The Public Environment Where Attitudes Develop: Stuttering Versus Mental Illness and Intelligence
About the presenters: Kenneth O. St. Louis, Ph.D. (West Virginia University, Morgantown, West Virginia), is the co-founder of the International Fluency Association and has carried out research in the areas of stuttering and cluttering for 25 years. He has actively collaborated with researchers, including investigators from other countries, on several large projects, e.g., a special edition of the Journal of Fluency Disorders on cluttering, is an associate editor for the Journal of Fluency Disorders, and has served on several key ASHA committees and task forces relating to specialty recognition and terminology in fluency disorders.
James D. Schiffbauer is currently a graduate student in forestry at West Virginia University. He completed his undergraduate honors degree at the same institution in biology with in 2000. Schiffbauer has a special interest in advocacy for the mentally ill.
Carolyn I. Phillips graduated from West Virginia University in 2000 with a double honors major in Spanish and elementary education. She has a special interest in bilingual education and has carried out research on political and practical issues involved in that area.
Andrea B. Sedlock is an honors student at West Virginia University studying animal and veterinary science. She aspires to become a veterinarian but has carried out research in attention-deficit/hyeractivity disorders.
Lisa J. Hriblan is currently a graduate student in speech-language pathology at West Virginia University. Hriblan also received her honors baccalaureate degree in that field in 2000 and as an undergraduate carried out research in the area of cleft palate.
Rebecca M. Dayton is currently an honors student in a 5-year teacher education program at West Virginia University wherein she will receive a master's degree. She plans to become a classroom teacher. Dayton has carried out research on the effects of mental illness of parents on their children.
The Public Environment Where Attitudes Develop: Stuttering Versus Mental Illness And Intelligence
by Kenneth O. St. Louis, James D. Schiffbauer, Carolyn I. Phillips, Andrea B. Sedlock, Lisa J. Hriblan, and Rebecca M. Dayton
from West Virginia, USA
The speaking problems experienced by those who stutter are compounded by erroneous and negative attitudes held by society about this mysterious speech disorder. For example, a number of studies have reported the public perception that stutterers are nervous, shy, fearful, and introverted. This "stereotype" is held by most groups that have been investigated: the lay public, professionals (including many speech-language pathologists), teachers, and even persons who stutter (Shapiro, 1998). It seems logical, therefore, that changing societal attitudes must involve educating the public about the stuttering and replacing erroneous ideas with those that are factual.
Many education efforts have focused especially on stuttering children or their parents. Why? Because we know that the vast majority of cases of stuttering begin around three years of age and that chronic cases persist through childhood (Bloodstein, 1995). We also know that young children are impressionable; they typically adopt the attitudes and positions taken by their families and the society in which they are reared. It is no surprise, then, that children who stutter, growing up within a social milieu that fosters incorrect or maladaptive attitudes, end up holding many of those same incorrect or maladaptive attitudes. Two examples of organizations that have undertaken education campaigns to alter the internalization of inappropriate or erroneous attitudes in stuttering children are the Stuttering Foundation of America and the Stuttering Information Center of Denmark though their inexpensive distribution of books, videotapes, and other materials about stuttering and its therapy. The rationale is that if societal attitudes can be altered, stuttering children will be better understood and treated more appropriately by parents, relatives, peers, teachers, and others.
This position is both logical and appealing; nevertheless, there are a number of important gaps in our information. First, in spite of considerable research on attitudes toward stuttering, it is premature to assume that we completely understand public opinion about stuttering. For example, Klassen (2000) found that when nonstutterers were asked questions about stuttering that related to a stuttering individual whom they actually knew well, many of the aforementioned stereotypes did not appear. Second, the data available generally do not compare stuttering to other anchoring conditions so that we may estimate the seriousness of the misperceptions within a broader societal context. Third, while there is limited evidence that public education campaigns do achieve their desired effect, anecdotal evidence exists suggesting that certain activities may not be effective (Pill, Personal communication).
