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Journal of Speech, Language, and Hearing Research : JSLHR logoLink to Journal of Speech, Language, and Hearing Research : JSLHR
. 2024 Aug 14;67(9):2920–2934. doi: 10.1044/2024_JSLHR-24-00069

Evaluating Stuttering Self-Stigma and Its Relationship to Adverse Impact in Children and Adolescents With the Child Stuttering Self-Stigma Scale

Chelsea A Johnson a, Katelyn L Gerwin a, Seth E Tichenor b, Michael P Boyle c, Bridget Walsh a,✉
PMCID: PMC11427442  PMID: 39141882

Abstract

Purpose:

Self-stigma occurs when a person internalizes and applies stereotypes, prejudice, and discrimination to themselves. For adults who stutter, self-stigma is linked to negative outcomes and reduced quality of life. The development of self-stigma in people who stutter is not well understood. The aim of this study is to evaluate stuttering self-stigma in school-age children and adolescents and explore potential relationships to stuttering's overall adverse impact.

Method:

One hundred one children and adolescents who stutter, aged 10–18 years, completed the Overall Assessment of the Speaker's Experience of Stuttering (OASES), a measure of adverse impact related to stuttering, and the Childhood Self-Stigma of Stuttering Scale (Child 4S), our novel adapted version of the Self-Stigma of Stuttering Scale (4S) created for this study. The Child 4S comprises three subscales measuring three stages of self-stigma: Awareness, Agreement, and Application. Each stage was evaluated for relationships with child age and the adverse impact of stuttering.

Results:

We found a range of self-stigma scores among children and adolescents who stutter. Child age did not correlate with Awareness and Agreement; however, older children and adolescents reported greater Application. All stages of self-stigma strongly predicted adverse impact as measured by the OASES, and latter stages of the model were stronger predictors than earlier stages.

Conclusions:

Children as young as 10 years old may experience stuttering self-stigma, and the application of self-stigma increases in adolescence, a critical period in the development of personal identity. Importantly, all stages of self-stigma predicted adverse impact related to stuttering, with latter stages being stronger predictors than earlier ones consistent with the progressive model of self-stigma being tested. The findings highlight the need for targeted, early intervention to mitigate downstream effects of stuttering self-stigma.

Supplemental Material:

https://doi.org/10.23641/asha.26352556

Stigma comprises the traits or characteristics that separate some individuals from others, along with the negative consequences for the person possessing the perceived undesirable trait (e.g., stereotypes, prejudice, discrimination; see Corrigan & Watson, 2002; Link & Phelan, 2006). Stuttering is a stigmatized neurodevelopmental condition associated with publicly held stereotypes (Craig et al., 2003; Kalinowski et al., 1996; MacKinnon et al., 2007). Stuttering emerges in early childhood, around age 3 years, and is characterized, in part, by disruptions to the fluent production of speech such as repetition of sounds or syllables, prolongations, and blocks. Approximately 1% of the general population is diagnosed with stuttering (Bloodstein et al., 2021). Although stuttering is most often associated with observable disruptions to speech, individuals often experience adverse impact from their stuttering in the form of negative thoughts, feelings, and behaviors that a person develops in reaction to the underlying impairments as well as limitations that result from living with the condition (Tichenor & Yaruss, 2019; Yaruss & Quesal, 2004). People who stutter are perceived to be less confident, shy, and unsuitable for jobs with high speaking demands (Boyle, 2017; Boyle et al., 2009; Cooper & Cooper, 1985; Gabel et al., 2004; Hurst & Cooper, 1983; Irani et al., 2009; Kalinowski et al., 1996; Seitz & Choo, 2022; Silverman & Bongey, 1997; Silverman & Paynter, 1990; St. Louis, 2015; Turnbaugh et al., 1981; Woods & Williams, 1976). Stigmatization of people who stutter may contribute to the adverse impact related to stuttering, particularly one aspect called self-stigma.

Self-stigma occurs when an individual internalizes negative public perception of stuttering such as stereotypes, prejudice, and discrimination and applies them to themselves (Corrigan et al., 2006; Corrigan & Watson, 2002). Greater self-stigma is associated with poorer somatic health outcomes in adults who stutter (Boyle & Fearon, 2018) and lower levels of self-esteem, self-efficacy, quality of life, hope, and empowerment, along with higher levels of anxiety and depression (Boyle, 2013a, 2015). Adults reporting greater stuttering self-stigma are more likely to report reduced communicative participation and poorer mental health over and above what is accounted for by speech-related and demographic variables (Boyle et al., 2023). Although self-stigma is associated with negative life sequelae in adults, it is unclear when stuttering self-stigma emerges in children or adolescents. This knowledge gap impedes the development of interventions to mitigate or prevent the development of stuttering self-stigma throughout life.

The Progressive Model of Self-Stigma and Stuttering Self-Stigma

Self-stigma is hypothesized to emerge in individuals systematically, as part of the progressive model of self-stigma (Corrigan et al., 2006, 2010, 2011; Corrigan & Watson, 2002; Watson et al., 2007). The first stage of Corrigan et al.'s model is stereotype awareness, or simply “Awareness.” During this stage, people with the stigmatized trait develop awareness of public stigma of that trait. The next stage of the progressive model of self-stigma is stereotype agreement, or “Agreement.” At this hypothesized stage, people with the stigmatized trait agree with publicly held stereotypes about “other” individuals with that trait. The third stage of self-stigma is stereotype application, or “Application.” At this stage, people with a stigmatized trait internalize the negative public stereotypes and personal beliefs about people with the trait and apply these to themselves. Each stage of self-stigma can be experienced to varying degrees; however, the progressive model of self-stigma predicts that the Awareness, Agreement, and Application stages are progressive and ultimately lead to negative outcomes such as poorer overall well-being and lower self-esteem and self-efficacy as people apply negative stereotypes to themselves (Corrigan et al., 2006, 2010, 2011).

