Public Knowledge of Stuttering: Cross-Cultural Perspectives
Abstract:
400 African American and Caucasian American adults who did not stutter were surveyed regarding their knowledge of stuttering. A 21-item questionnaire was used to query participants. The major findings of the study were that most persons knew someone who stuttered, viewed stuttering as having a neurological or physiological causation, overestimated the prevalence of stuttering, saw stuttering as occurring more often within their own culture, and identified the speech-language pathologist as the professional who treats stuttering.
Introduction:
Stuttering is a universal phenomenon that has been identified in ethnic and cultural groups around the world (Cooper & Cooper, 2002; Van Riper, 1982). It has been suggested that attitudes toward stuttering are different for various cultural groups (Robinson & Crowe, 2002). Knowledge of, and attitudes toward stuttering have been studied extensively in Caucasian populations but to a lesser degree in other cultural and language groups (Bernstein-Ratner & Benitez, 1985; Richmond, Brown, Jenkins, & Mayo, 2002; Williams & Mayo, 2000). However, one study suggested that negative attitudes toward persons who stutter might also be found among African Americans. Williams and Mayo (2000) examined the reactions of 132 African American college students to videotaped speaking segments of two African American adults--one fluent and the other exhibiting mild-moderate stuttering. The results revealed that the students ascribed significantly more negative traits to the speaker who stuttered.
It has been reported that African Americans hold a number of myths or stereotypes pertaining to the cause and treatment of stuttering (Robinson & Crowe, 1998) and it is likely such stereotypes exist among all American cultures. Therefore, for the purpose of this article, we asked…Would these views interfere with assessment and treatment with African American adults who stutter?
Presumably, one way of reducing individual or group negative attitudes toward persons who stutter would be by increasing the individual or groups’ knowledge and understanding of the nature and treatment of stuttering.
Current and predicted demographic changes in the United States population suggest that the numbers of ethnically and culturally diverse persons who stutter will be increasingly represented in the speech-language pathologist’s caseload. While the prevalence of stuttering among Caucasian populations has been reported as one percent or less (Andrews, 1984; Guitar, 1999), surveys have indicated that the disorder occurs more often in people of African ancestry---ranging from 2.8% among African Americans (Gillespie & Cooper, 1973) to a high of 9.2% among Nigerians (Nwokah, 1988). In comparison, epidemiological data on the occurrence of stuttering in other cultural groups such as Hispanics, Asians, and Native Americans are generally limited but are thought to range from 0.82 to 2% (Tellis & Tellis, 2003).
Cooper and Cooper (1993) stated that with respect to stuttering, “Relatively few data exist concerning variations from culture to culture in the disorder’s affective, behavioral, and cognitive components” (p. 189). They also noted that the study of differences in the “ABCs of stuttering” from one culture to another is critical to professional understanding of fluency disorders. Following multicultural focus group studies in three major United States cities, Smith (1992) concluded that African Americans have little knowledge of communication disorders and even less knowledge of the professionals trained and certified to offer treatment for communication disorders. Thus, the availability of information about what persons of different cultures know about stuttering might help clinicians provide appropriate education about the disorder without disregarding a client’s belief systems or erecting potential barriers to effective intervention. Moreover, to successfully transform misconceptions about stuttering possessed by members of a culture, we must first determine their level of knowledge about the disorder.
The purpose of this study was to examine cross-culturally, African American and Caucasian American adults’ knowledge of stuttering.
Method
Participants
The participants in this study consisted of 400 African American and Caucasian adults (200 per cultural group, 100 per gender group). Volunteers ranged in age from 18 to 82 years (M=36, SD=8.3). Individuals participating in this study resided in the Raleigh-Durham-Chapel Hill, Charlotte, and Greensboro, North Carolina metropolitan areas. Their average level of education was 14.1 years (range=12-22). None of the participants were trained in the field of communication sciences and disorders.