To address these issues, a major initiative is underway at several locations around the world known as the International Project on Attitudes Toward Stuttering (IPATS). The first phase of IPATS was to develop and pilot a prototype of an attitude questionnaire. A description of the purposes of IPATS and initial activity was presented in the 2nd ISAD On-Line Conference (St. Louis, Lubker, Yaruss, Pill, & Diggs, 1999). The first prototype of an instrument was developed and eventually named the Experimental Edition of Public Opinion Survey of Human Attributes (POSHA-E). About 1000 POSHA-Es were printed and given out to members of the public in a number of communities in North America and elsewhere. The POSHA-E is a lengthy questionnaire, requiring 30 minutes or more to fill out. It consists of a cover sheet with instructions, a one-page general section asking a few questions about nine different human attributes, some assumed "positive," some relatively "neutral, and some "negative" (stuttering, mental illness, overweight, wheelchair user, old, left handed, multilingual, good talker, and intelligent), three longer specific sections (a stuttering section plus sections pertaining to two of the other eight attributes), and a demographic section. Importantly, the cover letter points out that the survey is designed to "explore public opinion about a number of human attributes and characteristics…"; stuttering, per se, is not singled out. Most of the responses on the experimental version consist of vertical lines drawn through dotted horizontal lines to show respondents’ opinions on continua, e.g., from "not at all" to "very much." The vertical lines are then converted to numbers from 0 to 100 by measuring responses with a template ruler.
As a group project in an undergraduate honors class on advocacy and social science at West Virginia University, students used the POSHA-E to investigate selected attitudes of university students and nonstudents. Their purpose was to compare public attitudes of stuttering with the other "anchor" human attributes in these groups, but with special emphasis on the divergent attributes of mental illness (assumed to be negative) and intelligence (assumed positive). This report focuses on selected results from that investigation, especially those results that relate to the public opinion environment where individual attitudes develop in children.
METHOD
The honors class students distributed 175 POSHA-Es directly and indirectly (i.e., through third parties) to university student and nonstudent acqaintances in the Morgantown, West Virginia and surrounding areas. They collected 90 completed questionnaires (a 51% return rate), 52 from students in a variety of majors and 38 from nonstudents. Five states were represented, but 88% of the respondents were from West Virginia. The mean age of the combined group was 31.3 years, and the mean years of education were 15.6. The student respondents ranged in age from 18 to 40, with a mean age of 21.3 years, whereas the nonstudent sample ranged from 21 to 70 years, with a mean of 44.7 years. Of the 50 students who identified their sex, 14 were male and 36 were female. Sixteen of the 37 nonstudents who identified their sex were male; 21 were female. The nonstudent respondents represented a wide variety of occupations and professions, but, notably, 17 of this group were teachers or professors.
Recalling that subjects received specific sections on stuttering and two of the eight other attributes, 25% of the total subjects responding to the stuttering section would be expected to respond to sections on each of the other attributes. In fact, of the 90 total subjects, 12 students and 7 nonstudents (21%) received and responded to the specific mental illness section and 16 in each group (36%) received the intelligence section. This was so in spite of the fact that POSHA-Es handed out had been counterbalanced and collated to virtually equalize the number of respondents receiving each of the eight attributes (aside from stuttering) if all distributed questionnaires were returned.
Very few respondents in either group regarded themselves as stutterers (2%), two students and no nonstudents, respectively. Six percent of the total group indicated they were mentally ill (all students). Forty-four percent of all of the respondents considered themselves to be intelligent. By contrast, the percentage of respondents reporting knowing "nobody" with the attribute in question was 31% for mental illness, 18% for stuttering, and 1% for intelligent. The percentages of respondents reporting close relatives were 9% for stuttering, 16% for mental illness, and 72% for intelligent. Respondents were asked to rate, negative to positive, on continuum lines four characteristics about themselves with results as follows: their physical health (66), mental health (71), ability to learn new things (82), and speaking ability (80), all out of 100.
RESULTS
We tested the significance of differences between the 1-100 numbered ratings of student and nonstudent respondents on the general, stuttering, mental health, and intelligence sections. Only 11 of 245 comparisons were statistically significant at the .05 level. Given the high probability of a Type I error with this large number of comparisons, we determined that there was little evidence that the adults and students rated the items differently. The data for students and nonstudents were therefore combined.
Respondents’ "overall impression" of stuttering was 49 out of 100, nearly equal to mental illness (48). Not surprisingly, both of these attributes were lower than being intelligent (77). By contrast, when asked to indicate the extent "I would want to be a person who..." respondents’ mean rating of "has a stuttering disorder" was 10 (39 points lower) and 5 for "is mentally ill" (43 points lower). Their mean score increased to 90 for a person who "is intelligent."