The progressive model of self-stigma provided a conceptual framework for the Self-Stigma of Stuttering Scale (4S), a measurement of stuttering self-stigma for adults (Boyle, 2013a). The 4S comprises statements related to stuttering for each stage of self-stigma (see Figure 1): Awareness (i.e., “Most people in the general public believe that people who stutter are insecure”), Agreement (i.e., “I believe that people who stutter are generally insecure”), and Application (i.e., “Because I stutter, I feel just as confident as people who don't stutter”). Scores on the 4S reveal that adults who stutter indeed experience Awareness, Agreement, and the Application of self-stigma. On average, about 85% of adults who stutter demonstrate high levels of stigma Awareness, and fewer, approximately one third, report high levels of Agreement and Application. Many studies also have found an association between higher self-stigma scores and negative outcomes such as lower self-esteem, self-efficacy, life satisfaction, hope, empowerment, global mental health, communicative participation, and physical health and higher levels of anxiety, depression, and stress (Boyle, 2013a, 2015; Boyle et al., 2023; Boyle & Fearon, 2018). This research has consistently shown that Application of self-stigma has a stronger association with negative outcomes than Awareness and Agreement, which supports the progressive model.

Figure 1.

A diagram illustrates the 3 progressive stages of stuttering self-stigma. Stage 1: Awareness, People who stutter become aware of stuttering stigma. Stage 2: Agreement, People who stutter express agreement with publicly held stereotypes about other individuals who stutter. Stage 3: Application, People who stutter internalize negative public stereotypes and personal beliefs about people who stutter and apply these to themselves.

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The three progressive stages of stuttering self-stigma measured in this investigation.

Stuttering Stigma in Children and Adolescents Who Stutter

Like adults, children and adolescents who stutter are also vulnerable to stuttering stereotypes. Even preschool-age children may view stuttering negatively (Ezrati-Vinacour et al., 2001; Langevin et al., 2009), and school-age children who stutter are less likely to be perceived as popular or as leaders and more likely to be perceived as someone who is bullied or needs help (Davis et al., 2002). Adolescents and young adults who stutter are deemed less attractive and less suitable as romantic partners by their peers (Van Borsel et al., 2011). Children who stutter are also vulnerable to adverse societal reactions to stuttering, or “enacted stigma” (Boyle, 2018; Boyle et al., 2023), including bullying and teasing (Blood & Blood, 2004; Blood, Blood, et al., 2003; Blood et al., 2011; Erickson & Block, 2013). Negative perceptions and experiences could, in turn, affect how children and adolescents perceive themselves. Adolescents who stutter report lower self-perceived communication competence (Blood & Blood, 2004; Erickson & Block, 2013) and higher self-reported anxiety (Blood et al., 2007; Iverach et al., 2016) and may strive to conceal their stuttering (Blood, Blood, et al., 2003; Erickson & Block, 2013). Similar negative outcomes in adults have been related to stuttering self-stigma (Boyle, 2013a, 2015; Boyle et al., 2023; Boyle & Fearon, 2018). Therefore, stuttering self-stigma may play a role in the development of stuttering's overall adverse impact documented in many children and adolescents (Beilby & Byrnes, 2012; Samson et al., 2021).

To date, the hypothesized stages of self-stigma reviewed in this article have not been explicitly studied in children and adolescents to examine potential relationships between self-stigma and stuttering's adverse impact. However, limited research has been done regarding “perceived enacted stigma” and how it may contribute to the adverse impact of stuttering. “Perceived enacted stigma,” sometimes called experienced stigma, is the extent that individuals who stutter report stuttering-related discrimination or negative treatment by others (as defined by Boyle et al., 2023). Three studies have examined the extent that young people who stutter report perceived enacted stigma (although the authors of those studies did not use that specific term) using a three-item measure, the Stigmatization and Disclosure in Adolescents Who Stutter Scale (Adriaensens et al., 2015; Blood, Blood, et al., 2003; Erickson & Block, 2013). This questionnaire asks the adolescent who stutters if stuttering affects whether their peers become friends with them, like them, and invite them to go to parties or on dates. Contrary to expectations, adolescents who stutter inconsistently reported perceived enacted stigma related to their stuttering (Blood, Blood, et al., 2003; Erickson & Block, 2013) and perceived stuttering stigma to a lesser degree than their peers who do not stutter predicted they would (Adriaensens et al., 2015). Nevertheless, the scope of this three-question measure is too limited to sufficiently capture the complexity of perceived enacted stigma, and predictions provided by adolescents who do not stutter are an inadequate proxy for lived experiences. Given these limitations, we sought to adapt a theoretically driven, psychometrically sound scale for stuttering self-stigma to be utilized with children and adolescents. Measuring stigma via the progressive model of stigma is critical to understanding how and when stigma may develop in children and adolescents who stutter.

