Caregiver Predictions of Their 3- to 6-Year-Old Child Who Stutters' Communication Attitude

Abstract

Purpose:

Caregivers share critical insight during their child's stuttering evaluation; yet, there have been no empirical studies evaluating whether caregivers provide similar accounts of their 3- to 6-year-old child's communication attitude compared to their child's self-report. This study examined caregiver- and child-reported communication attitude and assessed potential moderators of more comparable caregiver and child ratings (i.e., caregiver confidence, caregiver–child conflict, observer-rated stuttering severity).

Method:

One hundred thirteen children who stutter ages 3 through 6 years and a primary caregiver were recruited from clinical settings across the United States. Children completed the Communication Attitude Test for Preschool and Kindergarten Children Who Stutter (KiddyCAT) and three speaking samples, which were recorded to assess observer-rated stuttering severity using the Stuttering Severity Instrument–Fourth Edition. Caregivers predicted their child's communication attitude (C-KiddyCAT) and provided a confidence rating for their prediction. Caregivers also rated caregiver–child conflict using the Child–Parent Relationship Scale–Short Form (CPRS-SF). Multiple regression was used to (a) evaluate whether caregiver C-KiddyCAT scores predicted child KiddyCAT scores and (b) assess potential moderators of the relationship between C-KiddyCAT and KiddyCAT scores.

Results:

Caregiver ratings of their child's communication attitude (C-KiddyCAT) predicted child communication attitude ratings (KiddyCAT). A significant interaction between caregiver–child conflict (CPRS-SF) and caregiver ratings of their child's communication attitude (C-KiddyCAT) suggested caregiver–child conflict changed the underlying relationship between C-KiddyCAT and KiddyCAT scores, such that low conflict resulted in more similar C-KiddyCAT and KiddyCAT scores. Neither caregiver confidence nor observer-rated stuttering severity influenced the relationship between C-KiddyCAT and KiddyCAT scores.

Conclusions:

Although many caregivers predicted communication attitude ratings that closely aligned with their child's report, some caregiver–child dyads provided divergent ratings. Clinicians should interpret caregiver predictions of their child's communication attitude within the context of their full evaluation and the caregiver–child relationship. Assessing both self-reported communication attitude and caregiver predictions of their child's communication attitude provides a meaningful starting point to counseling caregivers about cognitive components of stuttering for preschool- and kindergarten-age children who stutter.

Children near the onset and early development of stuttering are at risk for both negative communication attitudes and acute adverse reactions to stuttering during communication exchanges (Lowe et al., 2021; Vanryckeghem et al., 2015). Between the ages of 3 and 6 years, children who stutter report more negative attitudes toward their overall communication compared to their peers who do not stutter ¹ (Aydin Oral et al., 2022; Bernardini et al., 2009; Brce & Vanryckeghem, 2017; Clark et al., 2012; Vanryckeghem & Brutten, 2007; Vanryckeghem et al., 2005; Walsh et al., 2019; Węsierska & Vanryckeghem, 2015). Caregivers ² across cultural and linguistic backgrounds describe their children as aware of and negatively impacted by moments of stuttering as young as ages 2 and 3 years (56.8% and 66.9%–70%, respectively; Boey et al., 2009; Kikuchi et al., 2021; see also Ambrose & Yairi, 1994; Ezrati-Vinacour et al., 2001). Caregivers have also reported concerns about how their own stress, emotions, and negative reactions to their child's stuttering may be impacting their child's own attitude as well as their relationship with their child (Druker et al., 2019; Humeniuk & Tarkowski, 2016; Langevin et al., 2010; Salehpoor et al., 2020). Relatedly, when asked to reflect on their stuttering as a young child, older children share they were aware of their stuttering's impact on their family and their family's worry regarding later school and vocational success (Yandeau et al., 2022).

Although studies specific to preschool- and kindergarten-age children who stutter have either (a) assessed children's negative attitudes toward their communication (e.g., Vanryckeghem et al., 2005) or (b) investigated caregiver reports of their child's reactions to stuttering (e.g., Guttormsen et al., 2021), to date, no study has measured child and caregiver reports simultaneously to evaluate whether caregivers and young children provide similar accounts of the child's communication attitude. Caregivers of older school-age children who do and do not stutter provide inaccurate estimates of their communication attitudes and general quality of life (Berman et al., 2016; Guttormsen et al., 2015); however, it has yet to be determined whether caregivers of younger preschool- and kindergarten-age children who stutter are also likely to provide inaccurate estimates of their child's attitudes and what variables may affect the relationship between caregiver and child communication attitude ratings.

The paucity of data regarding caregiver estimates of preschool- and kindergarten-age children's communication attitudes is problematic, as current best practices recommend speech-language pathologists (SLPs) not only ask caregivers about the potential cognitive or emotional impact of stuttering on their child but also, in some cases, consider this perceived impact when determining whether to recommend or delay treatment for early childhood stuttering (American Speech-Language-Hearing Association [ASHA], n.d.-a; Bernstein Ratner, 2018; Brundage et al., 2021; Yaruss et al., 2006). Though SLPs should also consider the child's direct report of their communication attitude, there is little evidence regarding whether caregivers estimate their child's communication attitude similarly to their child's report and minimal guidance for what SLPs should do if caregivers and children provide inconsistent reports. Thus, the purpose of the present study was to investigate caregiver predictions of the reported cognitive aspects of stuttering near onset to inform critical decision making during clinical practice.

Communication Attitude

Communication attitude is both an awareness and evaluation of one's communication (Clark et al., 2012; Vanryckeghem & Brutten, 2007; Vanryckeghem et al., 2005). The KiddyCAT (Vanryckeghem & Brutten, 2007) is the only standardized self-report scale measuring children's cognitive reactions to communication, or speech-associated attitude, in children under 7 years of age. The KiddyCAT often demonstrates statistically significant differences between children who do and do not stutter, with more negative communication attitudes reported by groups of young children who stutter compared to peers who do not stutter across cultural and linguistic contexts (Aydin Oral et al., 2022; Bernardini et al., 2009; Brce & Vanryckeghem, 2017; Clark et al., 2012; Węsierska & Vanryckeghem, 2015) and yields good test–retest reliability for children who stutter (Vanryckghem et al., 2015). Though there are noted group differences, there is also individual variability within groups with children who do and do not stutter reporting both positive and negative communication attitudes.

Presently, we do not know which preschool- and kindergarten-age children who stutter are more likely to report a negative communication attitude. The few studies evaluating potential relationships between a child's communication attitude and standard diagnostic features provide insufficient evidence that these features are correlated with or predict a child's negative communication attitude (i.e., age, time since onset of stuttering, observer-rated stuttering severity; Brundage et al., 2021; Clark et al., 2012; Groner et al., 2016; Millager et al., 2023; Vanryckeghem et al., 2005; Winters & Byrd, 2021). Some studies, however, note differences in communication attitudes reported by young children who stutter are related to differences in caregiver reports. For example, Groner et al. (2016) observed an association between children who reported more negative communication attitudes and caregivers who perceived their children to stutter with greater severity.

More recently, Millager et al. (2023) differentiated two clusters of preschool-age children who stutter. One cluster was composed of children (n = 33) who, when compared to the second cluster, reported more negative communication attitudes on the KiddyCAT and whose caregivers observed their child to have more secondary behaviors and perceived speaking frustration and avoidance on the Disfluency-Related Consequences Rating Scale of the Test of Childhood Stuttering (TOCS; Gillam et al., 2009). The second cluster was composed of children (n = 53) who, when compared to the first cluster, reported more positive communication attitudes on the KiddyCAT and whose caregivers noted fewer secondary behaviors and less perceived frustration and avoidance on the TOCS. Taken together, these studies suggest caregivers are aware of the child's cognitive and behavioral reactions to stuttering in addition to their child's stuttering severity. It has yet to be established if caregiver perceptions of their child's stuttering severity or presence of secondary behaviors have any relationship to how caregivers estimate or perceive their child's internal attitudes about their communication. Additional research exploring caregiver estimates of their young child's communication attitude and how stuttering severity (e.g., presence of secondary behaviors) may be related to these predictions is needed.

