A study of the relation between stuttering and self-esteem of adolescents through mediating internal processes, peer group

status and the teacher-student relationship.

Towards more transparency of a complex speech disorder.

University of Antwerp (Belgium):Institute of Education and Information SciencesFaculty of Medicine and Health Sciences (Department ENT – ear, nose, throat)

In cooperation with University of Ghent

Stuttering…more than words

Stefanie Adriaensens

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Stefanie

Introduction

Master thesis

Phd

Future

Stuttering…more than words

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Stuttering…more than words

Stefanie

Introduction

Master thesis

Phd

Future

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More than words

Definition of stuttering DSM IV TR: “A communication disorder characterized by excessive involuntary disruptions in the smooth and rythmic flow of speech, particulary when such

disruptions consist of repetitions or prolongation of a sound or a syllable, and when they are accompanied by emotions such as fear and anxiety, and behaviors

such as avoidance and struggle” (APA, 2001)

Complexity of stuttering

Metaphor of the iceberg

Emphasis on observable, external stutter behavior

“What is the influence of thoughts and feelings on people who stutter? Does this internal stutter behavior causes someone who stutters to describe himself as a

stutterer? Does there exist a self-concept of stutterer? And if so, is this image negative?”

The iceberg beneath the surface: the impact of stuttering on the of

through processes

Master thesis Clinical psychology (2006-2008)

self-esteem adolescents mediating

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Self-esteem

• Development- Sense of self - Cognitive (who am I?)+ affective (+/-) component- ‘Real’ self vs ‘Ideal’ self- Neg evaluations rare in toddlers and young children- Social comparisons increase

• Domain specific- People form an image about their appearance and

their athletic, social and school capacities. - + a global image of personal functioning

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Adolescence

• Cognitive development- More social comparisons- Perspective taking- More formal thinking

=> Consequences:- Worried about attractiveness- Egocentric thinking, very focused on themselves- Strengthened self-consciousness- Diminish the attention on negative aspects (Santrock, 2001)

( i.a. De Wit, Van der Veen, & Slot,1995; Larsen & Buss, 2005; Seifert & Hoffnung, 1991 )

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Stutter research

- Within the development of chronic stutter behavior, experiences with stuttering could leave a mark on someone’s self-esteem.

- Severe communication disorders could have a negative impact on someone’s quality of life.

- Adult research• negative consequences of stuttering, such as anxiety, helplessness,

shame and low self-esteem. • Adult people who stutter experience functional difficulties in

communication and in activities required for their career. - Research on children

• Children who stutter probably have not yet developed a self-image of ‘stuttering’, because of their limited experiences with negative interactions (Green hypothesis).

(i.a. Bajina, 1995; Green, 1998, 1999; Klompas & Ross, 2004; Shames & Rubin, 1986; Shapiro, 1999; Yovetich, Leschied & Flicht, 2000)

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Adolescence

When do we notice an influence of stuttering on self-esteem? We need to take a closer look at ‘the period in between’.

• Research in adolescence- Just recently studied as separate group- Blood et al. (2003, 2007): Their stuttering teenagers pointed

out a positive self-image, comparable with their non-stuttering peers.

• Rosenberg Self-esteem Scale = only global self-esteem.• Closeness about their stuttering

- Landera (2004): Little attention on their stutter problem• N=9• Contradictions interviews vs questionnaires

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MediatorsCould internal factors explain the relationship between stuttering and self-esteem?• Negative communication attitudes (i.a. Vanryckeghem et al., 1995,

1997, 2005; De Nil & Brutten, 1991; Andrews & Cutler, 1974)- Hesitate to take the phone, rather be silent in certain speaking situations ...- At early age already aware of different speech

• Experienced stigma, resulting in closeness about stuttering (Craig et al, 2000; Blood et al., 2003)- People who stutter are described as stupid, shy, ...