The Current Study

In the current study, we examined the stages of self-stigma to describe how public stuttering stigma is internalized by children who stutter and how this degree of self-stigma predicts adverse impact related to stuttering. The first aim of this study was to adapt the adult 4S to assess the three stages of stuttering self-stigma in children and adolescents who stutter (Childhood Self-Stigma of Stuttering Scale [Child 4S]; Boyle, 2013a). As part of this aim, we will evaluate the potential relationships between child age and the three stages of self-stigma. It is possible that Awareness, Agreement, and Application scores would trend lower for school-age children compared to teens who stutter who have been living with the condition longer.

The second aim of the study examined the hypothesis that self-stigma is trickle-down in nature as postulated by Corrigan et al. (2011). In this regard, we hypothesized that mean scores for Awareness would be highest, followed by Agreement, and then finally Application. In addition, we hypothesized that correlations between proximal subscales would be stronger than those among distal subscales (i.e., the relationship between Awareness and Agreement and the relationship between Agreement and Application should be stronger than the relationship between Awareness and Application).

The third aim of this study was to explore potential relationships between the stages of stuttering self-stigma and the adverse impact of stuttering measured by the Overall Assessment of the Speaker's Experience of Stuttering (OASES; Yaruss & Quesal, 2006, 2016). The connection between self-stigma and a variety of adverse outcomes has been established in research with adults who stutter (Boyle, 2013a, 2015). Thus, we predicted that greater self-stigma (Awareness, Agreement, and Application) would be positively associated with the adverse impact of stuttering in children and adolescents. Finally, in support of the trickle-down self-stigma model being tested, we predicted that Application would have the strongest link to life impact, followed by Agreement, followed by Awareness. Examining these specific components of self-stigma and their relationships with the adverse impact of stuttering will deepen our understanding of how self-stigma develops in children and adolescents. Ultimately, this information may help prevent or mitigate the development of self-stigma seen in adults who stutter through interventions that target the stages of self-stigma.

Method

This study is part of a larger longitudinal survey project at Michigan State University investigating the development of adverse impact in children who stutter. The Michigan State University Human Subjects Research Protection Office approved this study (Study #00001704) by institutional review, and all participants provided informed assent or consent.

Participants and Procedure

One hundred one children who stutter between the ages of 10 and 18 years (M = 12.95, SD = 2.55) participated in this study. All children indicated that they stuttered. Parents also reported that their child stuttered and provided their child's demographic information and developmental history (see Table 1). Parents could assist their child in completing the 4S by reading or interpreting questions but were expressly instructed not to answer for their child or influence their responses. Parents were asked to indicate their agreement with this request. Parents/guardians of 31 children (30%) indicated that they assisted their child by reading/interpreting the questions.

Table 1.

Demographic data for participants.

Variable Children who stutter n (%)
Age (years)
 10 24 (23.7%)
 11 14 (13.8%)
 12 15 (14.8%)
 13 6 (5.9%)
 14 12 (11.8%)
 15 9 (8.9%)
 16 9 (8.9%)
 17 7 (6.9%)
 18 5 (4.9%)
Sex assigned at birth
 Female 27 (26.7%)
 Male 73 (72.3%)
 Prefer not to say/missing data 1 (1%)
Race
 Asian 4 (4.0%)
 Black or African American 7 (6.9%)
 Mixed 2 (2%)
 White or Caucasian 82 (81.2%)
 Prefer not to say/missing data 6 (5.9%)
Ethnicity
 Hispanic/Latino 6 (5.9%)
 Not Hispanic/Latino 91 (90.1%)
 Prefer not to say/missing data 4 (4%)
History of concomitant speech or language conditions
 Yes 29 (28.71%)
 No 10 (9.90%)
 Prefer not to say/missing data 62 (61.38%)
History of concomitant neurodevelopmental disorders
 Attention-deficit/hyperactivity disorder (ADHD) 16 (15.84%)
 Autism 1 (0.99%)
 Multiple (e.g., autism and ADHD) 7 (6.93%)
 Other (e.g., learning, Down syndrome) 3 (2.97%)
History of psychiatric disorder
 Anxiety 10 (9.90%)
 Depression 1 (0.99%)
 Both anxiety and depression 1 (0.99%)
 Unspecified psychiatric disorder 1 (0.99%)
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A mix of convenience, purposive, and snowball sampling methods were used to recruit participants (Goodman, 1961). Recruitment materials were disseminated to speech-language pathologists employed in schools, clinics, and private practices and to national stuttering associations. Recipients were encouraged to share the materials with colleagues or families of children who stutter who might be interested in participating. Due to the nature of recruitment, we cannot determine how many parents and children were contacted about the study, and response rates cannot be computed. We recruited speech-language pathologists across the United States to diversify our sample.

Recruitment materials contained a link to a brief screening survey asking parents to confirm that their child met inclusionary criteria for this study (child who stutters, aged 10–18 years, English as a primary language). If the child met inclusionary criteria, parents received an e-mail containing personalized links to our parent and child surveys conducted in Qualtrics. Measures of self-stigma and adverse impact (described below) were collected in two separate child surveys. Children aged 10 years or older were eligible for the survey containing the measure of self-stigma. Modest remuneration was provided for each completed survey.

