University of Antwerp (Belgium): Institute of Education and Information Sciences

1. A study of the relation between stuttering and self-esteem of adolescents through mediating internal processes, peer groupstatus and the teacher-student relationship. Towards more transparency of a complex speech disorder. Stuttering…more than words Stefanie Adriaensens University of Antwerp (Belgium): Institute of Education and Information Sciences Faculty of Medicine and Health Sciences (Department ENT – ear, nose, throat) In cooperation with University of Ghent

3. Stuttering…more than words • Stefanie • Introduction • Master thesis • Phd • Future

5. Stuttering…more than words • Stefanie • Introduction • Master thesis • Phd • Future

6. More than words • Definition of stuttering DSM IV TR: “A communication disorder characterized by excessive involuntary disruptions in the smooth and rythmic flow of speech, particulary when such disruptions consist of repetitions or prolongation of a sound or a syllable, and when they are accompanied by emotions such as fear and anxiety, and behaviors such as avoidance and struggle” (APA, 2001) • Complexity of stuttering • Metaphor of the iceberg • Emphasis on observable, external stutter behavior “What is the influence of thoughts and feelings on people who stutter? Does this internal stutter behavior causes someone who stutters to describe himself as a stutterer? Does there exist a self-concept of stutterer? And if so, is this image negative?”

7. The iceberg beneath the surface: the impact of stuttering on the of through processesMaster thesis Clinical psychology (2006-2008) self-esteem adolescents mediating

9. Self-esteem • Development • Sense of self • Cognitive (who am I?)+ affective (+/-) component • ‘Real’ self vs ‘Ideal’ self • Neg evaluations rare in toddlers and young children • Social comparisons increase • Domain specific • People form an image about their appearance and their athletic, social and school capacities. • + a global image of personal functioning

10. Adolescence • Cognitive development • More social comparisons • Perspective taking • More formal thinking => Consequences: • Worried about attractiveness • Egocentric thinking, very focused on themselves • Strengthened self-consciousness • Diminish the attention on negative aspects (Santrock, 2001) ( i.a. De Wit, Van der Veen, & Slot,1995; Larsen & Buss, 2005; Seifert & Hoffnung, 1991 )

11. Stutter research • Within the development of chronic stutter behavior, experiences with stuttering could leave a mark on someone’s self-esteem. • Severe communication disorders could have a negative impact on someone’s quality of life. • Adult research • negative consequences of stuttering, such as anxiety, helplessness, shame and low self-esteem. • Adult people who stutter experience functional difficulties in communication and in activities required for their career. • Research on children • Children who stutter probably have not yet developed a self-image of ‘stuttering’, because of their limited experiences with negative interactions (Green hypothesis). (i.a. Bajina, 1995; Green, 1998, 1999; Klompas & Ross, 2004; Shames & Rubin, 1986; Shapiro, 1999; Yovetich, Leschied & Flicht, 2000)

12. Adolescence When do we notice an influence of stuttering on self-esteem? We need to take a closer look at ‘the period in between’. • Research in adolescence • Just recently studied as separate group • Blood et al. (2003, 2007):Their stuttering teenagers pointed out a positive self-image, comparable with their non-stuttering peers. • Rosenberg Self-esteem Scale = only global self-esteem. • Closeness about their stuttering • Landera (2004): Little attention on their stutter problem • N=9 • Contradictions interviews vs questionnaires

13. Mediators Could internal factors explain the relationship between stuttering and self-esteem? • Negative communication attitudes(i.a. Vanryckeghem et al., 1995, 1997, 2005; De Nil & Brutten, 1991; Andrews & Cutler, 1974) • Hesitate to take the phone, rather be silent in certain speaking situations ... • At early age already aware of different speech • Experienced stigma, resulting in closeness about stuttering(Craig et al, 2000; Blood et al., 2003) • People who stutter are described as stupid, shy, ... • Perfectionism(Amster & Klein, 2004) • less tolerant to errors in their speech, • more concerned to say the wrong things • more intense in their reactions on non fluency • Perfectionism aggravates stuttering • Adaptive vs. maladaptive perfectionism (Stump & Parker, 2000)

14. - Negative communication attitudes + - + - + - ++ Stutter severity Experienced stigma and closeness about stuttering Self-esteem Maladaptive perfectionism Adaptive perfectionism