• Perfectionism (Amster & Klein, 2004)- less tolerant to errors in their speech,- more concerned to say the wrong things - more intense in their reactions on non fluency- Perfectionism aggravates stuttering- Adaptive vs. maladaptive perfectionism (Stump & Parker, 2000)

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-

+ - + - + - + +

Stutter severity Self-esteem

Negative communication attitudes

Maladaptive perfectionism

Adaptive perfectionism

Experienced stigma and closeness about

stuttering

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Stefanie

Introduction

Master thesis

Phd

Future

Stuttering…more than words

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Method

• Respondents• 55 AWS

- 34M, 18F, 3?- 26 early adolescence (M= 13 years, 3 months;

SD= 11 months) - 28 late adolescence (M= 19 years, 4 months;

SD= 1 year, 4 months). • Control group: 76 adolescents

- 46M, 21F, 9?• SES: (lower) middle class

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Method - measures

Subjective stutter severity SSS Subjective Screening of Stuttering; Riley, Riley, & Maquire (2004); α .91; 13 items; SSI (n=33) r .38, p<.05

Self-esteem CBSA

(SPPA, Harter)

Competentiebelevingsschaal voor Adolescenten; Treffers et al., 2002; α ≥.71; 35 items; 1 global self-esteem + 6 specific domains: social acceptance, school and athletic competence, close friendship, physical appearance and behavioral conduct

Negative communication attitudes

S-24 Erickson S-24; Andrews & Cutler (1974); α .92; 24 items

Stigmatization and introversion about stuttering

  Blood et al.(2003), questions adapted from study Westbrook et al. (1992) on epilepsy; 7 items

Perfectionism MPS Multidimensional Perfection Scale; Frost et al. (1990); α .88; maladaptive (13 items) / adaptive (7 items)

•How would you score your fluency during the last week?

•How often did you change words during the last week when you thought you might be stuck,

talking… with your friends, with your teacher/boss, and at the telephone?Subjective stutter severity

•I doubt that I'm as smart as my peers (school competence)

•I am easily liked (social acceptance)

•I think I'm not good at sports (athletic competence)

•I am satisfied with how I look (physical appearance)

•I often do things knowing that I'm not following the rules (behavioral conduct)

•I can keep a friendship for long time (close friendship)

•I am often disappointed in myself (global self-esteem)

Self-esteem

•I find it very easy to look at my audience while speaking in group.

•I find it hard to make talk when I meet new peopleNegative communication attitudes

•Do you think your stuttering affects that people want to be friends with you?

•If you can, do you keep your stuttering secret to others?Stigmatization and introversion about stuttering

•If I fail at school or at work, I'm a failure as a person (maladaptive)

•I set higher goals for myself than most people (adaptive)

Perfectionism

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Method• Procedure

- Year of study: 2007-2008- Speech therapists and centers that work on

stuttering in Flanders • Go-between

- ‘Stotterforum’ • former stutter association (BSV)

- Control group:• College (Herentals): 1st, 2d and 6th grade ASO• Mouth to mouth: post-graduates (19-20y)

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Results• Preliminary analyses

- No effect of SES and age group- Gender does matter

Boys Girls

Stutter severity 2,08 2,82

Athletic competence 3,55 2,97

Fysical appearance 3,77 3,27 

Global self-esteem 4,01 3,45 

Negative communication attitudes 2,52 2,89

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Results

Stutter

severity

Social acceptance, School competence,

Close friendship, Global self-esteem

• (Subjective) stutter severity and self-esteem

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Results• Mediation processes

+ −

+ −

Stutter Severity Social acceptance

School competence

Global self-esteem

Negative communication attitudes

Maladaptive perfectionisme

Close friendship

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Discussion

• Conclusions- In comparison to young children, we do see an influence of

stuttering on self-esteem in adolescence• Hypothesis Green: more negative experiences? => negative CA: Stuttering has an impact on self-esteem because AWS experience(d) communication situations as negative• Importance of domain specific self-esteem• Maladaptive perfectionism: Stuttering has een impact on self-

esteem because AWS more often are concerned about making mistakes and doubt their actions

- Other mediators:• Stigma / closeness:

• Experienced stigma independent of stutter severity• Effect of stuttering on closeness (cfr. Santrock, 2001)

• Adaptive perfectionism: higher standards in AWS? • Self-protective mechanism??