Survey Measures

Self-Stigma

Self-stigma was measured in children who stutter using the 4S (Boyle, 2013a) that we adapted for children. The adult 4S has demonstrated good internal consistency (α = .87) and temporal stability (r = .80), has been used in research and clinical settings, and has been translated to over 10 languages (Boyle, 2013a; see also Boyle, 2015). The three subscales of the adult 4S have also shown good internal consistency: Awareness (α = .84), Agreement (α = .70), and Application (α = .89; Boyle, 2015). To adapt the adult 4S for children, two certified speech-language pathologists (third and fifth authors) and the original author of the 4S (fourth author) modified the items using child-focused language (i.e., “Because I stutter, I feel more nervous than people who do not stutter” was adapted to “Because I stutter, I feel more nervous than kids who do not stutter”). Items for which a child equivalent was not available were removed (i.e., “Because I stutter, I stop myself from accepting promotions at work”). The third and fifth authors generated a draft version of the Child 4S. Feedback was obtained from the fourth author about the suitability of the terms used and how well the items generated covered the original three subcomponents of the adult 4S. Revisions to the original list of items were then made by the third, fourth, and fifth authors to cover the intended constructs more precisely. Several families piloted taking the child survey that included the Child 4S, and we sought their feedback regarding the clarity of the questions, length of the survey, and appropriateness of the remuneration. Feedback on the final version of the surveys including the Child 4S was provided by two practicing speech-language pathologists with expertise in stuttering. By the end of the adaptation process, the authors agreed that the adapted items and composite scale adequately covered the three different components of self-stigma measured by the original 4S and the theoretical model it tests. According to the Flesch–Kincaid grade level (Thomas et al., 1975), the Child 4S is appropriate for children as young as 8 years of age, indicating that the readability of items is appropriate for participants in our study. Items included in the Child 4S are listed in the Appendix.

The Child 4S items are divided into three sections that measure the components of the self-stigma model described by Corrigan et al. (2011): Awareness (e.g., “Most people think that people who stutter are insecure (afraid or hesitant)”), Agreement (e.g., “I believe that most people who stutter are nervous”), and Application (e.g., “Because I stutter, I feel less confident than kids who don't stutter”). Children rate each item on a 5-point agreement scale (1 = strongly disagree, 2 = somewhat agree, 3 = neither agree or disagree, 4 = somewhat agree, 5 = strongly agree). Following the adult 4S, items that are positively worded (e.g., “Most people think that people who stutter are confident”) are reverse scored. Ratings from items in each section are averaged to provide scores for the three sections, and all item ratings are averaged for an overall self-stigma score. Scores range from 1 to 5, with higher scores representing greater stuttering self-stigma. Internal consistency of the Child 4S was measured using Cronbach's alpha. Internal consistency for each subscale of the Child 4S as well as the total score ranged from acceptable to excellent Awareness (α = .86), Agreement (α = .72), Application (α = .88), and total score (α = .90). These internal consistencies of the Child 4S were comparable to published studies of the adult 4S (Boyle, 2013a, 2015). Given our sample size of 101 children and that the psychometric properties of the 4S have been evaluated and replicated in over 600 adults who stutter across different studies yielding a robust factor structure (Boyle, 2013a, 2015), no new exploratory or confirmatory factor analyses were conducted with the Child 4S for this study.

Adverse Impact of Stuttering

The adverse impact of stuttering was assessed using age-appropriate versions of the OASES (Yaruss & Quesal, 2006, 2016). This assessment includes four sections to capture how people who stutter perceive their stuttering, how they react to their own stuttering, how stuttering impacts daily communication, and how stuttering impacts their quality of life. Children ages 7–12 years took the school-age version of the OASES (OASES-S; ages 7–12 years), and children ages 13–18 years took the teen version (OASES-T). The OASES has been used in previous publications from our lab and was validated for internal consistency (Tichenor et al., 2022; Walsh et al., 2023). We also computed Cronbach's alpha for each section of the OASES to document internal consistency (see Supplemental Material S1). All sections reached or exceeded .7 indicating acceptable reliability. Given that the OASES section and total scores are averages, OASES-S and OASES-T scores were combined to limit the number of statistical tests run to increase statistical power.

Data Analysis

Aim 1: Analyses of Self-Stigma Scores in Children Who Stutter and Age

All participants completed the adapted Child 4S. Descriptive statistics were calculated for the three section subscales (Awareness, Agreement, and Application) as well as the total score (see Table 2). Three Spearman correlations examined the relationship between Age and each of the self-stigma subscales. Spearman correlations were selected because the assumption of normality was violated. Shapiro–Wilk tests revealed that while the Awareness (p = .09) and Agreement (p = .35) subscales were normally distributed Age (p < .001) and the Application subscale (p = .04) was not normally distributed.

Table 2.

Descriptive statistics for study variables.

Variable M (SD) Range observed Range possible
Awareness 2.93 (0.64) 1–4.23 1–5
Agreement 2.56 (0.58) 1–4.14 1–5
Application 2.42 (0.85) 1–4.85 1–5
Total Stigma score 2.70 (0.54) 1–3.96 1–5
OASES total score 2.28 (0.55) 1.20–3.70 1–5
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Note. OASES = Overall Assessment of the Speaker's Experience of Stuttering.

Aim 2: Examining the Progressive Model of Self-Stigma in Children Who Stutter

Three additional Spearman correlations evaluated the relationships among the self-stigma subscales, and a Friedman test and three post hoc Wilcoxon signed-ranks tests examined differences between average scores of the subscales. Spearman correlations, the Friedman test, and Wilcoxon signed-ranks tests were selected because the assumption of normality was violated.