Procedure
A 21-item survey questionnaire was developed for the purpose of this study. Portions of the questionnaire were adapted from Van Borsel and associates’ (1999) survey of public awareness of stuttering among a European population. Five of the questions pertained to participant background information. The remaining sixteen question items were designed to determine participants’ level of familiarity with persons who stutter, their knowledge of the onset and prevalence of stuttering, their understanding of which gender and cultural groups are at greater risk for stuttering, their knowledge of stuttering behaviors, their beliefs about the cause of stuttering, if they would seek treatment for a child or adult who stutters and from whom they would seek intervention services, and their beliefs about which forms of intervention are useful in treating stuttering. Most of the questions allowed for open-ended responses. The specific questionnaire items are provided in the Appendix. Participants were randomly selected from venues such as churches, community centers, schools, and places of employment in their respective cities. The authors, who did not identify themselves as being professionals in the field of communication sciences and disorders, administered the surveys in either individual or small group sessions. A total of 440 questionnaires were distributed to participants. Following the return of all surveys, the authors reviewed each questionnaire for completeness and participant eligibility. Subsequently, 40 questionnaires were eliminated because they were either incomplete (i.e., 31), individuals identified themselves as persons who stutter (i.e., seven), or respondents were found to have a background in communication sciences and disorders (i.e., two). Thus, the survey completion rate (viz: ‘return rate’) for this study was approximately 91 percent.
Results
Analysis of the data did not reveal gender differences in the participants’ responses to the questions. Thus, the findings were compared and are presented descriptively across cultural groups.
In terms of their level of familiarity with individuals with a fluency disorder, most participants (i.e., 189 out of 200 African Americans and 164 out of 200 Caucasians) had met or known a person who stutters who was not a relative (most commonly a friend, co-worker or schoolmate). There were 36 Caucasian and 11 African American respondents who stated they had never known a person who stuttered. African American adults were four times more likely than Caucasian respondents to report having a family member such as a parent, grandparent, or sibling who stuttered (i.e., 28.5% compared to 7%, respectively).
Participants who responded that they knew someone who stuttered other than a relative were asked how many such persons they knew. Their responses, shown in Table 1, reveal slightly more than one-half of Caucasian respondents indicated they had met only one to two persons who stutter. Conversely, 61 percent of African American participants reported meeting three or more persons who stutter.
Table 1. Participants’ level of familiarity with persons who stutter
The majority of the participants (i.e., 98%) knew that stuttering is a disorder that has its origins in childhood. According to the respondents, the average age that stuttering begins is 6.5 years. The average age of stuttering onset according to Caucasian adults was 5.4 years while African American participants on average, believed it was 7.6 years. Estimates of the prevalence of stuttering did vary between the participating cultural groups. African American respondents indicated that on average, 17.6 persons out of 100 stutter. Conversely, the average prevalence estimate for the Caucasian adults was 7.5 percent.
Participants’ beliefs about those groups at risk for stuttering are shown in Table 2. Almost all participants knew that males are disproportionally affected by stuttering compared to females. Interestingly, the African American and Caucasian respondent groups each believed that members of their own culture were at greater risk for stuttering than persons of other cultures. However, the Caucasian adults where more likely to express the latter belief than their African American peers. Persons from Native American, Hispanic, and Asian cultures were seen as being at less risk for stuttering by the African American and Caucasian participants.
Table 2. Participants’ responses to the question, ‘Stuttering occurs most frequently among which groups?’
The participants were asked to list those features or behaviors that constitute stuttering. The question was broadly framed as ‘What happens when a person stutters?’ in order to allow respondents to list a range of features, from motor behaviors to affective reactions. Their responses, shown in Table 3, reveal that the majority of participants knew about the most common forms of disfluencies produced by persons who stutter, i.e., repetitions and blocks. However, none of the respondents specifically listed phrase repetitions or sound prolongations among the core behaviors of stuttering. Both cultural groups listed secondary behaviors as features of stuttering but not to the level of their recognition of core stuttering behaviors. Only a few respondents listed behaviors that could be termed avoidance (e.g., ‘strays off the topic’) as features of stuttering behavior. Likewise, only three participants listed affective responses or feelings experienced by the person who stutters in their descriptions of stuttering behaviors.