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Discussion

• Conclusions- Theory: Importance of internal stutter behavior

• Self-concept ‘stutterer’• Emotional and cognitive processes

- Therapy: Challenging negative communication attitudes and perfectionistic thoughts

• More effect on self-esteem (Quality of life) stutter severity• cognitive behavioural therapy + traditional stutter

modification therapy (Amster & Klein, 2007; Blomgren et al., 2005)

=> Reduces stuttering, a perfectionistic attitude and negative attitudes

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Discussion• Future research

- Objective vs subjective stutter severity- Longitudinal research

• Complex bidirectional relations

- Mediators• Temperament: a sensitive temperament contributes to a

vulnerability to the development of stuttering (Guitar, 2006)

• Self-protective mechanisms?• Social mediators: peer group status and teacher-student

relation => Creating an ‘open’ class environment!

(Publication: under construction)

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Stefanie

Introduction

Master thesis

Phd

Future

Stuttering…more than words

29

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Added value

- Objective vs subjective stutter severity- Longitudinal research

• Complex bidirectional relations

- Mediators:• Temperament: a sensitive temperament contributes to a

vulnerability to the development of stuttering (Guitar, 2006)

• Self-protective mechanisms?• Social mediators: peer group status and teacher-student

relation => Creating an ‘open’ class environment!

Contingent self-esteem:

• Depending on reaching certain conditions, outcomes and performances (Kernis, 2002)

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Temperament• Guitar (2006) a sensitive temperament

contributes to a vulnerability to the development of stuttering.

• Karass et al (2006): emotional temperament in young stutterers develops after their experiences with stuttering and negative social feedback.- ‘Chicken or the egg’ problem

• Temperamental character traits more present in stuttering children (Boey, 2012)

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-

+ - + - + +

+ -

Stutter Severity Self-esteem

Negative communication attitudes

Maladaptive perfectionism

Adaptive perfectionism

Temperament

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Social mediators• More likely to be bullied

- Adolescence => greater emphasis on relationships with peers• Negative stereotypes

- Difficulties to adapt, shy, nervous,…- Teachers’ attitudes towards stuttering

• Less important problem, misinformed and stereotypical views, no diff according to experience, (e.g. Abdalla et al, 2012; Pachigar et al, 2012; Lass et al., 1992)

• Increased awareness/knowledge of stuttering leads to a more desirable attitude towards stuttering (Crowe and Walton, 1981)

• Limited research on impact of stuttering on teacher-student relationship- Surprising given the crucial role of the teacher in care policy +

increasing emphasis on action-oriented work (HGW)• A supporting T-S relationship can act as a buffer (Baker, 1998; Werner &

Smith, 1989)

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-

- + - + +

Stutter Severity Self-esteem

Peer group status

Teachers attitudes / knowledge on/of

stuttering

Teacher-student relationship

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Method• Procedure / Respondents

- Longitudinal study: feb2013 - april2015• 5 measurement points

- +/- every 6 months- Questionnaire + obj SE

• AWS 60 and 60 controls (minimum goal)

- School variables (‘Future’)• Mediation process:

- 1 measure: 2 teachers + classmates => 60 AWS- School year 2013-2014

• Qualitative study - Interviews => selection 60 AWS

• Exploratory quantitative study - Questionnaire => teachers secondary education

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Method - measures

Objective stutter severity

SSI (_3)

TvS-L

Stutter Severity Instrument; Riley (1980; 1994) IRR = 0.84.

Test voor Stotterernst-Lezers; Boey (2007)

=> Based on video records

Contingent self-esteem CZWConditionele zelfwaarde meting; Verschueren; 19 items, α=.93

Temperament EATQ

Early Adolescent Temperament Questionnaire;  Capaldi & Rothbart (1992); 4 higher order scales: Negative affect/frustration (7i), Positive reactivity (15i), Effortful control (15i), Affiliation (12i), α>.67.