The respondents in these samples indicated that they knew less about people who stutter (40) than those who are mentally ill (48) or intelligent (72). One set of items sampled respondents’ ratings of the contributions of various factors to the cause of these three attributes. The results were often ambiguous, with respondents rating contradictory items equally high. The strength of opinion was generally highest for mental illness (with a mean of 76 for the top five causes), followed by those for intelligence (mean of top five = 73), and then those relating to stuttering (mean of top five = 55). Psychological factors and brain functioning were rated highest for stuttering and mental illness as etiological factors, but emotional trauma, pressure or tension at home, and genetic inheritance were nearly as high. Brain functioning and learning or habits were rated highest for causing intelligence, but genetic and psychological factors were considered important as well. Information on the attributes reportedly came from a variety of sources, but it is significant that respondents rated "my school teachers" low as a source of knowledge for stuttering (24) and mental illness (26) but relatively high for intelligence (65). The most important source of information on stuttering was "my experience with others who stutter" (54) compared to "magazines, newspapers, or books" for mental illness (65) and "my family or friends" for intelligent (77).
Though relatively low, the results for two additional "causal" items are interesting. Respondents’ mean rating for "an act of God" was 18 for stuttering, 23 for mental illness, and 44 for intelligent. They also rated "ghosts, demons, or spirits" as 10 for stuttering, 15 for mental illness, and 7 for intelligent.
The respondents believed both those who stutter and are mentally ill should get help for their problems, 72 and 87, respectively. They were most likely to identify a "speech therapist or clinician" for stutterers (87) followed by a "medical doctor or pediatrician"(74). Mentally ill people were perceived to be best helped either by a "psychologist, psychiatrist, or counselor" (86) or a "medical doctor or pediatrician" (86) followed by " the family of the person who is mentally ill" (81).
Asked to identify how they would feel in the presence of someone with these attributes, respondents rated "comfortable or relaxed" from 50-59 for all three of these attributes. "Pity" was rated 31 for stuttering, 45 for mental illness, and 9 for intelligence. Embarrassment was rated from 12-19, highest for intelligent. Mean scores for "afraid the [attribute] might affect me" were 4 for stuttering and 11 for mental illness.
Respondents reported the greatest concern about their son (95) or daughter (95) being mentally ill or stuttering (73 and 74). These compared to only 12 and15* for intelligence. They were also concerned about their younger or older children’s teachers or friends being mentally ill (four items ranging from 72 to 81) or stuttering (32 to 54) but not for being intelligent (14 to 17)*.
Individuals with each attribute were rated for such things as being able to "lead normal lives": stuttering–85, mentally ill–54, and intelligent–83. But when rated for the extent to which the attributes affect people’s ability to function in various specific activities, ratings were much lower for stuttering (especially) and mental illness. For example, "interact with people socially" was 33 for stuttering, 34 for mental illness, and 71 for intelligent; "make friends" was 39 for stuttering, 36 for mental illness, and 72 for intelligent; "do well in school" was 44 for stuttering, 41 for mental illness, and 88 for intelligent; and "get a job" was 40 for stuttering, 37 for mental illness, and 87 for intelligent. Apparently, being able to lead a normal life is not perceived to include some of these activities.
DISCUSSION
The results of this attitude survey must be considered tentative primarily because the number of subjects responding to the specific sections on mental illness and intelligence were from 19 and 32 respondents, respectively, compared to 90 for the stuttering, general, and demographic sections. For this reason, comparable items across the three attributes were not subjected to significance testing. Nevertheless, the results of the total group and both subgroups in this study are quite consistent with six other small samples (n = 25) and one even smaller sample in another language (n = 14) that looked at results for the stuttering and general sections (St. Louis, Yaruss, Lubker, Pill, & Diggs, 2000). This suggests that the results of small samples are reasonably robust, although careful statistical treatment would be required to verify that assumption.
Given this caveat, the aforementioned results indicate quite strongly that stuttering is regarded, rightly or wrongly, as a serious handicap by the public, nearly as serious as mental illness. In some of the comparisons noted, mental illness is seen as a more serious condition, but in others, the differences between stuttering and mental illness were negligible. Whereas it is likely that respondents answered with an acceptable degree of honesty regarding their own opinions, it is also likely that many did not know the full ramifications of the discrimination, life difficulties, and despair experienced by many who are mentally ill (Secunda, 1997). The results may also suggest over-emphasis of the problems experienced by those who stutter. In any case, the findings point to an absence of important knowledge about stuttering as well as mental illness which no doubt influences public attitudes. We did not expect that being intelligent would be regarded as a problem, and, in general, it was not, even though a few ratings were not as high as one might have predicted.