15. Stuttering…more than words • Stefanie • Introduction • Master thesis • Phd • Future

17. Method • Respondents • 55 AWS • 34M, 18F, 3? • 26 early adolescence (M= 13 years, 3 months; SD= 11 months) • 28 late adolescence (M= 19 years, 4 months; SD= 1 year, 4 months). • Control group: 76 adolescents • 46M, 21F, 9? • SES: (lower) middle class

18. Method - measures

20. Method • Procedure • Year of study: 2007-2008 • Speech therapists and centers that work on stuttering in Flanders • Go-between • ‘Stotterforum’ • former stutter association (BSV) • Control group: • College (Herentals): 1st, 2d and 6th grade ASO • Mouth to mouth: post-graduates (19-20y)

22. Results • Preliminary analyses • No effect of SES andagegroup • Gender does matter

23. Results • (Subjective) stutter severityandself-esteem

24. Results Close friendship Negativecommunication attitudes • Mediationprocesses + − + − Socialacceptance School competence Global self-esteem Stutter Severity Maladaptive perfectionisme

25. Discussion • Conclusions • In comparison to young children, we do see an influence of stuttering on self-esteem in adolescence • Hypothesis Green: more negative experiences? => negative CA: Stuttering has an impact on self-esteem because AWS experience(d) communication situations as negative • Importance of domain specific self-esteem • Maladaptive perfectionism: Stuttering has een impact on self-esteem because AWS more often are concerned about making mistakes and doubt their actions • Other mediators: • Stigma / closeness: • Experienced stigma independent of stutter severity • Effect of stuttering on closeness (cfr. Santrock, 2001) • Adaptive perfectionism: higher standards in AWS? • Self-protective mechanism??

26. Discussion • Conclusions • Theory: Importance of internal stutter behavior • Self-concept ‘stutterer’ • Emotional and cognitive processes • Therapy: Challenging negative communication attitudes and perfectionistic thoughts • More effect on self-esteem (Quality of life)  stutter severity • cognitive behavioural therapy + traditional stutter modification therapy (Amster & Klein, 2007; Blomgren et al., 2005) => Reduces stuttering, a perfectionistic attitude and negative attitudes

27. Discussion • Future research • Objective vs subjective stutter severity • Longitudinal research • Complex bidirectional relations • Mediators • Temperament: a sensitive temperament contributes to a vulnerability to the development of stuttering (Guitar, 2006) • Self-protective mechanisms? • Social mediators: peer group status and teacher-student relation => Creating an ‘open’ class environment! (Publication: under construction)

28. Stuttering…more than words • Stefanie • Introduction • Master thesis • Phd • Future

30. Added value • Objective vs subjective stutter severity • Longitudinal research • Complex bidirectional relations • Mediators: • Temperament: a sensitive temperament contributes to a vulnerability to the development of stuttering (Guitar, 2006) • Self-protective mechanisms? • Social mediators: peer group status and teacher-student relation => Creating an ‘open’ class environment! • Contingent self-esteem: • Depending on reaching certain conditions, outcomes and performances (Kernis, 2002)

31. Temperament • Guitar (2006) a sensitive temperament contributes to a vulnerability to the development of stuttering. • Karass et al (2006): emotional temperament in young stutterers develops after their experiences with stuttering and negative social feedback. • ‘Chicken or the egg’ problem • Temperamental character traits more present in stuttering children (Boey, 2012)

32. - Negativecommunication attitudes + - + - ++ +- Stutter Severity Maladaptiveperfectionism Self-esteem Adaptiveperfectionism Temperament

33. Socialmediators • More likely to be bullied • Adolescence => greater emphasis on relationships with peers • Negative stereotypes • Difficulties to adapt, shy, nervous,… • Teachers’ attitudes towards stuttering • Less important problem, misinformed and stereotypical views, no diff according to experience, (e.g. Abdalla et al, 2012; Pachigar et al, 2012; Lass et al., 1992) • Increased awareness/knowledge of stuttering leads to a more desirable attitude towards stuttering (Crowe and Walton, 1981) • Limited research on impact of stuttering on teacher-student relationship • Surprising given the crucial role of the teacher in care policy + increasing emphasis on action-oriented work (HGW) • A supporting T-S relationship can act as a buffer (Baker, 1998; Werner & Smith, 1989)