Caregiver Predictions

Caregivers not only observe their child stuttering but may also observe nonverbal signs (e.g., child covering their mouth) and overt statements (e.g., “I can't talk”) indicating that their young child who stutters is aware of and negatively impacted by their stuttering (Boey et al., 2009). Despite these initial empirical findings and clinical recommendations to ask caregivers about their child's potential awareness and the negative impact of stuttering (e.g., Brundage et al., 2021), relatively little research to date has investigated the accuracy of caregiver estimates of their child's internal thoughts or attitudes toward stuttering and communication (see Guttormsen et al., 2015, for a meta-analytic review).

Children Who Stutter Ages 6 Years and Older

Two studies have evaluated the extent to which caregiver estimates align with their school-age children's attitudes toward stuttering. Vanryckeghem (1995) administered a Dutch version of the Communicative Attitude Test (CAT) to 55 children who stutter ages 6–13 years, 55 age-matched peers who do not stutter, and their caregivers. Caregivers of children who stutter estimated their child to have more negative communication attitudes (i.e., higher CAT scores) compared to their child's self-report (i.e., self-reports were characterized by lower CAT scores). By comparison, caregivers of children who do not stutter perceived their child's communication attitude as significantly more positive than their child did (i.e., lower CAT scores). For caregivers of children who stutter, this overestimation of their child's negative communication attitude may have been due, in part, to the caregivers' own negative reactions to or attitudes toward their child's stuttering.

This interpretation is consistent with a more recent study by Rocha et al. (2020), where 50 children who stutter ages 7–12 years and their caregivers in Portugal completed the Overall Assessment of the Speaker's Experience of Stuttering (OASES; Yaruss & Quesal, 2008). In this study, some caregivers overestimated adverse impact specific to their child's reactions to stuttering and quality of life (i.e., caregivers predicted greater or more adverse subscores for Reactions to Stuttering and Quality of Life sections of the OASES).

Notably, both the CAT and OASES include individual items that reference communication experiences that may occur without a caregiver present (e.g., at school), meaning caregiver predictions may be based on what their child may have shared with them, feedback from teachers or from other communication partners outside the child's home, and/or the caregivers' general thoughts and feelings about their child's stuttering. In contrast, items on the KiddyCAT are intended for younger children (ages 3–6 years) and thus may be most applicable to communication with family or in a home setting. As a result, caregiver predictions for this age range may be more accurate compared to predictions for older children because (a) more or most of the child's communication exchanges take place with caregivers and (b) young children are distinct in that they tend to view their abilities through the eyes of their caregivers (Felson & Reed, 1986; Frome & Eccles, 1998; Huang et al., 2018; McAdams et al., 2017; Pomerantz et al., 2009).

Children Who Stutter Under 6 Years of Age

Guttormsen et al. (2021) evaluated 38 caregivers' perceptions of their 2- to 5-year-old children's overall impact of stuttering in Norway using the OASES for Caregivers (Parents and Kindergarten Teachers), a modified version of the OASES (OASES-C). Caregiver impact ratings ranged from 1.00 to 3.91 on a scale from 1 (mild impact) to 5 (severe impact), with higher mean impact ratings and higher maximum impact ratings for sections evaluating parent perception of the child's knowledge about stuttering and emotional, behavioral, and cognitive reactions to stuttering. According to the authors, the caregivers' average confidence rating suggested that they were “certain” in their assessments.

Guttormsen et al. (2021) acknowledged limitations of this study including the absence of children's self-reports to evaluate caregiver–child alignment in overall impact. Additionally, caregivers noted their responses were informed, in part, by their child's young age and the fact that they had not discussed stuttering with their child due to the concern their child was either unaware or would experience a negative impact if they talked to them about stuttering. Therefore, although caregivers were confident or certain in their predictions, their estimates on the OASES-C may have been informed by their relationship with their child or by observed stuttering severity; as such, these predictions may or may not have accurately reflected the child's own perspective.

To date, no study has compared young children's (ages 3 through 6 years) self-reported attitudes to that of their caregivers' estimates. However, for young children who stutter in the United States, there is a precedent that caregiver estimates of other stuttering characteristics are related to children's self-reported communication attitudes (i.e., stuttering severity, Groner et al., 2016; secondary behaviors and perceived frustration, Millager et al., 2023). In addition, both pediatricians and SLPs consider caregiver estimates of the cognitive and emotional components of stuttering when recommending early intervention (e.g., Bernstein Ratner, 2018; Brundage et al., 2021; Winters & Byrd, 2020). Therefore, additional research is warranted regarding whether caregivers of young children who stutter estimate or predict their child's communication attitude and the potential influences that may increase how well caregiver estimates align with their child's self-report.

Potential Influences on Caregivers' Predictions

Caregiver Confidence and Accuracy

Though caregivers are often accurate in reporting concerns about their child's development when their child also presents with a developmental disability (e.g., Barbaro et al., 2011; Glascoe, 1997), there is a distinction between caregivers who accurately report behaviors associated with a clinical diagnosis (e.g., Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for autism [Coulter et al., 2021] and percent syllables stuttered and parent-reported stuttering severity [Onslow et al., 2018]) and caregivers who are inaccurate in identifying internal thoughts or attitudes characteristic of a diagnosis (e.g., under/overestimating acute stress disorder [Kassam-Adams et al., 2009], underestimating worry and anxiety [Lagattuta et al., 2012], and overestimating negative communication attitude in school-age children who stutter [Vanryckeghem, 1995]). In the latter scenario, caregivers may be confident in their prediction even if their prediction is incorrect. For example, caregivers who are confident in their perception of their autistic child's interpersonal efficacy ³ are also inaccurate compared to their child's self-perceptions (Locke & Mitchell, 2016).

Emerging research suggests caregivers are “certain” in their perception of stuttering's adverse impact on their young child (Guttormsen et al., 2021); however, we do not know whether caregivers who are certain in their estimates also provide estimates similar to their child's self-report. This distinction is critical given the significant role caregivers play in the assessment and intervention for young children who stutter. A caregiver who is confident their child is unaware of and not negatively impacted by stuttering may result in delayed intervention to facilitate stuttering education and more positive communication attitudes for a child with a negative communication attitude. Similarly, a caregiver who believes their child is aware of and negatively impacted by their stuttering but who is not confident in their prediction may be less likely to share this with a pediatrician or SLP, which may also result in delayed intervention (e.g., Winters & Byrd, 2020). Alternatively, perhaps a caregiver who is both confident in their prediction and provides a similar rating of their child's communication attitude as their child reports may be more likely to seek early intervention for their child who stutters.

Caregiver–Child Conflict

Caregiver–child conflict can be defined as commonly occurring interactions where both the caregiver and child engage in negative thoughts and behaviors (Driscoll & Pianta, 2011; Pianta, 1992; Weaver et al., 2015). All caregiver–child dyads experience conflict, and high conflict has been linked to childhood internalizing and externalizing behaviors, including childhood attention-deficit/hyperactivity disorder, depression, and conduct disorders (e.g., Burt et al., 2003; Weaver et al., 2015). More frequent caregiver–child conflict is also correlated with children's poorer psychological and social outcomes and decreased caregiver understanding of their child's psychosocial outcomes (e.g., De Los Reyes et al., 2012; Tillery et al., 2019).