Table 3. Participants’ listing of behaviors that constitute stuttering
For the question, ‘What do you think causes stuttering?’ participants were allowed to provide more than one answer. Their responses are shown in Table 4. Both groups of participants saw stuttering as having either neurological/physiological or psychological (including ‘anxiety’) origins. African American adults were twice as likely as Caucasian adults to attribute the cause of stuttering to speaking too fast or ‘thinking faster than the individual can talk.’ Interestingly, a small number of participants from both groups saw stuttering causation as having a hereditary or genetic link. Both respondent groups also listed origins of stuttering that the authors classified as ‘other’ causes. However, more African Americans than Caucasians cited ‘other’ causes of stuttering. The ‘other’ causes category included such responses as ‘the child having a short tongue’, ‘the person was tickled too much as a child’, ‘the person was frightened as a baby’, and ‘the individual was dropped as a baby.’
Table 4. Participants’ opinions on the causes of stuttering
When asked to compare the intelligence of persons who stutter to those who do not, the responses of both groups of participants were nearly the same. It was found that 70 percent of the adults believed the IQ of persons who stutter was equal to that of persons who do not stutter. However, 22 percent of respondents felt the IQ of individuals who stutter was lower and eight percent believed it was higher than persons who do not stutter.
Participants were asked if they would seek treatment for either an adult or a child family member who stuttered. In response, 73.8 percent of African American and 90.7 percent of Caucasian participants said they would seek treatment for an adult relative. Likewise, 78.2 percent of African American and 94.4 percent of Caucasian respondents indicated they would try to find treatment services for a child family member who stuttered.
When asked whom they would go to for stuttering treatment, 22 percent of Caucasian and 15 percent of African American respondents identified the physician as their first choice for intervention. Conversely, 77 percent of Caucasian and 73 percent of African American participants chose the speech-language pathologist as the primary professional they would seek out for stuttering therapy. An additional 10 percent of African American participants and one percent of Caucasian volunteers stated they would seek stuttering therapy services from a counselor or psychologist. Finally, two percent of African Americans revealed they would go to a clergyperson for intervention for stuttering.
Lastly, participants were asked what types of treatment are effective for managing stuttering. The respondents were allowed to provide more than one answer to this question. As seen in Table 5, both groups saw speech therapy as the most effective form of treatment for stuttering. Well over half of all respondents listed psychological counseling as an effective form of stuttering treatment. Additionally, two-thirds of African American as compared to one-third of Caucasian participants viewed prayer as an effective form of intervention for stuttering. Interestingly, nearly one-third of African American and 12 percent of Caucasian participants believed that “stuttering can be controlled by the speaker if he/she tries hard enough.”
Table 5. Participants’ opinions on effective treatments for stuttering. Responses are presented in overall rank order.
Discussion:
A major premise of this study was that determining the level of knowledge members of the general public possess about stuttering is a first step toward dispelling misinformation and ultimately reducing negative attitudes about persons who stutter. As negative opinions about persons who stutter appear to exist cross-culturally, it is important to assess the level of knowledge members of different cultural groups possess about stuttering and persons who stutter.
Among the disorders of speech and language, the American public has the greatest awareness of stuttering (Smith, 1992). The majority of participants in this study were familiar with at least one individual who stuttered, and some reporting having family members who stutter. Thus, participants likely drew some of their knowledge about stuttering from prior experiences with persons who stutter. White and Collins (1984) stated that stereotypes of the person who stutters may originate with inferences drawn from examples one is familiar with, and familiarity with persons who stutter may not translate into benign attitudes about individuals who stutter.
Williams and Mayo (2000) reported that 92 percent of African American college students surveyed indicated knowing at least one person who stuttered and 11 percent stated they had family members who stuttered. Yet, those subjects still ascribed more negative traits to persons who stutter than those who do not.
While the present study was not epidemiological in nature, the finding of higher numbers of African American participants who reported having family members who stutter is noteworthy. African American participants’ greater exposure to relatives and non-relatives who stutter may partly account for their overestimation of the prevalence of stuttering, as compared to Caucasian peers. Past stuttering epidemiology investigations of African American school-age children (Carson & Kantner, 1945; Pritchett, 1966; Waddle, 1938), high school students (Gillespie & Cooper, 1973), and adults (Conrad, 1992) showed a consistent trend for higher prevalence figures among African Americans as compared to Caucasians. No explanation for this phenomenon is available. Shames (1989) noted that understanding the demography of stuttering “may be indicative of what to expect in the way of information about the problem” (p. 68).