34. - Peer group status - + -+ + Stutter Severity Teacher-student relationship Self-esteem Teachers attitudes / knowledge on/of stuttering

35. Method • Procedure / Respondents • Longitudinal study: feb2013 - april2015 • 5 measurement points • +/- every 6 months • Questionnaire + obj SE • AWS 60 and 60 controls (minimum goal) • School variables (‘Future’) • Mediation process: • 1 measure: 2 teachers + classmates => 60 AWS • School year 2013-2014 • Qualitative study • Interviews => selection 60 AWS • Exploratory quantitative study • Questionnaire => teachers secondary education

36. Method - measures • Othermeasurescfr. master thesis: subjective stutter severity, (multidimensional) self-esteem, negativecommunication attitudes, perfectionism

38. Measurement 1 • Timing: February 15 - April 15, 2013 • 64initial participants • E.g. not right age, did not registered themselves, failed to reach • 40 AWS & 13 control group • control group through participants • 11-18 years (M = 14.17) ‘secondary education’ • 80.9% (lower) middle SES • AWS: 65% male / control: 46.2% male • 19 in therapy; 13 in past; 4 FU en 3 never • Internal mediation processes

39. - Negativecommunication attitudes + - + - ++ +- Stutter Severity Maladaptiveperfectionism Self-esteem Adaptiveperfectionism Temperament

40. Results • Preliminary analyses • AWS  control group • Subjective stutter severity • Neg CA: 3,04  2,31(p<.01) • Neg affect / frustration: 3,21  2,65 (p<.05) • Background variables: • SES: Physical appearance & global self-esteem (High) • Age: Close friendship (older), affiliation (younger) • Therapy: maladaptive perfectionism (not in therapy), effortful control (in therapy) • Adaptive perfectionism?! • Gender: athletic competence (Boys) • Not significant, but comparable differences master thesis, with exception of physical appearance

41. Results • (Subjective) stutter severityandself-esteem • Contingent SE: not significant (.10) • AWS: School competence -.27 and Global SE -.24

42. Results Neg CA: • School competence • Socialacceptance • Global SE • Neg CA: .68** • Keep track of • (mal+)adaptive-perfectionism • Pos reactivity- • Effortful control- • Mediationprocesses Effect of stutter severitydecreasessharply

43. Although not statistically significant, we see substantially similar trends in comparison with results master thesis: • Importance emotional and cognitive processes • Self-concept stutterer? • Hypothesis Green • Importance of negative communication attitudes • Perfectionism: • So far, we found no clear support for significance of maladaptive perfectionism conform master thesis • But: keep track of potential structural difference AWS  control

44. Stuttering…more than words • Stefanie • Introduction • Master thesis • Phd • Future

46. Longitudinalstudy • Feb2013 - april2015 • 5 measurement points (+/-every 6 months) • M1: compare results with objective stutter severity measures • M2: oct – nov 2013 • M3: march – april 2014 • confounding/moderating variables mediators  SE, e.g. home climat • AWS 60 and 60 controls (minimum goal) • Ongoing registrations! • Dutch speaking • 11 – 21 years • +/- 1h work every 6 months (questionnaire + recording) • http://www.onderzoekstotteren.be

47. Schoolstudy • Mediation process • peer-group status & teacher-student relation (controlled for their attitudes on stuttering) • 1 measure: 2 teachers + classmates => AWS • School year 2013-2014 • Qualitative study • ‘In depth-study’ of teacher-student relation  stuttering • Interviews => selection of teachers AWS • Quantitative study • ‘Exploratory large scale study’ of teachers knowledge and attitudes towards stuttering • Questionnaire => teachers secondary education • Measures(?): • Peer group status -> socio metric measure • Teacher-student relation -> STRS (Pianti, 2001) • Teacher attitudes towards stuttering: TATS (Crowe & Walton, 1986), TPSI (Yeakle & Cooper, 1986)

48. “If we go to therapy, we think about it. If we don't go to therapy, we think about it. It's always there. Either it defines us or we find ways of accommodating it, working toward a state of peaceful coexistence.” (Dan Slater, The Washington Post, 20th December 2010). Thank you! Stefanie.adriaensens@ua.ac.be www.onderzoekstotteren.be www.facebook.com/onderzoekstotteren stottercafeantwerpen@gmail.com