To the authors' knowledge, caregiver–child conflict has not been investigated within the context of early childhood stuttering directly. However, we know caregivers report moderate-to-high stress when seeking treatment for their young child who stutters (Park et al., 2021). Caregivers also report concerns regarding their own negative reactions to stuttering having an adverse impact on their relationship with their child (Druker et al., 2019; Langevin et al., 2010; Mehdizadeh Behtash et al., 2022). These findings coupled with caregiver perceptions of their child's negative reactions (e.g., anger, emotional reactivity, decreased ability to regulate their emotions; Eggers et al., 2010; Karrass et al., 2006) suggest caregiver–child conflict may affect caregiver predictions of their child's communication attitude and/or children's self-reported communication attitude.

Observer-Rated Stuttering Severity

Although there is inconsistent evidence that observer-rated stuttering severity is associated with children's reported communication attitudes (Millager et al., 2023; Vanryckeghem et al., 2005; Winters & Byrd, 2021), stuttering severity is related to caregiver estimates of their child's communication attitude (Groner et al., 2016; Tumanova et al., 2014). Therefore, caregivers may overestimate how negatively their children feel about their communication when the child also presents with more severe stuttering. This is consistent not only with related research suggesting greater observer-rated stuttering severity is associated with more negative attitudes toward and greater perceived adverse impact for individuals who stutter (e.g., Çaglayan & Özdemir, 2022; Gabel, 2006) but also with research suggesting caregivers provide similar estimates of stuttering severity compared to clinicians (Einarsdóttir & Ingham, 2009; Onslow et al., 2018).

The Present Study

The purpose of the present study was to (a) assess whether caregivers of young children who stutter, ages 3 through 6 years, predict their child's reported communication attitude and (b) evaluate whether the relationship between caregiver estimates of their child's communication attitude and the child's reported communication attitude is moderated by caregiver confidence, caregiver–child conflict, or observer-rated stuttering severity. Thus, the present study sought to answer the following research questions:

• (1)  Do caregivers of young children who stutter (ages 3–6 years) accurately predict their child's communication attitude?

• (2A)  Is the relationship between caregiver estimates of their young child who stutters' (ages 3–6 years) communication attitude and the child's reported communication attitude moderated by caregiver confidence in their prediction?

• (2B)  Is the relationship between caregiver estimates of their young child who stutters' (ages 3–6 years) communication attitude and the child's reported communication attitude moderated by caregiver–child conflict?

• (2C)  Is the relationship between caregiver estimates of their young child who stutters' (ages 3–6 years) communication attitude and the child's reported communication attitude moderated by observer-rated stuttering severity?

Method

This study was conducted during the COVID-19 pandemic when face-to-face human subjects research was suspended; this virtual method was approved by the authors' institutional review board.

Participants

One hundred thirteen dyads of children who stutter and a primary caregiver living in the United States participated in this study (N = 226 total participants). Children (n = 113) were between ages 3 years 0 months and 6 years 11 months (M_age = 4.98 years, SD = 1.12) and represented diverse backgrounds with respect to race, ethnicity, and socioeconomic status (see Table 1 for child demographics). English was the primary language reported for all children, though some caregivers reported their child was exposed to additional languages including Spanish (18 or 15.92%), Mandarin (4 or 3.53%), French (3 or 2.65%), Vietnamese (2 or 1.77%), Arabic (2 or 1.77%), Persian (1 or 0.9%), Korean (1 or 0.9%), Urdu (1 or 0.9%), and Nepali (1 or 0.9%). Per caregiver report, 31 of these 33 children had low proficiency in their non-English language (e.g., understood and/or used a couple of words) and were exposed either by family members at home or through new admission to an immersion program at school, where students receive 50% instruction in English and 50% in a non-English language. Two of the 33 children were reported to be highly proficient, one in Arabic (rated 9/10) and one in Korean (rated 8/10).

Table 1.

Demographics for children who stutter (N = 113).

Demographic variable	n (%)
Age (years)
3	21 (18.6)
4	34 (30.1)
5	31 (27.4)
6	27 (23.9)
Age range in years	3.0–6.92
Mean age in years (SD)	4.98 (1.1)
Gender
Male	82 (72.6)
Female	30 (26.5)
Prefer to self-describe	1 (0.9)
Race
White	63 (55.7)
Black or African American	20 (17.7)
American Indian or Alaska Native	2 (1.8)
Asian	7 (6.2)
Two or more	3 (2.7)
Did not report	18 (15.9)
Ethnicity
Hispanic or Latino	16 (14.2)
Not Hispanic or Latino	80 (70.8)
Did not report	17 (15)
Socioeconomic status
SNAP eligible	6 (5.3)
Medicaid	12 (10.3)
Free lunch	12 (10.3)
Reduced lunch	10 (8.8)

Note. SNAP = Supplemental Nutrition Assistance Program.

Forty-eight children had a family history of stuttering (41.48%). Eighty-two children were male (72.6%), which is consistent with proposed male-to-female ratios for childhood stuttering (Yairi & Ambrose, 2013). Caregivers reported their children had been stuttering for less than 1 month to 5.67 years (mean time since onset = 1.90 years, SD = 1.17). Sixty-one children had not participated in any previous speech or language evaluation or intervention (54% of total sample). Of the remaining 52 children, 36 reportedly participated in a nominal number of intervention sessions with a focus on facilitating fluency, where caregivers reported that the child's communication attitude was neither evaluated nor discussed with them or their child (31.9% of total sample).

Caregiver demographics are reported in Table 2. Caregivers ranged in age from 23 to 55 years (M_age = 38.11 years, SD = 5.39). Ninety-nine (87.61%) caregivers were mothers. Caregivers reported completing an average of 17.41 years of education (range: 12–24, SD = 2.71), ranging from a high school diploma or General Educational Diploma equivalent to a doctorate degree. Most caregivers were married (95 or 84.07%), though some reported being a single parent (10 or 8.85%), divorced or separated (3 or 2.65%), or in a domestic partnership (2 or 1.77%).

Table 2.

Caregiver demographics (N = 113).

Demographic variable	n (%)
Relationship to child
Mother	99 (87.61)
Father	14 (12.39)
Age
Range in years	23–55
Mean age in years (SD)	38.11 (5.39)
Did not report	7 (6.20)
Total years of education
Range in years	12–24
Mean total in years (SD)	17.41 (2.71)
Did not report	5 (4.42)
Highest degree obtained
High school diploma or GED	9 (7.96)
Associate's or certificate	3 (2.65)
Bachelor's	36 (31.86)
Master's	34 (30.10)
Doctorate	21 (18.58)
Did not report	10 (8.85)
Marital status
Single parent	10 (8.85)
Parents are married	95 (84.07)
Parents are divorced or separated	3 (2.65)
Parents are in domestic partnership	2 (1.77)
Did not report	3 (2.65)

Note. GED = General Educational Diploma.

Recruitment

Children who stutter and their caregivers seeking an evaluation or intervention for stuttering were recruited via a waiting list for services provided at the second author's university research institute and through clinical referrals from SLPs across the United States. Referring providers were full-time SLPs practicing in public and charter school settings as well as outpatient settings in urban areas serving historically minoritized populations. All children who stutter and their caregivers were invited to participate in the present study as part of a comprehensive, virtual stuttering evaluation.

Families were offered $30 for their time and participation. Additional incentives for participation included a one-page summary of the child's performance and a 30- to 45-min feedback session for caregivers via Zoom with two SLPs to discuss the results of the evaluation and intervention recommendations. Children who stutter and their caregivers were invited to participate in an intervention study at no cost; participants were also provided free, professional consultation for a child's community SLP (i.e., practicing in a school, private practice, or other setting) to assist in making recommendations, writing treatment goals, and planning treatment activities. Finally, families were also invited to participate in weekly Zoom calls offered to the community to ask questions about stuttering with a certified SLP.