Both cultural groups demonstrated knowledge consistent with the traditional understanding of stuttering. That is; stuttering is a disorder that begins in childhood and significantly impacts more males than females. However, recent information about the onset of stuttering suggests it may start earlier in childhood, i.e., beginning between two and five years of age (Conture, 1990; Yairi & Ambrose, 1992a, 1992b). This information has important implications for stuttering assessment and referrals for intervention.
While members of both participant groups perceived persons of their own cultural group as being at greater risk for stuttering, Caucasian adults were more likely to express this belief than their African American counterparts. The relative rarity of stuttering in the general population probably limits the average person’s opportunities to interact with those who stutter. Thus, Caucasian participants’ exposure to persons who stutter may have been circumscribed to members of their own culture with few opportunities to meet African Americans who stutter. Societal factors (e.g., residential choices) as well may contribute to this situation. Conversely, societal factors mandate that most African Americans engage in long-term cross-cultural interactions in educational and work settings as well as in their day-to-day activities. Therefore, their exposure to persons who stutter may frequently include members of other cultures.
Smith’s (1992) focus group findings derived from African American, Hispanic, and Asian adults, revealed that African Americans were the most sensitive to the potential impact of a communication disorder on them as a community.
Participants from both cultural groups saw repetitions and blocks as constituting the major features of what persons who stutter do when they stutter. Additionally, participants described secondary behaviors such as closing of the eyes and extraneous body movements as part of what represents stuttering. This finding is supported by Cooper and Cooper’s (1993) statement that sound repetitions and secondary behaviors in the form of physical concomitants are universally observed features of stuttering that exist in all cultures. However, few of our participants acknowledged secondary behaviors like avoidance or feelings such as embarrassment in their descriptions of what happens when a person stutters. The latter finding is of importance because as Cooper and Cooper (1993) stated, it is with respect to feelings such as shame and embarrassment that cultural differences in stuttering are frequently reported (see Leith, 1986; Leith & Mims, 1975; Ralston, 1981).
The question, ‘What causes stuttering?’ is asked frequently by persons who stutter, their families, and the public (Shapiro, 1999). The present study revealed that when members of two American cultural groups were asked this question, both indicated that stuttering has a neurological/physiological or psychological causation. While the cause of stuttering remains unknown, current opinion (i.e., theory), suggests that stuttering may be related to the interactions between atypically organized neural processing for speech and language (through genetic inheritance or early trauma), a sensitive temperament (due to constitutional bias) and the influence of environmental factors such as family pressures or life events (Guitar, 1998). Silverman’s (1992) statement, “all knowledge is tentative and subject to change as new information becomes available” (p. 110) can certainly be applied to theories about stuttering etiology. Thus, our participants, quite expectedly, exhibited a partial understanding of current views of stuttering etiology by citing neurological causative factors. Additionally, respondents’ belief that stuttering has a psychological basis including “nervousness” or anxiety or that it represents the person’s efforts to ‘speak faster than they can think’ are what Bloodstein (1995) terms “ambiguous” explanations for the cause of stuttering.
Of particular concern is the notion (as represented by both cultural groups in this study) that stuttering has a psychological etiology or that persons who stutter have psychosocial problems. A substantial body of research provides evidence to the contrary (Bloodstein, 1995; Guitar, 1998; Van Riper, 1982). Obviously, the need exists to educate all segments of the American public about these misconceptions of stuttering etiology.
More African American than Caucasian participants ascribed the cause of stuttering to ‘other’ factors. Their suggestions in this category were what Robinson and Crowe (2002) described as ‘stereotypes’ or ‘myths’ about stuttering. Robinson and Crowe (2002) noted that such stereotypes represent explanations that are culture-specific and tend to be passed from generation to generation within a culture. Interestingly, when examined closely, most of these myths suggest that stuttering causation is beyond the control of the person who stutters (e.g., ‘the work of the devil’) or may be the fault of parents or caregivers (e.g., ‘the mother dropped the child as a baby’). Thus, as locus of control of stuttering appears to differ among the cultural groups, clinicians should collect and use this information as part of an assessment/treatment protocol.
To paraphrase Robinson and Crowe (1998) in this regard, a fluency client’s perceptions of the cause of stuttering may not match the clinician’s and if not, there is a high likelihood that therapy, and especially counseling, will not be maximally effective.