Aim 3: Relationship Among Self-Stigma, Age, and OASES Total Score

Ninety-six children also completed the age-appropriate version of the OASES, allowing for an analysis of the relationship between self-stigma and adverse impact related to stuttering. Three separate multiple linear regression models, one for each self-stigma subscale, were conducted to examine the relationships between self-stigma, child age, and adverse impact (see Tables 3–5). These regression models were examined to confirm that the assumptions for linear regression were met: linearity, homoscedasticity, independence of observations, and normality. Each regression model included two predictors: self-stigma subscale score and child age. The interaction term between each stigma subscale score and Age was not included given the sample size of this study.

Table 3.

The effects of Age, Awareness, and their interactions on Overall Assessment of the Speaker's Experience of Stuttering (OASES) total score.

Measure Effect B SE t p
OASES total score Intercept 1.13 0.23 4.81 < .001*
Age 0.05 0.02 2.29 .024*
Awareness 0.39 0.08 5.06 < .001*
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*

p < .05.

Table 4.

The effects of Age, Agreement, and their interactions on Overall Assessment of the Speaker's Experience of Stuttering (OASES) total score.

Measure Effect B SE t p
OASES total score Intercept 1.19 0.22 5.32 < .001*
Age 0.06 0.02 2.85 .005*
Agreement 0.43 0.09 5.05 < .001*
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*

p < .05.

Table 5.

The effects of Age, Application, and their interactions on Overall Assessment of the Speaker's Experience of Stuttering (OASES) total score.

Measure Effect B SE t p
OASES total score Intercept 1.16 0.12 9.87 < .001*
Age 0.01 0.02 0.80 .427
Application 0.47 0.05 10.20 < .001*
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*

Significant at p < .05.

Results

Aim 1: Analyses of Self-Stigma Scores in Children Who Stutter and Age

The descriptive statistics for the Child 4S total and subscale scores are presented in Table 2, and the mean scores of Awareness, Agreement, and Application are presented in Figure 6. Correlations between Age and Awareness, r(99) = .11, p = .29, and Age and Agreement, r(99) = .04, p = .70, were not significant. Age and Application showed a modest positive correlation, r(99) = .27, p < .01 (see Figure 2).

Figure 6.

The image displays violin plots depicting the distribution of the self-stigma score. 1. Awareness. The widest portion of the violin plot is near a self-stigma score of 3 units. The narrowest portion of the violin plot are near 0.5 and 4.8. 2. Agreement. The widest portions of the violin plot are near self-stigma scores of 2.3 and 2.9. The narrowest portions of the violin plot are near self-stigma scores of 0.5 and 4.7. 3. Application. The widest portion of the violin plot is near a self-stigma score of 2. The narrowest portions of the violin plot are near self-stigma scores of 0.2 and 5.

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Distribution of Awareness, Agreement, and Application scores in our sample of children and adolescents who stutter.

Figure 2.

A scatterplot depicts the correlation between the self-stigma score, on the y axis, and the age in years, on the x axis. The regression line for awareness runs between (10, 2.9) and (18, 3). The regression line for agreement runs between (10, 2.7) and (18, 2.7). The regression line for application runs between (10, 2.2) and (18, 2.9).

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The relationship between Age and Awareness, Agreement, or Application. Application was positively associated with Age. Awareness and Agreement were not.

Aim 2: Examining the Progressive Model of Self-Stigma in Children Who Stutter

Spearman correlations between participants' raw scores were all statistically significant and showed small to moderate associations. Awareness scores were significantly and positively correlated with Agreement scores, r(99) = .37, p ≤ .001, and Agreement scores significantly and positively associated with Application scores, r(99) = .44, p ≤ .001. Contrary to predictions, however, scores for the distal subscales (Awareness and Application) showed a slightly stronger positive correlation, r(99) = .41, p ≤ .001, than the proximal subscales Awareness and Agreement.

The Friedman test indicated significant overall differences between average scores for Awareness, Agreement, and Application, χ2(2) = 333.08, p < .001. The trickle-down nature of the progressive model of self-stigma predicts that the first stage, Awareness, should have the highest score, followed by the next stage, Agreement, and lastly, Application. Post hoc Wilcoxon signed-ranks tests with Bonferroni adjustments revealed that children's Awareness scores were higher than both their Agreement and Application scores (p < .001). However, there was no significant difference between Agreement and Application scores after correction for multiple comparisons (p = .04).

Aim 3: Relationship Among Self-Stigma, Age, and OASES Total Score

The descriptive statistics for the OASES total score are presented in Table 2. Model 1, the Awareness model, was significant F(2, 95) = 16.64, p < .001, R2 = .26, R2adjusted = .25, f2 = 0.35, indicating a medium effect size (see Figure 3). Awareness (β = 0.39, p < .001) and Age (β = 0.05, p = .02) were both significant predictors of OASES total score (see Table 3). Model 2, the Agreement model, was also significant, F(2, 95) = 16.61, p < .001, R2 = .26, R2adjusted = .25, f2 = 0.35, indicating a medium effect size (Cohen, 1988; see Figure 4). Both Agreement (β = 0.43, p < .001) and Age (β = 0.06, p < .01) were significant predictors of OASES total score (see Table 4) in this model. Lastly, Model 3, the Application model, was significant, F(2, 95) = 58.38, p < .001, R2 = .55, R2adjusted = .55, f2 = 1.22, indicating a very large effect size (see Figure 5). Application (β = 0.47, p < .001) significantly predicted OASES total score, but Age (β = 0.01, p = .43) did not (see Table 5).