In total, 129 families were invited to participate, and 113 completed the present study (87.6%). Of the families who did not complete the present study, nine of 16 did not respond to two phone and e-mail invitations (56.3% of families who did not participate or 7% of total families invited), six of 16 scheduled an evaluation and later cancelled because caregivers no longer noticed the child stuttering and/or the child's pediatrician was not concerned (37.5% of families who did not participate or 4.5% of total families invited), and one of 16 withdrew during the study to pursue in-person services (6.2% of families who did not participate or 0.8% of total families invited).

Inclusionary Criteria

Children who (a) were between ages 3 years 0 months and 6 years 11 months, (b) spoke and understood English, (c) did not have a diagnosis of a developmental disorder that may account for differences in social cognition (e.g., autism spectrum disorder), and (d) had not previously participated in programming at the authors' affiliations were eligible to participate. Consistent with what is reported in other studies with young children (e.g., Gerwin et al., 2022; Glascoe, 1997; Oppenheimer et al., 2023; Walsh et al., 2023), children who stutter received a stuttering diagnosis based on the following criteria: (a) A primary caregiver reported the child stuttered by describing behaviors indicative of stuttering (i.e., repetitions, prolongations, and/or blocks), (b) a certified SLP with expertise in stuttering observed the quality and type of behaviors indicative of stuttering (i.e., sound/syllable repetitions, prolongations, and/or blocks), and (c) a primary caregiver reported the child received a diagnosis of stuttering prior to participation in the present study. Because some children who stutter present with co-occurring communication differences or disorders (i.e., 7%–46%; Blood et al., 2003; Unicomb et al., 2020), these children were not excluded from the present study.

Adults who (a) were a primary caregiver to a child included in this study and (b) used and understood oral and written English were eligible to participate. In addition to these individual inclusionary criteria for children and adults, families needed to live in the United States and have access to a device with internet connection.

Procedure

Telepractice Considerations

All participation took place virtually via a secure Health Insurance Portability and Accountability Act–compliant Zoom account that allowed for recording of participant sessions. Methods were piloted to ensure feasibility and followed all recommendations of ASHA related to privacy and security, client selection, practice area, licensure, and ethical considerations (ASHA, n.d.-b). Importantly, research prior to and during the COVID-19 pandemic documented the effectiveness of conducting clinical services and assessments specific to stuttering and young children who stutter, noting minimal or no differences in service between telehealth or face-to-face contexts (Aldukair & Ward, 2022; Ferdinands & Bridgman, 2019) and favorable telehealth experiences (Eslami Jahromi et al., 2022).

Child Protocol

First, children participated in a 5-min conversation with a caregiver, during which researcher and research assistant cameras and microphones were turned off. Caregivers were encouraged to ensure their child stayed within the Zoom video frame and to allow their child to do most of the talking. After the caregiver–child conversation, children engaged in a 5-min conversation with a researcher and completed the KiddyCAT (Vanryckeghem & Brutten, 2007). To evaluate if the order of administration influenced KiddyCAT scores, these two tasks and four additional tasks (not described in the present study) were presented in one of six possible administration orders. Finally, children completed a third speaking task: a narrative retell using the wordless picture book Frog, Where Are You? (Mayer, 1969). These three speaking tasks were used to analyze observer-rated stuttering severity via the Stuttering Severity Instrument–Fourth Edition (SSI-4; Riley, 2009).

Child Standardized Measures: KiddyCAT and SSI-4

The KiddyCAT (Vanryckeghem & Brutten, 2007) is a standardized self-report assessment designed to measure communication attitude in children ages 3 through 6 years. Following the administration procedures for the KiddyCAT⁴, children were instructed, “I will ask you what you think about your talking. If what I say about how you talk is true, you say yes. If what I say is not true, you say no.” Children responded to two practice items followed by 12 scored items. Items are balanced such that six items affirm a positive communication attitude (e.g., “Do you think that you talk right?”) and six affirm a negative communication attitude (e.g., “Do you think that talking is difficult?”). After the administration, the researcher summed the number of responses indicative of a negative communication attitude following the scoring key in the assessment manual. KiddyCAT scores range from 0 to 12, with higher scores indicative of more negative communication attitudes.

The KiddyCAT consistently demonstrates significant group differences between young children who stutter and who do not stutter (Bernardini et al., 2009; Clark et al., 2012; Vanryckeghem et al., 2005; Węsierska & Vanryckeghem, 2015). A categorical data principal components factor analysis extracted speech difficulty as the single factor represented in the measure (Clark et al., 2012). The KiddyCAT has demonstrated good test–retest reliability for children who stutter within 7–12 days of the first administration (r = .90; Vanryckeghem et al., 2015).

The SSI-4 (Riley, 2009) characterizes observed stuttering severity by frequency, duration, and presence of physical concomitants, resulting in a total score and percentile based on a sample of 72 young children who stutter. A certified SLP with specialization in stuttering and research assistants analyzed both conversation samples and a narrative retell sample for each child from video recordings. To maintain interrater reliability consistent with the stuttering literature for clinician and student ratings (Brundage et al., 2006; Davidow & Scott, 2017), research assistants participated in a 1-hr training and achieved an agreement of at least 80% for each stuttering characteristic (frequency, duration, physical concomitants) across at least two training samples prior to analyzing data for the present study. Across research assistants, interrater reliability (interclass correlation coefficient) ranges for 20% of the data for the present study were r = .93–.95 for stuttering frequency, r = .68–.94 for stuttering duration, and r = .82–.98 for physical concomitants.

Caregiver Protocol

Prior to the first session, caregivers completed permission and consent documentation, a case history for their child, and a caregiver survey via Qualtrics. The case history included demographic information and information specific to children who stutter, including the time and nature of the onset of stuttering. The caregiver survey included the following measures in a randomized order. During the first session, caregivers participated in the initial 5-min caregiver–child conversation sample. Caregivers were asked to step out of the room during the child protocol but remain nearby to assist with technical support, as needed.

Caregiver Adapted or Standardized Measures: C-KiddyCAT and Child–Parent Relationship Scale–Short Form

Caregivers completed a caregiver-adapted version of the KiddyCAT (abbreviated here as C-KiddyCAT). This assessment was adapted, piloted, and revised based on caregiver feedback (N = 20) for the present study. Each caregiver received the following instructions: “Below are 12 yes/no questions about your perception of your child's communication attitude. I want you to answer these questions as if you were your child. In other words, I am asking you to take your child's perspective and answer as they would, if asked the same questions.” Caregivers responded to the same 12 scored items as the original KiddyCAT with no wording changes. At the end of the assessment, caregivers rated their confidence in their answers from 1 to 5 (1 = not at all confident, 2 = slightly confident, 3 = somewhat confident, 4 = fairly confident, 5 = very confident). The number of responses indicative of a negative communication attitude was summed to determine a C-KiddyCAT score, representing the caregiver's perception of their child's communication attitude. Of note, caregivers completed the C-KiddyCAT within 7–12 days of their child's KiddyCAT administration (i.e., within the test–retest administration window yielding good reliability).

In addition to the C-KiddyCAT, caregivers completed the Child–Parent Relationship Scale–Short Form (CPRS-SF; Pianta, 1992). The CPRS-SF (Pianta, 1992) evaluates caregiver perception of their relationship with their child ages 3–12 years. Caregivers rate 15 items on a 5-point Likert scale, and ratings are summed for an eight-item subscale measuring conflict (i.e., “the degree to which a parent feels that his or her relationship with a particular child is characterized by negativity”; Driscoll & Pianta, 2011, p. 9) and a seven-item subscale measuring closeness (i.e., “the extent to which a parent feels that the relationship is characterized by warmth, affection, and open communication”; p. 10), where higher scores are indicative of greater conflict or closeness, respectively. The Conflicts subscale included items such as “My child and I always seem to be struggling with each other,” and the Closeness subscale included items such as “It is easy to be in tune with what my child is feeling” (Pianta, 1992).