Considering the environment in which stuttering children grow up, a number of challenges are highlighted by this investigation. The public–and by inference the average parent of a child who stutters–recognize that they do not know much about stuttering. Accordingly, it is not surprising that respondents were unclear about the nature and cause of the disorder. The information they do have seems to come rarely from schools. The public correctly identifies speech-language professionals as appropriate personnel to consult for help, but also believes that a number of other less qualified individuals are appropriate sources as well, such as physicians, psychologists, physical/occupational therapists, or even one’s family. The public appears to be reasonably tolerant of stuttering and optimistic about life in general for those who stutter so long as stuttering is considered as an abstraction. By contrast, when asked to be more specific, respondents viewed stuttering as an extremely undesirable condition to have, nearly as undesirable as mental illness; were quite concerned about stuttering in others affecting their children; and were quite pessimistic about stutterers’ success in such activities as making friends, doing well in school or on the job, and interacting socially with others effectively. These more specific activities were similarly lower for mental illness. By contrast, it is important to note that specific activity ratings (e.g., "make friends") were similar to the general rating, "can lead normal lives," for the positive attribute of intelligence.
If children who stutter are to be reared in a more enlightened society, it appears that we have a great deal of work to do in educating the public about stuttering. In addition to the ongoing activities of the Stuttering Foundation of America, the National Stuttering Association, and other well-known organizations, a number of recent initiatives are underway to improve the environment for youth who stutter, e.g., the peer teasing and bullying project in Canada (Langevin, 1997, 2000), the efforts in Friends (a self —help group for children who stutter and their parents), and the publishing of children’s books about stuttering (e.g., Lew, 1999; Sugarman, 1995). These efforts must impact schools, families, and communities if they are to reach a large segment of the population.
Yet, in order for public education to be effective, it must eventually translate into positive changes in attitudes. It seems plausible to assume that some efforts will be more effective than others. In order to begin to isolate those efforts, research is needed on the effectiveness of a variety of approaches and settings. In such research we believe that a systematically documented and standardized measure such as the POSHA will be extremely useful. Based on the outcome of this and other pilot investigations using the POSHA-E, the current version will by systematically modified and further field-tested to eventually provide such an instrument.
*The question for stuttering and mental illness was "If the following people [stuttered/were mentally ill], I would be concerned." For intelligence, the question was worded, "If the following people were intelligent, I would be pleased." Therefore, the mean results for intelligence were subtracted from 100.
ACKNOWLEDGMENT
The authors gratefully acknowledge the efforts of the following IPATS Task Force members in developing the POSHA-E: J. Scott Yaruss, Bobbie Boyd Lubker, Jaan Pill, and Charles C. Diggs.
REFERENCES
Bloodstein, O. (1995). A handbook on stuttering, 5th ed. San Diego, CA: Singular.
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Langevin. M. (1997). Peer teasing project. In E. Healey and H.F.M. Peters (Eds) 2nd world congress on fluency disorders: Proceedings (pp. 169-171). The Netherlands: Nijmegen University Press.
Langevin, M. (2000) Teasing and bullying: Unacceptable behaviour. Edmonton, Alberta: The Institute for Stuttering Treatment and Research.
Lew, G. W. (1999). Jeremy and the hippo (A boy’s struggle with stuttering). Anaheim Hills, CA: National Stuttering Association.
Secunda, V. (1997). When madness comes home. New York: Hyperion.
Shapiro, D. A. (1999). Stuttering intervention: A collaborative journey to fluency freedom. Austin, TX: Pro-Ed.
St. Louis, K. O., Yaruss, J. S., Lubker, B. B., Pill, J., & Diggs, C. C. (2000). An international public opinion survey of stuttering: Pilot results. Seminar presented at the 3rd World Congress on Fluency Disorders. Nyborg, Denmark.
St. Louis, K. O., Lubker, B. B., Yaruss, J. S., Pill, J., & Diggs, C. C. (1999). International Project on Attitudes Toward Stuttering: Initial planning and status report. Paper presented at the 2nd International Stuttering Awareness Day On-Line Conference.
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September 13, 2000