Most participants from both cultural groups believed the intelligence level of persons who stutter is the same as or superior to that of persons who do not. Research in this area has been controversial. Studies of IQ suggest that a small intellectual delay exists in children who stutter compared to their peers who do not (Andrew et al., 1983; Guyette & Baumgartner, 1988; Okasha et al., 1974). However, it appears that these differences do not persist beyond childhood in those with normal intellectual function (Guitar, 1998; Silverman, 1992). The responses of the participants of the present study are similar those of Tran and Craig’s (2003) 502 adults who had never met a person who stuttered--they too, believed that persons who stutter have average or above average intelligence.
Referral often constitutes the first step in stuttering intervention. While respondents from both cultural groups stated they would seek treatment services for a child or adult family member who stuttered, greater numbers of Caucasian as compared to African American participants indicated a willingness to access such services (i.e., 92% vs. 76%). In fact, the response rates of our Caucasian participants were similar to those of Killarney and Lass’ (1981) 200 respondents who took part in a study of rural public awareness of speech-language pathology. Those authors reported that 98 percent of their rural volunteers said they would refer a relative for treatment if she/he had a speech or language problem.
Some possible explanations for the differences between our cultural participant groups in their willingness to refer for stuttering therapy could be that the African American respondents were unsure of which professional to refer a relative to for stuttering intervention, or they were less convinced about the effectiveness of stuttering therapy than the Caucasian volunteers and thus, might view referral as “a waste of time.”
Nonetheless, both cultural groups demonstrated similar levels of awareness that the speech-language pathologist was the appropriate professional to provide fluency therapy and that speech therapy is the most effective means of managing stuttering. It is possible that the greater number of African American participants who indicated they would not make a referral for therapy did not perceive stuttering as a condition that merits professional help, or perhaps their past personal experiences with relatives or non-relatives who stuttered, negatively influenced their referral criteria. Participants were nearly unanimous in their view that speech therapy is an effective treatment option for stuttering. Indeed, rank ordering their responses revealed they believed speech therapy to be the most effective means of treating stuttering.
However, over half of our respondents also felt that psychological counseling was an effective treatment for stuttering. Manning (1996) observed that while persons who stutter do not tend to have chronic life-adjustment problems, they experience real and normal reactions to a serious communication disorder (p. 199). In this regard, counseling can be valuable in the intervention process. Silverman (1992) underscored the fact that counseling and other forms of psychotherapy used in isolation, are not effective in eliminating or significantly reducing stuttering severity (p. 79). Others have reported that people who stutter report greater success with intervention that addresses both speech fluency and attitude change than therapy focused solely on fluency or stuttering modification (Yaruss, Quesal, & Murphy, 2002). Thus, counseling when used, as an adjunct to fluency therapy may be effective in helping a person who stutters cope with the effects of stuttering.
More African American than Caucasian participants viewed the application of faith through prayer as an effective means of stuttering intervention. While members of Western cultures may seek the counsel of a minister in matters of health and wellness, African Americans (and persons from other non-Western cultures) frequently seek assistance from ministers or faith healers (Battle, 1997). The extent to which this finding represents a cultural, regional, or cultural-regional phenomenon and whether or not persons who stutter also hold this belief merits further investigation across cultures and geographic regions of the country.
As some of our participants from both cultural groups felt that the speaker who stutters can control stuttering if he/she tries hard enough, further public education appears warranted. This type of thinking can add or reinforce guilt that the person who stutters may have about stuttering (Silverman, 1992).
Finally, the growth in recent years of self-help and support groups such as the National Stuttering Association and the Stuttering Foundation has played a greater role in the recovery process for many people who stutter (Bloodstein, 1995; Bradberry, 1995; Ramig, 1993; Yaruss et al. 2002). These groups can serve important educational and advocacy roles for persons who stutter and their families. However, as the vast majority of people who stutter do not participate in stuttering support groups (Yaruss et al. 2002), it was not unusual that none of the participants in this study knew of such groups or saw them as a resource for stuttering intervention.
Summary:
Based on our research (above), most adults who do not stutter have been exposed to at least one person who stuttered at some point in their lives. These same adults know that stuttering is a disorder that begins in childhood, and they recognize that more males than females stutter.