Cronbach's alphas for the CPRS-SF derived from a sample of 714 children ages 4.5–5.5 years and their families were .83 (good) for the Conflicts subscale and .72 (acceptable) for the Closeness subscale (Pianta, 1992). Average scores were reported across parent–child dyads for two time points (child age 4.5 and 5.5 years), with mean closeness ratings ranging from 35.57 (closeness between fathers and sons at 4.5 years of age) to 38.22 (closeness between mothers and daughters at 5.5 years of age). Mean conflict ratings ranged from 14.02 (conflict between fathers and daughters at 5.5 years of age) to 16.36 (conflict between mothers and daughters at 4.5 years of age).

Data Analysis

Prior to answering our research questions, multiple linear regression was used to test for an effect of task administration order in the prediction of child KiddyCAT score. Independent variables included dummy variables representing six levels (i.e., six possible task administration orders).

For our research questions, an a priori power analysis sample size calculation for a medium effect with α set to .05 and power to .8 for a regression analysis predicting child-reported communication attitude with seven independent variables (described below) yielded a sample size of 103 caregiver–child dyads (total N = 113 dyads). We used this overarching regression methodology to answer our research questions about a shared dependent variable (i.e., child-reported communication attitude or KiddyCAT score). All data collected via Qualtrics were exported into Microsoft Excel for data cleaning; all statistical analyses were conducted in RStudio (RStudio Team, 2020).

Our analysis met all assumptions needed for multiple regression. Normality of model residuals, linear model fit, and heteroscedasticity were assessed visually in RStudio. Outliers were identified using Cook's distance, where any observation with a Cook's distance of more than 3 times the mean was considered a possible outlier, and visual inspection. Multicollinearity was assessed via the variance inflation factor (VIF) where independent variables with a VIF over 5 were removed from the model. Moderation analysis with a significant interaction was further described using a pick-a-point approach recommended by Aiken et al. (1991) to determine simple slopes at the mean and 1 SD above and below the mean for the moderator variable. The Johnson–Neyman technique (Bauer & Curran, 2005) was used to determine regions of significance for the impact of the moderator variable on the outcome variable. Unstandardized (b) and standardized (β) estimates are included in tables, and unstandardized estimates are included in text.

Research Question 1: Do Caregivers of Young Children Who Stutter (Ages 3–6 Years) Accurately Predict Their Child's Communication Attitude?

Multiple linear regression was used to determine whether caregiver C-KiddyCAT score predicted child KiddyCAT score. Independent variables in addition to caregiver C-KiddyCAT included caregiver confidence, child age, child gender (dichotomized as male or not male), and time since onset of stuttering.

Research Question 2A: Is the Relationship Between Caregiver Estimates of Their Young Child Who Stutters' (Ages 3–6 Years) Communication Attitude and the Child's Reported Communication Attitude Moderated by Caregiver Confidence in Their Prediction?

To investigate whether caregiver confidence moderated the relationship between C-KiddyCAT and KiddyCAT (i.e., whether the strength and direction of the relationship between C-KiddyCAT and KiddyCAT scores differ based on caregiver confidence), multiple linear regression was used with KiddyCAT as the outcome variable and C-KiddyCAT, caregiver confidence, child age, time since onset of stuttering, and an interaction between caregiver C-KiddyCAT and caregiver confidence as independent variables. We included an interaction between caregiver C-KiddyCAT and caregiver confidence because we hypothesized the relationship between C-KiddyCAT and KiddyCAT would vary based on caregiver confidence (e.g., the relationship between C-KiddyCAT and KiddyCAT scores may be stronger when caregivers also report greater confidence in their C-KiddyCAT responses). Gender was not included in this model to maintain statistical power after removing potential outliers, as KiddyCAT score reportedly does not vary by gender (e.g., Vanryckeghem et al., 2005) and did not vary in this study, t(56.5) = −1.67, p = .10.

Research Question 2B: Is the Relationship Between Caregiver Estimates of Their Young Child Who Stutters' (Ages 3–6 Years) Communication Attitude and the Child's Reported Communication Attitude Moderated by Caregiver–Child Conflict?

To assess whether caregiver–child conflict moderated the relationship between C-KiddyCAT and KiddyCAT (i.e., whether the strength and direction of the relationship between C-KiddyCAT and KiddyCAT scores differ based on caregiver–child conflict), multiple linear regression was used with KiddyCAT as the outcome variable and caregiver C-KiddyCAT, caregiver confidence, child age, child–caregiver closeness, child–caregiver conflict, stuttering severity, and an interaction between caregiver C-KiddyCAT and caregiver–child conflict as independent variables. We included an interaction between C-KiddyCAT and caregiver–child conflict because we hypothesized the relationship between C-KiddyCAT and KiddyCAT would vary based on reported conflict (see Langevin et al., 2010, for relationship consequences reported by caregivers of children who stutter). Note that stuttering severity was added as a predictor to this model given previous research associating caregiver reactions to their child's stuttering to the frequency of observed stuttering (e.g., Tumanova et al., 2014).

Research Question 2C: Is the Relationship Between Caregiver Estimates of Their Young Child Who Stutters' (Ages 3–6 Years) Communication Attitude and the Child's Reported Communication Attitude Moderated by Observer-Rated Stuttering Severity?

To test whether observer-rated stuttering severity moderated the relationship between C-KiddyCAT and KiddyCAT (i.e., whether the strength and direction of the relationship between C-KiddyCAT and KiddyCAT scores differ based on observer-rated stuttering severity), multiple linear regression was used with KiddyCAT as the outcome variable and caregiver C-KiddyCAT, caregiver confidence, child age, child–caregiver closeness, child–caregiver conflict, stuttering severity, and an interaction between caregiver C-KiddyCAT and stuttering severity as independent variables. We included an interaction between C-KiddyCAT and observer-rated stuttering severity because we hypothesized the relationship between C-KiddyCAT and KiddyCAT may vary when children present with more or less severe observer-rated stuttering severity, particularly within the context of caregivers accurately estimating observer-rated stuttering severity (e.g., Onslow et al., 2018) and previous research suggesting caregiver concern for their child is related to stuttering severity (Tumanova et al., 2014).

Results

Descriptive Statistics

Communication Attitude: KiddyCAT and C-KiddyCAT

Table 3 summarizes descriptive statistics for the KiddyCAT, C-KiddyCAT, and the normative data for the KiddyCAT. The KiddyCAT and caregiver-adapted C-KiddyCAT were scored between 0 and 12, with 0 representing the most positive communication attitude the scale can capture and 12 representing the most negative communication attitude the scale can capture. Children who stutter (N = 113) earned KiddyCAT scores ranging from 0 to 10 (M = 3.24, SD = 2.64). Caregiver C-KiddyCAT scores (N = 113) ranged from 0 to 10 (M = 3.65, SD = 2.82). Caregivers also completed a confidence rating on a 5-point Likert scale, with 1 representing not at all confident and 5 representing very confident. Confidence ratings ranged from 1 to 5 (M = 3.82, SD = 0.89), suggesting caregivers, as a group, were somewhat confident (3) to fairly confident (4) in their responses for the C-KiddyCAT.

Table 3.

Descriptive statistics for self-report measures.

Variable	M	SD	Minimum	Maximum
KiddyCAT
Normative sample (n = 45a)	4.36	2.78	0	10
Children in this study (n = 113)	3.24	2.64	0	10
C-KiddyCAT
Caregiver KiddyCAT score (n = 113)	3.56	2.82	0	10
Caregiver confidence rating (n = 113)	3.82	0.89	0	5
CPRS-SF
Normative sample (n = 563b)
Conflicts subscore	15.95	5.00	—	—
Closeness subscore	37.59	2.42	—	—
Caregivers in this study (n = 111)
Conflicts subscore	16.39	5.16	8	29
Closeness subscore	33.30	1.75	26	35

Note. KiddyCAT = Communication Attitude Test for Preschool and Kindergarten Children Who Stutter; C-KiddyCAT = Caregiver Communication Attitude Test for Preschool and Kindergarten Children Who Stutter (this study); CPRS-SF = Child–Parent Relationship Scale–Short Form.

