Journal of Communication Disorders 52 (2014) 143–155
Contents lists available at ScienceDirect
Journal of Communication Disorders
Understanding perceptions of stuttering among school-based speech–language pathologists: An application of attribution theory Michael P. Boyle * Department of Communication Sciences and Disorders, Oklahoma State University, 042 Murray Hall, Stillwater, OK 74078, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 21 December 2013 Received in revised form 13 June 2014 Accepted 28 June 2014 Available online 7 July 2014
Introduction: The purpose of this study was to investigate whether attribution theory could explain speech–language pathologists (SLPs) perceptions of children with communication disorders such as stuttering. Specifically, it was determined whether perceptions of onset and offset controllability, as well as biological and non-biological attributions for communication disorders were related to willingness to help, sympathy, and anger toward children with these disorders. It was also of interest to determine if blame for stuttering was related to perceived controllability of stuttering and negative attitudes toward people who stutter (PWS). Method: A survey was developed to measure perceived onset and offset controllability, biological and non-biological attributions, willingness to help, sympathy, and anger toward middle school children with developmental stuttering, functional articulation disorders, and cerebral palsy. In addition, a scale was developed to measure blame and negative attitudes toward PWS in general. Surveys were mailed to 1000 school-based SLPs. Data from 330 participants were analyzed. Results: Supporting the hypotheses of attribution theory, higher perceived onset and offset controllability of the disorder was linked to less willingness to help, lower sympathy, and more anger across conditions. Increased biological attributions were associated with more reported sympathy. Increased blame for stuttering was linked to higher perceived controllability of stuttering, more dislike of PWS, and more agreement with negative stereotypes about PWS. Conclusions: Educating SLPs about the variable loss of control inherent in stuttering could improve attitudes and increase understanding of PWS. Reductions in blame may facilitate feelings of sympathy and empathy for PWS and reduce environmental barriers for clients. Learning outcomes Readers should be able to: (1) identify the main principles of Weiner’s attribution theory (2) identify common negative perceptions of people who stutter (3) describe how disorders of stuttering, articulation disorders, and cerebral palsy are differentiated in terms of perceived onset and offset controllability, and biological and non-biological attributions (4) describe relationships between perceived onset and offset controllability of disorders and sympathy, anger, and willingness to help. ß 2014 Elsevier Inc. All rights reserved.
Keywords: Stuttering Attribution theory Blame Controllability Stereotypes
* Corresponding author. Tel.: +1 405 744 8946; fax: +1 405 744 8070. E-mail address: [email protected] http://dx.doi.org/10.1016/j.jcomdis.2014.06.003 0021-9924/ß 2014 Elsevier Inc. All rights reserved.
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1. Introduction Stuttering is experienced as an intermittent and unpredictable loss of control over the speech production process (Quesal, 2010; Perkins, 1990). Improving speech fluency can be a beneficial and worthy treatment goal for PWS (Herder, Howard, Nye, & Vanrycheghem, 2006; Nye et al., 2013). However, it is also known that maintenance of these efforts over time and situations is very difficult for PWS, especially in anxiety provoking situations (Craig, 1998). Due to the chronic nature of stuttering, attaining completely normal and lasting fluency may be an unrealistic goal for many PWS, despite the noticeable benefits of learning speech modification strategies for improved fluency (Cooper, 1993). Because stuttering involves a variable loss of control over speech production that can result in social penalties (Blood et al., 2011), PWS experience challenges such as negative communication attitudes and emotions, social anxiety, reduced quality of life, activity limitations and participation restrictions (Bricker-Katz, Lincoln, & Cumming, 2013; Bricker-Katz, Lincoln, & McCabe, 2009; Craig, Blumgart, & Tran, 2009; Daniels, Gabel, & Hughes, 2012; Iverach & Rapee, 2013; De Nil & Brutten, 1991; Plexico, Manning, & Levitt, 2009; Vanryckeghem & Brutten, 1996). In order to increase feelings of control over speech production, improve overall communication skills, and reduce the negative life impact of stuttering in PWS, speech–language pathologists (SLPs) need to be trained to deliver quality services that address cognitive and affective domains, in addition to speech modification (Cooper, 1993; Yaruss, Coleman, & Quesal, 2012). Unfortunately, research has shown that SLPs and students