8/12/2019 4Stigma stuttering
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
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
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.
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
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
Journal of Speech, Language, and Hearing Research Vol. 56
15171529 October 2013 AAmerican Speech-Language-Hearing Association
8/12/2019 4Stigma stuttering
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,
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
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
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,
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
). 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
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
1518 Journal of Speech, Language, and Hearing Research Vol. 56
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8/12/2019 4Stigma stuttering
(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
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
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
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,
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
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
of measuring the hidden dimensions of the stuttering
disorderthat are relevant to well-being and quality of life in
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
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
Boyle: Self-Stigma of Stuttering 1519
8/12/2019 4Stigma stuttering
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
and a section measuring demographic information.
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
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
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, &
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).
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
(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
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
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
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
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
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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8/12/2019 4Stigma stuttering
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
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
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=
and stereotype agreement scores (r = .27); however,
stigmaawareness scores were not significantly related to
stereotypeagreement scores (r = .06).
Reliability: Internal Consistency and
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).
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
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
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 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)
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
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
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
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,
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
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
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
or that lower well-being leads to increased self-stigma. The
latter interpretation seems less likely, as it has been shown
baseline self-esteem is not a long-term predictor of
but self-stigma is a long-term predictor of self-esteem
(Link,Struening, Neese-Todd, Asmussen, & Phelan, 2001).
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
sociated with stuttering that could be relevant, depending
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
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
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.
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
This research was conducted as part of the authors 2012
doctoral dissertation in the Department of Communication
and Disorders at The Pennsylvania State University. Parts of
research were presented at the 2012 annual convention of the
ican Speech-Language-Hearing Association in Atlanta, GA.
thanks to my mentor and primary advisor, Gordon Blood, for all
hissupport, reviews, helpful feedback, and suggestions throughout
study. Thanks to committee members Ingrid Blood, Robert
and James Herbert for their reviews, suggestions, and
comments.Thank you to Rodney Gabel, Kenneth St. Louis, and Robert
for their reviews on an early version of the scale used in this
Thanks to Frank Germann and Daisy Phillips for their
consulting. Thank you to the National Stuttering Association
the Board Recognized Specialists in Fluency Disorders who
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
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
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
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.
1528 Journal of Speech, Language, and Hearing Research Vol. 56
15171529 October 2013
8/12/2019 4Stigma stuttering
Appendix(p. 2 of 2)
Items in the first version of the Self-Stigma of Stuttering
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
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
Boyle: Self-Stigma of Stuttering 1529
8/12/2019 4Stigma stuttering
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 .