who stutters38. avoid having a romantic relationship with a person who stutters39. work with a person who stutters

I believe that most people who stutter areI

40. nervous41. self-confident42. confused43. intelligent44. capable45. incompetent46. insecure47. outgoing48. shy49. optimistic50. stressed



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Appendix(p. 2 of 2)

Items in the first version of the Self-Stigma of Stuttering Scale (4S).

Because I stutter, I feelI51. less adequate than people who dont stutter52. more nervous than people who dont stutter53. just as confident as people who dont stutter54. just as secure as people who dont stutter55. less capable than people who dont stutter56. less competent than people who dont stutter57. just as intelligent as people who dont stutter58. less sociable than people who dont stutter59. just as outgoing as people who dont stutter60. more confused than people who dont stutter61. just as ambitious as people who dont stutter62. less assertive than people who dont stutter

Because I stutter, I stop myself fromI63. taking jobs that require lots of talking64. accepting promotions at work

65. selecting the career that I really want66. asking for promotions at work67. going for higher education opportunities68. talking to people I know well69. talking to people I dont know well70. starting conversations with other people71. speaking in front of a group of people72. participating in social events73. taking part in discussions



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C o p y r i g h t o f J o u r n a l o f S p e e c h , L a n g u a g e & H e a r i n g R e s e a r c h i s t h e p r o p e r t y o f A m e r i c a n

S p e e c h - L a n g u a g e - H e a r i n g A s s o c i a t i o n a n d i t s c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o

m u l t i p l e s i t e s o r p o s t e d t o a l i s t s e r v w i t h o u t t h e c o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n .

H o w e v e r , u s e r s m a y p r i n t , d o w n l o a d , o r e m a i l a r t i c l e s f o r i n d i v i d u a l u s e .

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