in communication disorders are uncomfortable, unconfident, and often unprepared to work with PWS (Brisk, Healey, & Husk, 1997; Kelly et al., 1997; St. Louis & Lass, 1980; St. Louis & Lass, 1980; St. Louis & Durrenberger, 1993; Tellis, Bressler, & Emerick, 2008). Furthermore, SLPs and classroom teachers tend to hold negative stereotypical views about personality characteristics (e.g., that they are nervous and nonassertive) of PWS regardless of their age (Abdalla & St. Louis, 2012; Cooper & Cooper, 1996; Horsley & FitzGibbon, 1987; Lass, ¨ zdemir, & Tog˘ram, 2013; Ragsdale & Ashby, 1982; Ruscello, Pannbacker, Schmitt, & Everly-Meyers, 1989; Mavis¸, St. Louis, O Turnbaugh, Guitar, & Hoffman, 1979; Woods & Williams, 1976). Stigmatizing attitudes and unfavorable perceptions held by SLPs toward individuals who stutter represent an environmental barrier to optimal service delivery (American Speech-Language-Hearing Association (ASHA), 2007) and may limit therapy gains experienced by PWS. Qualitative data from interviews of PWS suggest that some SLPs can be perceived as judgmental, annoyed, and not understanding of the unpredictable and intermittent loss of control experienced during stuttering and this contributes to the perception of ineffective therapy (Plexico, Manning, & DiLollo, 2010). Furthermore, awareness of negative public perceptions of stuttering is very high among PWS and this is significantly correlated with internalization of negative stigmatizing thoughts (Boyle, 2013). From this evidence, environmental factors (e.g., listener perceptions) do appear to be relevant for the psychological well-being of the individual and the effectiveness of therapy. These negative public perceptions of PWS should be eradicated. 1.1. Attribution theory One potentially useful lens through which to look at negative stigmatizing attitudes toward PWS and their possible mitigation is Weiner’s (1985, 1986) attribution theory. Attribution theory states that the more controllable a stigmatizing condition is perceived, the more anger and blame it will create in the public, and the less willingness to help and sympathy will be demonstrated (e.g., blindness will receive more sympathy and willingness to help, and less anger and blame compared to alcoholism) (Menec & Perry, 1998; Weiner, 1995; Weiner, Perry, & Magnusson, 1988). Attribution theory has been supported in previous research with several different stigmatized conditions and disorders including schizophrenia and depression (Boysen & Vogel, 2008; Jorm & Griffiths, 2008; Lincoln, Arens, Berger, & Rief, 2008), eating and weight disorders (Crandall, 1994; Ebneter, Latner, & O’Brien, 2011), challenging behaviors (Dilworth, Phillips, & Rose, 2011), drug addiction (Corrigan, Kuwabara, & O’Shaughnessy, 2009), autistic behaviors (Ling, Mak, & Cheng, 2010), mental disorders (Mukolo & Heflinger, 2011), and self-harm (Law, Rostill-Brookes, & Goodman, 2009). Two of the most frequently mentioned concepts in attribution theory include dimensions of onset controllability and offset controllability. Onset controllability refers to beliefs about how much the person, compared with external forces (e.g., biological or environmental factors), is responsible for the onset of a specific condition or disability that is stigmatized. Offset controllability refers to beliefs about how much a person is held responsible for the offset, or solution, of the condition. Biological attributions (e.g., genetic and neurological explanations of conditions) are related to less onset and offset controllable deficits whereas non-biological attributions are related to higher perceived onset and offset controllability (Phelan, 2002, 2005). Physically based conditions (e.g., paraplegia, blindness, Alzheimer’s disease) are generally perceived as having more biological attributions and therefore less onset and offset controllability than disorders that are perceived as mental-behavioral (e.g., drug abuse, obesity, mental illness) (Corrigan et al., 2000; Weiner et al., 1988). Applying this model to speech–language pathology, it has been noted that disorders such as cerebral palsy are perceived as being more onset and offset uncontrollable whereas disorders like functional articulation disorders are on the opposite end of the continuum in terms of being perceived as more controllable (i.e., more amenable to change) (Murphy, Quesal, & Yaruss, 2012). These disorders would then theoretically serve as useful anchors and points of comparison to other disorders on the continuum of controllability and biological attributions. It should be noted that some research studies have not entirely supported Weiner’s attribution theory (Jones & Hastings, 2003). In some cases higher offset controllability is