Figure 3.

A scatterplot depicts the correlation between the total OASES score, on the y axis, and the Awareness self stigma score, on the x axis. The regression line runs between (1, 1.5) and (4.3, 3).

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Relationship between Awareness, Age, and total OASES score. Awareness and Age significantly predict total OASES score. OASES = Overall Assessment of the Speaker's Experience of Stuttering.

Figure 4.

A scatterplot depicts the correlation between the total OASES score, on the y axis, and the Agreement self-stigma score on the x axis. The regression line runs between (1, 1.6) and (4.2, 3).

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Relationship between Agreement, Age, and total OASES score. Agreement and Age significantly predict total OASES score. OASES = Overall Assessment of the Speaker's Experience of Stuttering.

Figure 5.

A scatterplot depicts the correlation between the total OASES score, on the y axis, and the application self-stigma score, on the x axis. The regression line runs between (1, 1.7) and (5, 3.4).

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Relationship between Application, Age, and total OASES score. Application significantly predicts total OASES score. OASES = Overall Assessment of the Speaker's Experience of Stuttering.

Discussion

Stuttering self-stigma is associated with poorer somatic health outcomes, lower self-esteem, and reduced quality of life and mental health in adults who stutter (Boyle, 2013a, 2015; Boyle & Fearon, 2018). Self-stigma has not been explicitly studied in children and adolescents who stutter, so it is unclear whether children who stutter also experience stuttering self-stigma. The purpose of this study was to examine the stages in a theoretically grounded progressive model of self-stigma in children who stutter and to explore the potential relationship between self-stigma and the overall adverse impact related to stuttering. We discuss results corresponding to each aim and provide clinical implications to foster stuttering-specific self-stigma intervention strategies that leverage speech-language pathologists' existing skill sets and knowledge of holistic stuttering treatment. Interventions to treat stuttering self-stigma have not been advanced in studies with adults, yet future interventions tailored to the progressive stages of stuttering self-stigma could ultimately inhibit its progression and mitigate longer-term adverse impact.

Children Who Stutter Experience Self-Stigma

The first aim of this study was to assess the three stages of stuttering self-stigma in children and adolescents who stutter using our adapted version of the 4S, the Child 4S. We found that, like adults in Boyle's (2015) study, school-age and adolescents reported a range of stuttering self-stigma (see Table 2 and Figure 6). Children in the current study demonstrated mean scores comparable to those from 354 adults who stutter for Agreement (M = 2.68, SD = 0.65), and Application (M = 2.60, SD = 0.93; see Table 2; Boyle, 2015). Adults in the Boyle (2015) study showed a higher mean for Awareness (M = 3.54, SD = 0.05) compared to the children in the current study suggesting that degree of awareness may increase in adulthood. Contrary to the hypothesis that children who stutter may not be aware of stuttering stigma (Adriaensens et al., 2015; Blood, Blood, et al., 2003), we documented that Awareness and Agreement stages of stuttering self-stigma are present in 10- to 18-year-old children who stutter. Clinicians treating children who stutter can assess the stages of stuttering self-stigma so they can take measures to address this in speech therapy. Interventions to reduce mental health stigma espouse psychoeducation to address stereotypes, myths, or misconceptions and provide accurate information regarding mental health disorders (Yanos et al., 2015). Encouragingly, education is already recommended as a piece of holistic therapy for children who stutter (Coleman, 2018; Coleman & Yaruss, 2014; Daniels, 2012; Murphy et al., 2007a; Yaruss et al., 2018), and future studies can determine whether it is an effective approach for treating Awareness and Agreement of self-stigma in children who stutter.

According to the progressive model of self-stigma, Awareness and Agreement lay the foundation for Application. We also found that children as young as 10 years may apply stuttering stigma to themselves. Application, however, increased significantly with age, suggesting that adolescence is a developmental window for this stage. Adolescence is also a critical period for establishing one's identity (Erikson, 1968), and this developing identity includes social connections and group affiliations (Newman & Newman, 2001). Isolation and feeling different from peers are common experiences reported by adolescents with diagnoses of mental health conditions or attention-deficit/hyperactivity disorder in the broader self-stigma literature (Kranke et al., 2011; McKeague et al., 2015). Teens who stutter may increasingly apply stuttering stigma as they evaluate themselves relative to peers and consider broader group identities (Daniels & Gabel, 2004; Hagstrom & Daniels, 2004). As such, group-based therapy activities may help adolescents who stutter counter Application processes. Attending stuttering support groups is associated with reduced internalized stigma in adults (Boyle, 2013b). For both children and adults, participation in stuttering support conferences lead to lasting decreases in adverse impact related to stuttering (Gerlach et al., 2019; Trichon & Tetnowski, 2003). Stuttering-focused summer camps provide children who stutter with community (Byrd et al., 2016) and reduce adverse impact related to stuttering for at least 6 months after the camp experience (Byrd et al., 2018; Herring et al., 2022).

Cognitive strategies may also be used to specifically target the Application stage of self-stigma, as they provide “opportunities to learn and practice skills to identify and combat self-stigmatizing thoughts and beliefs” (Yanos et al., 2015, p. 177). Cognitive therapies have been described for stuttering intervention with adults and children, including cognitive behavioral therapy (Kelman & Wheeler, 2015; Menzies et al., 2009; Nicholas, 2015), mindfulness (Harley, 2018), and acceptance and commitment therapy (Beilby & Byrnes, 2012; Palasik & Hannan, 2013).