^a Vanryckeghem and Brutten (2007).

^b Pianta (1992). Descriptive statistics are for mothers' ratings for their boys at age 54 months. Minimum and maximum values were not provided.

Twenty-five (22%) caregivers reported a confidence rating of 5, 53 (47%) caregivers reported a confidence rating of 4, 26 (23%) caregivers reported a confidence rating of 3, eight (7%) caregivers reported a confidence rating of 2, and only one (1%) caregiver reported a confidence rating of 1. Caregivers reporting confidence ratings of 5 (very confident) perceived their children to have a range of communication attitudes, earning C-KiddyCAT scores between 0 and 10. Their children also reported a variety of communication attitudes, earning KiddyCAT scores between 0 and 10. For these 25 caregiver–child dyads, 44% of children reported more negative communication attitudes (i.e., higher KiddyCAT scores) than their caregivers perceived, eight children reported more positive communication attitudes (i.e., lower KiddyCAT scores) than their caregivers perceived, and six caregiver–child dyads reported the same communication attitude (i.e., KiddyCAT and C-KiddyCAT scores were the same). The one caregiver who reported a confidence rating of 1 earned the same C-KiddyCAT score (1) as what their child reported on the KiddyCAT, suggesting both indicated the child had a relatively positive communication attitude.

Caregiver–Child Relationship: CPRS-SF

CPRS-SF scores were available for 111 of 113 participants. The CPRS-SF Conflicts subscores ranged from 8 to 29 (M = 16.39, SD = 5.16), and the CPRS-SF Closeness subscores ranged from 26 to 35 (M = 33.30, SD = 1.75). Cronbach's alpha coefficients were acceptable for CPRS-SF Conflicts (eight items, α = .79, 95% CI [.73, .84]) and questionable for CPRS-SF Closeness (seven items, α = .61, 95% CI [.51, .71]). Descriptively, the mean CPRS-SF Closeness subscore was lower than the averages reported in the normative sample (35.57–38.22 across parent–child dyads), and the mean CPRS-SF Conflicts subscore was higher than the averages reported in the normative sample (14.02–16.36 across parent–child dyads).

Observer-Rated Stuttering Severity: SSI-4

Descriptive statistics for stuttering characteristics and SSI-4 scores for all 113 children who stutter are reported in Table 4. As a group, children were observed to stutter with a frequency range from 0.64 to 39.93 percent stuttered syllables (%SS; M = 6.63, SD = 7.30) across all three speaking samples (i.e., caregiver–child conversation, researcher–child conversation, and narrative retell). This resulted in an average SSI-4 Frequency score of 9.84 (SD = 3.83, range: 4–18). Longest average stuttering duration ranged from less than 0.5 to 10.78 s (M = 2.73, SD = 2.09), resulting in an average SSI-4 Duration score of 7.56 (SD = 2.72, range: 2–14). Physical concomitants including distracting noises (e.g., noisy breathing, blowing), facial grimaces (e.g., tongue protruding, lip pressing), head movements (e.g., back and forward), and movements of the extremities (e.g., hand and arm movement) were rated separately. Descriptively, children who exhibited physical concomitants most often demonstrated facial grimaces. When present, head movements and movements of the extremities were rated as more noticeable or distracting compared to distracting sounds and facial grimaces. SSI-4 Physical Concomitants scores ranged from 0 to 13 (M = 2.5, SD = 2.92). These three subscores were summed to create an SSI-4 Total Score, which ranged from 6 (1st–4th percentile of a sample of 72 preschool-age children, considered to be “very mild”) to 39 (96th–99th percentile, considered to be “very severe”). The average SSI-4 Total Score was 19.90, considered to be “moderate” stuttering severity.

Table 4.

Descriptive statistics for stuttering characteristics and SSI-4 scores (N = 113).

Variable	M	SD	Minimum	Maximum
SSI-4 Frequency
Average %SS	6.63	7.30	0.64	39.93
Frequency score	9.84	3.83	4	18
SSI-4 Duration
Average longest duration	2.73	2.09	0a	10.78
Duration score	7.56	2.72	2	14
SSI-4 Physical Concomitants
Distracting sounds	0.63	1.08	0	3
Facial grimaces	1.14	1.41	0	5
Head movements	0.48	1.03	0	4
Movements of the extremities	0.26	0.80	0	4
Physical Concomitants score	2.50	2.92	0	13
Total score	19.90	9.90	6	39

Note. SSI-4 = Stuttering Severity Instrument–Fourth Edition (Riley, 2009); %SS = percent stuttered syllables (total stuttered syllables / total syllables spoken).

^aHere, 0 may indicate there were not three stuttering moments for which to calculate an average of the three longest stuttering moments.

Evaluating Potential Order Effect on KiddyCAT Scores

Multiple linear regression was used to evaluate if there was a significant effect of task order (1–6) in the prediction of KiddyCAT score for children who stutter. Results indicated no significant effect of task order, and the model was not significant, F(5, 106) = 0.39, p = .86.

Research Question 1: C-KiddyCAT Scores Predict KiddyCAT Scores

Multiple linear regression was used to determine the best predictor of child KiddyCAT score. Independent variables in the model included caregiver C-KiddyCAT score, caregiver confidence, child age, child gender (dichotomized as male or not male), and time since onset of stuttering. The overall model showed significant prediction of KiddyCAT score, F(5, 98) = 3.86, p < .01, with an R² of .16. The strongest and only statistically significant predictor of child KiddyCAT score was caregiver C-KiddyCAT score, b = 0.29, t(98) = 3.51, p < .01. See Table 5 for full regression results.

Table 5.

Multiple linear regression predicting child KiddyCAT.

Variable	b	β	SE	t	p
Caregiver KiddyCAT	0.29	0.34	0.08	3.51	.0007***
Caregiver KiddyCAT confidence	−0.43	−0.17	0.24	−1.78	.08
Child age (years)	−0.34	−0.17	0.24	−1.43	.16
Child gender (male)	0.26	0.05	0.48	0.54	.59
Time since onset (years)	0.19	0.09	0.25	0.76	.45

Note. KiddyCAT = Communication Attitude Test for Preschool and Kindergarten Children Who Stutter.

^***p < .001 (two-tailed).

Research Question 2A: Caregiver Confidence Does Not Moderate the Relationship Between C-KiddyCAT and KiddyCAT Scores

Multiple linear regression was used to examine if caregiver confidence moderated the relationship between C-KiddyCAT and KiddyCAT. The overall model showed a significant prediction of child KiddyCAT, F(5, 98) = 4.12, p < .01, with an R² of .17. The interaction between caregiver confidence and C-KiddyCAT was not significant, b = −0.10, t(98) = −1.16, p = .25. See Table 6 for full regression results.

Table 6.

Multiple linear regression predicting child KiddyCAT: Moderation by caregiver confidence.

Variable	b	β	SE	t	p
Caregiver KiddyCAT	0.71	0.84	0.37	1.94	.06
Caregiver KiddyCAT confidence	−0.09	−0.03	0.39	−0.22	.83
Child age (years)	−0.31	−0.15	0.24	−1.31	.19
Time since onset (years)	0.17	0.08	0.24	0.70	.48
Caregiver KiddyCAT × Confidence	−0.10	−0.52	0.09	−1.16	.23

Note. KiddyCAT = Communication Attitude Test for Preschool and Kindergarten Children Who Stutter.