• Other measures cfr. master thesis: subjective stutter severity, (multi dimensional) self-esteem, negative communication attitudes, perfectionism

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•If I do poorly at school, i feel bad about myself

•If others like me, I feel more positive about myself

Contingent self-esteem

•I get very upset, when I want to do something and my mom or dad says no (neg affect)

•I feel at ease, when I meet other people (pos reactivity)

•If I try to keep my focus on my schoolwork, I am easily distracted by sounds around me

(effortful control)

•When I like someone, I will do almost anything to help him or her (Affiliation)

Temperament

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Measurement 1• Timing: February 15 - April 15, 2013• 64 initial participants

- E.g. not right age, did not registered themselves, failed to reach

• 40 AWS & 13 control group- control group through participants- 11-18 years (M = 14.17) ‘secondary education’- 80.9% (lower) middle SES - AWS: 65% male / control: 46.2% male- 19 in therapy; 13 in past; 4 FU en 3 never

• Internal mediation processes

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-

+ - + - + +

+ -

Stutter Severity Self-esteem

Negative communication attitudes

Maladaptive perfectionism

Adaptive perfectionism

Temperament

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Results• Preliminary analyses

- AWS control group• Subjective stutter severity• Neg CA: 3,04 2,31(p<.01)• Neg affect / frustration: 3,21 2,65 (p<.05)

- Background variables: • SES: Physical appearance & global self-esteem (High)• Age: Close friendship (older), affiliation (younger)• Therapy: maladaptive perfectionism (not in therapy),

effortful control (in therapy)- Adaptive perfectionism?!

• Gender: athletic competence (Boys)- Not significant, but comparable differences master thesis,

with exception of physical appearance

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Results• (Subjective) stutter severity and self-esteem

MT M1 (phd)

Social acceptance -.31** -.21

School competence -.26** -.20

Athletic competence .06 .03

Fysical appearance .01 .03

Behavioral conduct -.05 -.07

Close friendship -.26** -.19

Global self-esteem -.23* -.27

• Contingent SE: not significant (.10)

• AWS: School competence -.27 and Global SE -.24

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Results• Mediation processes

Neg CA: .68**

Keep track of

• (mal+

)adaptive- perfectionism

• Pos reactivity-

• Effortful control-

Neg CA:

• School competence

• Social acceptance

• Global SE

Effect of stutter severity decreases sharply

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• Although not statistically significant, we see substantially similar trends in comparison with results master thesis:- Importance emotional and cognitive processes

• Self-concept stutterer?• Hypothesis Green

- Importance of negative communication attitudes• Perfectionism:

- So far, we found no clear support for significance of maladaptive perfectionism conform master thesis

- But: keep track of potential structural difference AWS control

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Stefanie

Introduction

Master thesis

Phd

Future

Stuttering…more than words

45

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Longitudinal study- Feb2013 - april2015- 5 measurement points (+/-every 6 months)

• M1: compare results with objective stutter severity measures

• M2: oct – nov 2013 • M3: march – april 2014

- confounding/moderating variables mediators SE, e.g. home climat

- AWS 60 and 60 controls (minimum goal)• Ongoing registrations!• Dutch speaking• 11 – 21 years• +/- 1h work every 6 months (questionnaire + recording)• http://www.onderzoekstotteren.be

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School study- Mediation process

• peer-group status & teacher-student relation (controlled for their attitudes on stuttering)

• 1 measure: 2 teachers + classmates => AWS• School year 2013-2014

- Qualitative study • ‘In depth-study’ of teacher-student relation stuttering• Interviews => selection of teachers AWS

- Quantitative study • ‘Exploratory large scale study’ of teachers knowledge and attitudes

towards stuttering • Questionnaire => teachers secondary education

- Measures(?): • Peer group status -> socio metric measure• Teacher-student relation -> STRS (Pianti, 2001)• Teacher attitudes towards stuttering: TATS (Crowe & Walton, 1986), TPSI

(Yeakle & Cooper, 1986)

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“If we go to therapy, we think about it. If we don't go to therapy, we think about it. It's always there. Either it defines us or we find ways of accommodating it, working toward a state of peaceful coexistence.” (Dan Slater, The Washington Post, 20th December 2010).

Thank you!

Stefanie.adriaensens@ua.ac.bewww.onderzoekstotteren.bewww.facebook.com/onderzoekstotteren

stottercafeantwerpen@gmail.com