Overall, our results highlight that progression through the stages of self-stigma may be protracted, beginning at least by age 10 years, and extending into adolescence, where identity formation processes may leave teens particularly vulnerable to the Application of negative stuttering stereotypes. Longitudinal studies of stuttering self-stigma involving younger children are needed to understand how individuals progress through the self-stigma stages over development to inform effective approaches for mitigating stuttering self-stigma.

The Progressive Model of Self-Stigma in Children Who Stutter

The second aim of this study was to evaluate the progressive, trickle-down nature of the self-stigma in children who stutter by comparing subscale means and interrelationships among subscales (Corrigan et al., 2011). The progressive model proposes that the highest endorsement will be for awareness, followed by lower endorsements for each subsequent stage. In an earlier study with adults who stutter, Awareness received the highest average score, and Application received the lowest average score (Boyle, 2015). Our study confirmed a similar overall pattern in children and adolescents who stutter with Awareness having the highest average scores but Agreement and Application not being statistically different after correction.

We also assessed the progressive nature of self-stigma by comparing the interrelationships between the stages of self-stigma. According to the progressive model (Corrigan et al., 2011), proximal subscales (Awareness and Agreement, Agreement and Application) should show stronger associations than distal subscales (Awareness and Application). However, in children and adolescents who stutter, the Awareness subscale scores were more strongly correlated with Application scores than Agreement scores. Subscale means from children and adolescents show that Agreement and Application may trickle-down from Awareness, but scores from proximal subscales did not show stronger relationships than scores from distal subscales. This pattern of findings was also seen in adults who stutter (Boyle, 2013a, 2015).

This study and earlier studies with adults who stutter suggest that there may be subtle differences in the progression of self-stigma in the stuttering population compared to what is proposed by the progressive model. Specifically, agreeing with negative stereotypes about people who stutter does not necessarily need to precede the application of stereotypes to the self in both children and adults who stutter. Future studies should examine whether Agreement and Application should continue to be considered separately when considering stuttering self-stigma. The relatively low amount of shared variance between Agreement and Application (see Tables 4 and 5) suggests that these constructs are measuring different aspects of self-stigma in children who stutter. To fully understand the nature of subtle differences in stuttering populations with the progressive model of self-stigma, replication studies are needed. Overall, our findings support the notion that self-stigma is a multistage process and provides a basis for future studies of the development of self-stigma across the life span in people who stutter.

Self-Stigma Predicts Childhood Adverse Impact

The third aim of this study was to examine whether a progressive model of self-stigma informs adverse impact related to stuttering in school-age children and adolescents. Research in adults who stutter has established a strong connection between stuttering self-stigma and unfortunate consequences, such as poorer health and reduced quality of life (Boyle, 2013a, 2015; Boyle et al., 2023; Boyle & Fearon, 2018). Therefore, this aim is a critical step toward understanding the relationship between stuttering self-stigma and the adverse impact of stuttering. We found that each stage of self-stigma—Awareness, Agreement, and Application—significantly predicted children's adverse impact related to stuttering, with Application having the strongest effect (see Tables 3–5). Not only do school-age children and adolescents report experiencing the progressive stages of self-stigma, but these stages also differentially contributed to adverse impact related to stuttering. This finding substantiates the progressive model of self-stigma as demonstrated by the latter stage of self-stigma predicting adverse impact of stuttering more strongly compared to earlier stages.

The relationships between self-stigma stages and adverse impact revealed in this study have important clinical implications for mitigating longer-term adverse impact. Interventions for self-stigma related to mental health disorders in adults are in the nascent stages of development (Corrigan et al., 2013; Fung et al., 2011; Lucksted et al., 2011; McCay et al., 2006, 2007; Mittal et al., 2012; Roe et al., 2010, 2014; Rüsch et al., 2014; Russinova et al., 2014; Yanos et al., 2011, 2012, 2015). Notably, key components of these interventions, such as psychoeducation, group experiences, and cognitive strategies, align with aspects of holistic therapy for stuttering. In addition, some treatments for mental health self-stigma incorporate self-disclosure, a form of narration that involves sharing something personal with others (Yanos et al., 2015). Self-disclosure can be a beneficial strategy for managing the negative effects of stigma (Chaudoir & Fisher, 2010). Self-disclosure of stuttering has been linked to less stuttering concealment, lower self-stigma, and higher quality of life for adults (Boyle et al., 2018; Young, Byrd, & Gabel, 2023). A single-subject case report suggests similar benefits for children (Murphy et al., 2007b).

Overall, aspects of emerging interventions in mental health align with existing holistic stuttering therapy approaches and, with additional empirical support, could be tailored toward the treatment of the stages of stuttering self-stigma. Additional research is necessary to understand the effects of these treatment strategies on stuttering self-stigma specifically and to determine which components, or combination of components, might be most effective for children or adults who stutter and for individuals at different stages in the progression of self-stigma.