Research Question 2B: Caregiver–Child Conflict Moderates the Relationship Between C-KiddyCAT and KiddyCAT Scores

Multiple linear regression was used to examine if levels of caregiver–child conflict (CPRS-SF Conflicts) changed the underlying relationship between C-KiddyCAT and KiddyCAT. Independent variables in the model included caregiver C-KiddyCAT, caregiver confidence, child age, caregiver–child closeness (CPRS-SF Closeness), caregiver–child conflict (CPRS-SF Conflicts), and an interaction between caregiver C-KiddyCAT and caregiver–child conflict (CPRS-SF Conflicts).

The overall model showed a significant prediction of child KiddyCAT, F(6, 104) = 3.44, p < .01, with an R² of .17 (see Table 7). The interaction between CPRS-SF Conflicts and C-KiddyCAT was significant, b = −0.04, t(104) = −2.72, p < .01. Decomposing the interaction of C-KiddyCAT and CPRS-SF Conflicts showed that as caregiver–child conflict increased, the slope of the effect of C-KiddyCAT on KiddyCAT decreased by −0.04. Using the pick-a-point approach recommended by Aiken et al. (1991), at 1 SD below the mean of CPRS-SF Conflicts (a value of 11.23), the simple slope of C-KiddyCAT on KiddyCAT was 0.47, t(104) = 4.08, p < .01, while at 1 SD above the mean of CPRS-SF Conflicts (a value of 21.55), the simple slope was 0.02, t(104) = 0.18, p = .86, as depicted by Figure 1. Applying the Johnson–Neyman technique (Bauer & Curran, 2005), the regions of significance for the impact of CPRS-SF Conflicts on KiddyCAT were determined to be outside the CPRS-SF Conflicts values of 17.88 and 40.04 (see Figure 2). Below CPRS-SF Conflicts of 17.88, the impact of C-KiddyCAT on KiddyCAT becomes negative and significant.

Table 7.

Multiple linear regression predicting child KiddyCAT: Moderation by caregiver–child conflict.

Variable	b	β	SE	t	p
Caregiver KiddyCAT	0.96	1.02	0.27	3.55	.0005***
Caregiver KiddyCAT confidence	−0.12	−0.04	0.29	−0.41	.68
Child age (years)	−0.15	−0.06	0.22	−0.68	.50
CPRS-SF Closeness	0.25	0.16	0.16	1.52	.13
CPRS-SF Conflicts	0.23	0.44	0.09	2.51	.01*
Caregiver KiddyCAT × CPRS-SF Conflicts	−0.04	−0.87	0.02	−2.72	.008**

Note. KiddyCAT = Communication Attitude Test for Preschool and Kindergarten Children Who Stutter; CPRS-SF = Child–Parent Relationship Scale–Short Form (Pianta, 1992).

^*p < .05.

^**p < .01.

^***p < .001 (two-tailed).

Figure 1.

Interaction of caregiver-reported conflict and caregiver KiddyCAT on KiddyCAT for children who stutter. KiddyCAT = Communication Attitude Test for Preschool and Kindergarten Children Who Stutter; CPRS-SF = Child–Parent Relationship Scale–Short Form.

Figure 2.

Regions of significance for the impact of caregiver KiddyCAT on KiddyCAT for children who stutter. KiddyCAT = Communication Attitude Test for Preschool and Kindergarten Children Who Stutter; CPRS-SF = Child–Parent Relationship Scale–Short Form.

Research Question 2C: Stuttering Severity Does Not Moderate the Relationship Between C-KiddyCAT and KiddyCAT Scores

Multiple linear regression was used to examine if stuttering severity (SSI-4 Total Score) moderated the relationship between C-KiddyCAT and KiddyCAT. Independent variables in the model included caregiver C-KiddyCAT, caregiver confidence, child age, caregiver–child conflict (CPRS-SF Conflicts), stuttering severity (SSI-4 Total Score), and an interaction between caregiver C-KiddyCAT and stuttering severity (SSI-4 Total Score).

The overall model showed significant prediction of KiddyCAT, F(6, 95) = 2.24, p < .05, with an R² of .12. The interaction between stuttering severity and C-KiddyCAT was not significant, b = 0.01, t(95) = 1.04, p = .30. See Table 8 for full regression results.

Table 8.

Multiple linear regression predicting child KiddyCAT: Moderation by stuttering severity.

Variable	b	β	SE	t	p
Caregiver KiddyCAT	−0.04	−0.05	0.24	−0.27	.86
Caregiver KiddyCAT confidence	−0.24	−0.09	0.26	−0.90	.37
Child age (years)	−0.31	−0.16	0.20	−1.55	.12
CPRS-SF Conflicts	0.07	0.15	0.04	1.48	.14
SSI-4 Total Score	−0.01	−0.03	0.05	−0.19	.85
Caregiver KiddyCAT × SSI-4 Total Score	0.01	0.35	0.01	1.04	.30

Note. KiddyCAT = Communication Attitude Test for Preschool and Kindergarten Children Who Stutter; CPRS-SF = Child–Parent Relationship Scale–Short Form (Pianta, 1992); SSI-4 = Stuttering Severity Instrument–Fourth Edition (Riley, 2009).

Discussion

The present study offers preliminary support that caregivers provide estimates of their 3- to 6-year-old child who stutters' communication attitude that reflect their child's self-reported communication attitude. This work extends emerging research in the cognitive aspects of stuttering close to its onset in two distinct ways. First, we investigated caregiver predictions of their young child's communication attitude by including young children's self-reported communication attitudes. Second, we assessed the influence of three potential moderators of the relationship between caregiver prediction and child report. Findings suggest the caregiver–child relationship—and specifically caregiver–child conflict—plays a significant role in caregiver estimates of their young child's communication attitude.

Caregivers Predict Their Young Children's Communication Attitudes

Caregiver C-KiddyCAT score predicted child-reported KiddyCAT while accounting for caregiver confidence in their C-KiddyCAT responses, child age, time since onset of stuttering, and child gender. This finding suggests that in contrast to caregivers of older children who stutter who are more likely to overestimate how negatively their child views their communication, caregivers of young children who stutter may be more accurate in their prediction of their child's communication attitudes. One reason for this discrepancy may be that caregivers of young children who stutter observe more of their child's communication and reactions to stuttering. In comparison, caregivers of school-age children may not observe the entirety of their child's communication and reactions to stuttering, particularly as their communication expands to contexts outside the home environment (e.g., school setting). Alternatively, caregiver–child conflict may have contributed to the findings reported in older children. Perhaps the caregivers included in prior research had a high conflict relationship with their child, which compromised their ability to accurately perceive their child's communication attitude.

Caregiver–Child Conflict and Predicting Child Communication Attitudes

Caregivers who earned lower conflict scores were more accurate in their predictions of their child's communication attitude, while higher caregiver–child conflict yielded inaccurate caregiver predictions. Over half (60.2%) of caregivers reported low caregiver–child conflict within the significant range, as suggested by the Johnson–Neyman technique (Bauer & Curran, 2005). Of these caregivers, 30 reported C-KiddyCAT scores equivalent to their child's KiddyCAT score or within 1 point of their child's score. Communication attitudes reported by caregivers and children in this subsample ranged from positive to negative and encompassed the full range of the analytic sample (0–10). This finding suggests that caregiver–child dyads can experience low conflict, even for children who report a markedly negative attitude toward their communication.

Early research in parent–child relationships suggests young children and their caregivers experience conflict multiple times every hour (Dix, 1991; Driscoll & Pianta, 2011). Thus, the results of the present study cannot be interpreted to suggest that caregiver–child conflict is uniquely higher in families with children who stutter. Having said that, caregivers of children who stutter who reported higher conflict were also less likely to perceive their child's communication attitude correctly. These findings suggest SLPs should consider assessing caregiver–child conflict with the understanding that intervention focused on communication and advocacy skills (e.g., listening to the speaker, advocating for speaking time) may be particularly beneficial for families who report higher caregiver–child conflict and whose children report a negative communication attitude.