However, persons from both of our cultural groups grossly overestimate the prevalence of stuttering. Additionally, while members of both cultures know about the exterior features of stuttering, their understanding of the internal or affective features of the disorder is limited.
The views from our lay participants about the cause of stuttering were as varied as those of practicing professionals. A surprisingly high number of respondents from both cultural groups linked stuttering causation to psychological factors and nervousness and anxiety.
As our understanding of the cause(s) of stuttering increases, this information should be shared with other health professionals and the general public on a regular and consistent basis.
Recommendations:
- The clinician should be prepared to address alternative views of the cause of stuttering a client may possess. For example, if a client were to say, “People have told me that I stutter because I speak/think faster than I can talk. Is that what causes my stuttering?” the clinician might respond, “That is certainly an interesting view of stuttering that has been with us a long time. Now, let me share with you what most professionals currently believe are the factors that lead to stuttering.”
- To address reluctance to seek or initiate treatment for stuttering, clinicians should demonstrate for a fluency client or parents that fluency or reductions in disfluent speech can be achieved. This might be accomplished during the assessment session through use of diagnostic therapy. The clinician would demonstrate fluency facilitating or stuttering modification techniques and have the client attempt them. Likewise, the clinician could motivate a potential client to seek treatment for stuttering by showing him/her video sample of successful former clients at the beginning, middle, and end points of their therapy.
- Clinicians should seek to examine the experiences or beliefs of persons who stutter about their experiences or beliefs about the effects of stuttering on their social life, employment, etc. Clinicians should understand that some persons who stutter might believe themselves to be doubly at risk for ostracism based on their cultural background and the fact that they stutter.
- Fluency clinicians should provide ample opportunity for cross-cultural communicative interactions for clients as part of treatment programs to promote transfer and maintenance of fluency skills in the real world
- Public awareness campaigns about stuttering should include faces and voices of persons who stutter from a wide range of cultural backgrounds.
- Future studies may wish to determine the quantity of people who stutter that study participants have been exposed to, and the nature of their communicative interactions (e.g., general conversations, teasing, etc.).
- Professional efforts to educate members of the diverse American public about stuttering might be strengthened by including African American, Hispanic, Asian, and Native American participants in longitudinal studies of stuttering onset, familial trends, and spontaneous recovery.
- Studies that examine the reactions of listeners from various cultural groups to untreated and treated stuttering (see O’Brian et al. 2003) are needed.
- Fluency specialists should explore the value of pairing traditional forms of stuttering therapy with culture-specific treatment philosophies of persons who stutter when appropriate to examine their effect on treatment outcome.
- Promotion of stuttering support groups via media campaigns, the Internet, etc. across cultures using diverse images and in languages familiar to the variety of American communities, can go a long way toward increasing the public’s awareness of this valuable resource.
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Appendix
Questionnaire Items
- Have you ever met/known a person who stuttered (Not a member of your family)?
- Was the person an acquaintance (friend, schoolmate, neighbor)?
- Is there anyone in your family who stutters?
- If yes, what is the relationship of this family member?
- If you answered ‘yes’ to Question # 1, how many persons have you known that stuttered?
1 to 2 __ 3 to 5 __ 6 to 8__ 9 or more__ - Do you stutter?
- At what age does stuttering typically begin?
- How many people out of 100 do you think stutter?
- Stuttering occurs most frequently among which groups?:
Males Females
Caucasians African Americans Hispanics Asians Native Americans - What happens when a person stutters?
- What do you think causes stuttering? (Note: Participants were allowed to provide more than one answer to this question)
- Compared to persons who do not stutter, the IQ of persons who do stutter is:
Higher Lower Equal - Would you seek treatment for an adult family member who stuttered?
- Would you seek treatment for a child family member who stuttered?
- Who would you go to for treatment?
- What types of treatment are effective in treating stuttering? (Note: Participants were allowed to provide more than one answer to this question)
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Correspondence concerning this research should be addressed to:
Robert Mayo, Ph.D.
School of Health and Human Performance
University of North Carolina at Greensboro
401 HHP Building, P.O. Box 26170
Greensboro, NC 27402-6170
phone (336) 334-5900
e-mail: rmayo@nc.rr.com