Considerations and Conclusions

This study provides compelling findings from a relatively large sample of over 100 children who stutter using a novel self-stigma measure, the Child 4S. The adult 4S has been validated in larger groups of people who stutter (Boyle, 2013a, 2015; Boyle et al., 2023; Boyle & Fearon, 2018), while the Child 4S awaits validation with a larger sample of children and adolescents. As an initial step toward researching stuttering self-stigma in children, we adapted and utilized the 4S as it is a robust and valid measure of stuttering self-stigma in adults who stutter. We thus adhered to the original structure of the 4S to ensure the integrity of the underlying constructs of the progressive model of self-stigma. However, future studies could explore aspects of self-stigma specific to childhood stuttering that could be incorporated into the Child 4S (e.g., through open-ended questions or interviews). After reviewing data from our sample of children along with feedback from speech-language pathologists with experience treating stuttering, five questions (in italics) have been added to the Child 4S after the conclusion of this study for follow-up investigation and validation with larger samples of children who stutter (see the Appendix).

While this study included children who stutter from across the United States, most participants were Caucasian (81%) and male (72%). Demographic characteristics such as race and ethnicity affect how people who stutter view themselves and their stuttering (e.g., Daniels et al., 2006) and factors such as sex may also contribute to how the adverse impact associated with stuttering develops (Samson et al., 2021). Concomitant conditions, including speech and language diagnoses or other developmental disorders, may compound the degree of stuttering self-stigma experienced by children. This is important to consider given the high rates of concomitant conditions observed in populations of children who stutter (Blood, Ridenour, et al., 2003; Briley & Ellis, 2018). Lastly, considering preliminary evidence of relationships between self-reported stuttering severity and adverse impact (Horton et al., 2023; Plexico & Erath, 2023), future investigations should also examine how self-reported stuttering severity impacts self-stigma. Follow-up studies with larger samples of children who stutter will allow us to begin to unravel potential relationships between stuttering, concomitant diagnoses, and self-stigma.

Children may progress through the stages of self-stigma at different ages and rates. Our cross-sectional data establish a means for researchers and clinicians to document self-stigma in school-age children and teenagers who stutter and lay the foundation for future longitudinal studies to document the onset and development of stuttering self-stigma more precisely. This longitudinal research will also help clarify the ways in which self-stigma contributes to the development of adverse impact associated with stuttering in an individual at different ages and stages. Efforts such as these could contribute to therapy approaches that impede the progression of self-stigma and, ultimately, the development of adverse impact in children who stutter.

Author Contributions

Chelsea A. Johnson: Conceptualization, Data curation, Visualization, Formal analysis, Writing – original draft. Katelyn L. Gerwin: Conceptualization, Data curation, Writing – original draft, Project administration. Seth E. Tichenor: Conceptualization, Writing – review & editing, Project administration. Michael P. Boyle: Conceptualization, Writing – review & editing. Bridget Walsh: Conceptualization, Data curation, Funding acquisition, Methodology, Writing – original draft, Writing – review & editing, Project administration.

Data Availability Statement

Deidentified data are available upon request by contacting the last author, Bridget Walsh, via her e-mail: walshb16@msu.edu.

Supplementary Material

Supplemental Material S1. Internal consistency of OASES (Cronbach's alpha).
JSLHR-67-2920-s001.pdf (74.9KB, pdf)

Acknowledgments

This research was supported by the National Institute on Deafness and Other Communication Disorders (Grant R01DC018000) awarded to Bridget Walsh. The authors are grateful to all the children and their families for sharing their time and insights to help them better understand stuttering self-stigma experienced by some children who stutter. The authors would also like to thank J. Scott Yaruss and Caryn Herring for their invaluable feedback on the project and initial review of the surveys used in the research including the Child 4S.

Appendix

Child 4S Questionnaire

We are interested to know how you think other people view stuttering. For each item below, please click the response to tell us how much you agree or disagree with the statement.

  1. Most people think that people who stutter are:

    1. Insecure (afraid or hesitant)

    2. Confident (bold or fearless)

    3. Friendly

    4. Capable (able to do things)

    5. Outgoing (open or social to others)

  2. When talking to a person who stutters, most people feel:

    1. Patient

    2. Annoyed

    3. Comfortable

    4. Anxious

    5. Embarrassed

  3. Most people think that people who stutter should:

    1. Avoid speaking in front of large groups

    2. Have others speak for them

    3. Avoid things that require a lot of talking

  4. I believe that most people who stutter are:

    1. Nervous

    2. Confident

    3. Capable (able to do things)

    4. Incompetent (helpless or usefulness)

    5. Insecure (afraid or hesitant)

    6. Outgoing (open or social to others)

    7. Shy

  5. Because I stutter, I feel …

    1. Less confident than kids who don't stutter

    2. Less able to do things than kids who don't stutter

    3. Less intelligent than kids who don't stutter

    4. More nervous than kids who don't stutter

    5. Less outgoing or social than kids who don't stutter*

    6. Less able to stand up for myself than kids who don't stutter*

  6. Because I stutter, I stop myself from …

    1. Talking to other people

    2. Participating in social events

    3. Being involved in discussions

    4. Doing things that require lots of talking*

    5. Selecting what I really want to be when I grow up*

    6. Planning to go to college*

*Italicized questions were not included in the current analyses and are being developed for follow-up studies.

Note. Adapted from Boyle (2013a).

Funding Statement

This research was supported by the National Institute on Deafness and Other Communication Disorders (Grant R01DC018000) awarded to Bridget Walsh. The authors are grateful to all the children and their families for sharing their time and insights to help them better understand stuttering self-stigma experienced by some children who stutter.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Material S1. Internal consistency of OASES (Cronbach's alpha).
JSLHR-67-2920-s001.pdf (74.9KB, pdf)

Data Availability Statement

Deidentified data are available upon request by contacting the last author, Bridget Walsh, via her e-mail: walshb16@msu.edu.

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