Caregiver Confidence and Predicting Child-Reported Communication Attitudes

Descriptively, caregivers who reported high confidence in their responses on the C-KiddyCAT predicted their children had positive and negative communication attitudes, and these caregivers correctly estimated, overestimated, and underestimated their child's communication attitude. In other words, confidence cannot be relied upon as an accurate reflection of the child's perspective. However, caregiver–child dyads with a caregiver confidence rating of 5 of 5 who also earned the same scores on the C-KiddyCAT and KiddyCAT represented a wide range of child communication attitudes, earning scores of 0, 1, 3, and 10. Perhaps caregivers who were confident in their estimate of their child's communication attitude and whose scores match their child's score are also caregivers who have had open dialogue with their child about their child's stuttering. This hypothesis is consistent with data from a recent study by Guttormsen et al. (2021), which reported caregivers who were less certain in their perception of the adverse impact of stuttering on their child (OASES) also shared they had not discussed stuttering directly with their child.

Caregivers who are confident in their predictions, but who overestimate their child's negative communication attitude, may be influenced by their own attitudes toward stuttering rather than their child's attitudes. For example, Cremeens et al. (2006) reported parent proxy ratings of a child's overall quality of life were more strongly correlated with the parents' own quality-of-life ratings than with the child's own self-reported quality-of-life ratings for children ages 5.5–8.5 years.

By comparison, caregivers who are confident, but who underestimate, may do so because of a lack of observable behaviors (e.g., visible frustration). Caregivers are more accurate when rating concrete or observable behaviors and behaviors that occur at home compared to school (e.g., Comer & Kendall, 2004; Van Doorn et al., 2018). Therefore, SLPs should take caution relying on a confident caregiver's estimate, particularly when this confidence is based on an absence of overtly displayed negative communication attitudes. This is particularly important given the number of SLPs who do not feel confident in their own clinical practice for stuttering (Byrd et al., 2020; Coalson et al., 2016) and the influence of low provider confidence on providing unrealistic caregiver expectations for intervention (e.g., in childhood cancer; Mack et al., 2007).

Observer-Rated Stuttering Severity and Predicting Child-Reported Communication Attitude

Observer-rated stuttering severity did not significantly predict child-reported KiddyCAT. Thus, the present findings align with previous research investigating the potential relationship between stuttering severity and child-reported communication attitude in young children who stutter (e.g., Groner et al., 2016; Winters & Byrd, 2021). Additionally, the present findings extend previous work by suggesting that stuttering severity is not only unrelated to child-reported communication attitude but also distinct from the relationship between caregivers' predictions and their child's reported communication attitude.

Importantly, these data support both clinical and research efforts to measure cognitive components of stuttering separately from analyses related to observed stuttering behaviors. SLPs and researchers should not only measure cognitive components of stuttering (e.g., communication attitude) as distinct from any listener-determined stuttering behavior (e.g., SSI-4 scores) but also consider a change in communication attitude as an independent, clinically meaningful intervention outcome (e.g., Byrd et al., 2021, 2022; Millard et al., 2018).

Limitations and Future Directions

This study offers important preliminary findings, and its limitations provide opportunities for future research. First, previous research suggests caregivers of older, school-age children who stutter perceive their child's communication attitude more negatively than caregivers of same-age children who do not stutter do (Vanryckeghem, 1995). Like Guttormsen et al. (2021), the present study did not include a comparison group of caregiver–child dyads with children who do not stutter. Data collection is currently ongoing with the purpose of investigating potential differences in caregiver estimates of their child's communication attitude between groups. For example, it has yet to be determined whether group assignment (stuttering or not) moderates the relationship between caregiver estimates (C-KiddyCAT) of their child's communication attitude (KiddyCAT).

The scale used to evaluate caregiver–child conflict also measured caregiver–child closeness (CPRS-SF; Pianta, 1992). Though the motivating rationale for our third research question was to explore caregiver–child conflict based on previous research findings (e.g., Langevin et al., 2010), we were able to do so while accounting for caregiver–child closeness both descriptively and in our statistical analysis. Descriptively, caregivers in the present sample showed less variability in closeness scores compared to conflict scores, suggesting the caregiver–child relationship in early childhood stuttering can include a similar level of closeness in the presence of either high or low conflict. Having said that, future research could consider additional exploration of caregiver–child closeness with either the same or a different, more sensitive measure.

One additional limitation of this study, and stuttering research more generally, is the measurement of observer-rated stuttering severity. The SSI-4 provides a snapshot of a speaker's stuttering frequency, duration, and presence of physical concomitants across multiple speaking samples and has been used extensively in the literature; however, more recent work has captured the variability of stuttering as a more meaningful construct that may be more associated with self-reported adverse impact of stuttering (Constantino et al., 2016; Tichenor & Yaruss, 2021). The SSI-4 is also limited by its normative sample of young children who stutter (N = 72), which is markedly smaller than the present sample (N = 113) and, other than stating the children lived in California, does not contain demographic information to describe the normative sample. While it is possible a different metric of stuttering severity may have changed the results for the fourth research question, this is unlikely given the correlation between %SS, which is used in determining SSI-4 scores, and clinical or caregiver estimates of stuttering severity (Onslow et al., 2018).

The present study suggests caregiver C-KiddyCAT and child KiddyCAT scores are related to one another, but the data do not discern whether caregivers are accurate in their estimates because they are truly aware of their child's distinct attitude or if children's responses were influenced by caregiver or family reactions to their stuttering. In fact, clinical experience and recent research (Druker et al., 2019; Yandeau et al., 2022) indicate children are aware of their family's reactions to stuttering, suggesting children and their caregivers may be influenced by as well as may influence one another's attitudes toward stuttering and overall communication.

Although this preliminary investigation includes a relatively diverse sample, individual differences in identity, previous experience with stuttering (e.g., family history), and concomitant communication identities (e.g., speech sound performance) were not included in this initial analysis. Future research with this sample should investigate individual characteristics of children who stutter and caregiver–child dyads as they relate to caregiver predictions and explore characteristics of outlier caregiver–child dyads where caregivers were inaccurate in their estimates. Particularly within the context of caregiver–child conflict and caregiver interventions, there is significant research investigating aspects of individual and cultural identities (e.g., Parra-Cardona et al., 2017, 2021, 2022).

Conclusions

Results of this study are based on a relatively large and diverse sample of young children who stutter and provide clinical implications for SLPs working with young children near or shortly after stuttering onset. Specifically, assessing both self-reported communication attitude and caregiver predictions of their child's communication attitude may support clinicians (a) counseling caregivers about the cognitive components of stuttering in young children and (b) educating families about the distinction between communication attitude and observer-rated stuttering severity. Neither a caregiver's confidence nor a child's stuttering severity uniquely influences caregiver predictions of their child's communication attitude, meaning caregiver predictions should be interpreted with caution and within the context of the child's full evaluation and the caregiver–child relationship.

Data Availability Statement

The data sets generated and/or analyzed during the current study are not publicly available due to university institutional review board restrictions but are available from the corresponding author on reasonable request.

Funding Statement

This research was supported by the National Institute on Deafness and Other Communication Disorders (Award No. F31DC019859; PI: Winters), the Texas Speech-Hearing Foundation (PI: Winters), and the Blank Family Foundation Legacy Grant (PI: Byrd). This content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors would like to extend their sincere gratitude to Michael Mahometa, Ruben Parra-Cardona, Matthew McGlone, and Rajinder Koul for their thoughtful feedback and discussion on an early version of this article and to Michael Mahometa for his assistance with statistical analysis. They thank Peyton Donovan, Denise Kim, and Kim Rendon for their assistance with data analysis.