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associated with increased willingness to help (Willner & Smith, 2008). Other findings indicate that uncontrollable biological and genetic attributions may negatively impact perceptions of prognosis and recovery potential (Lam & Salkovskis, 2007; Lincoln et al., 2008; Phelan, 2002, 2005). 1.2. Attributions for stuttering To date there have been no studies conducted that analyze perceptions of controllability or biological attributions of stuttering among school-based SLPs toward children who stutter, however previous research shows that misunderstandings about the etiology of stuttering are common. Studies have shown that only 7% of the public believes that stuttering has neurogenic causes, and 45% believed that stuttering had psychogenic causes (Van Borsel, Verniers, & Bouvry, 1999). Among school teachers in the U.S., 55.6% agreed that stuttering is caused by underlying psychological problems and 48.5% disagreed that most stuttering is caused by underlying physical problems (Yeakle & Cooper, 1986). Other studies have similarly supported the notion that the majority of listeners (as much as over 80%) believe that the etiology of stuttering is an emotional problem, and far less believe in neurological or genetic causes (Abdalla & St. Louis, 2012; de Britto Pereira, Rossi, & Van Borsel, 2008; St. Louis, 2011; Xing Ming, Jing, Yi Wen, & Van Borsel, 2001). Boyle, Blood, and Blood (2009) found that providing university students with psychological explanations of stuttering resulted in more negative stereotypes and more social distance toward PWS compared with genetic explanations. Overall, the findings of previous research indicate that misunderstandings and lack of knowledge about stuttering etiology and controllability may be contributing to negative attitudes toward PWS. 1.3. Purpose of the current study Given the importance of addressing environmental factors in the treatment of stuttering (American Speech-LanguageHearing Association (ASHA), 2007), and the possibility that unfavorable attitudes toward children who stutter from SLPs are related to inaccurate perceptions of the controllability of stuttering, it was desired to investigate perceptions of onset and offset controllability, and biological and non-biological attributions for the disorder of stuttering. Specifically, following Weiner’s model, this investigation sought to answer the following two questions involving the disorders of stuttering, functional articulation disorders, and cerebral palsy: (1) How do perceptions of stuttering compare to perceptions of cerebral palsy and functional articulation disorders in terms of perceived onset controllability, offset controllability, biological attributions, and non-biological attributions among school-based SLPs? (2) Are there correlations between the previously mentioned variables and sympathy, willingness to help, and anger across these three disorders? In addition, two questions were asked specifically pertaining to stuttering: (1) Is blame for stuttering related to perceived onset and offset controllability and negative attitudes toward PWS? (2) Are there relationships between SLPs’ responses and age, years of experience working as an SLP, number of children who stutter treated over the course of the career, number of children on current caseload, completion of a graduate course in stuttering, and average number of continuing education hours acquired in fluency disorders each year? Answers to these questions would help establish how onset and offset controllable stuttering is perceived to be among SLPs relative to other speech disorders and whether these variables are important to consider for the reduction of environmental barriers faced by PWS. The idea that stuttering represents a variable loss of control is important for SLPs to understand because an overestimation of controllability of stuttering might perpetuate feelings of self-blame, guilt, shame, frustration, inadequacy, and discouragement among clients who stutter (Cooper, 1993; Plexico et al., 2010; Quesal, 2010). It was hypothesized that stuttering would be perceived as less onset and offset controllable than functional articulation disorders but more onset and offset controllable than cerebral palsy for school-age children. It was also hypothesized, following Weiner’s (1985) attribution model that onset and offset controllability would be negatively correlated with biological attributions and positively correlated with non-biological attributions. In addition, higher onset and offset controllability were expected to be related to more anger, less sympathy, and less willingness to help. Finally, it was hypothesized that blame for stuttering would be related to higher perceived onset and offset controllability, and negative attitudes toward PWS. 2. Methods 2.1. Participants Participants in this study came from a simple random sample of ASHA certified speech–language pathologists whose professional titles were listed as clinical service providers. Participants had their place of employment listed as educational facilities including pre-elementary, elementary school, secondary school, combined school settings, and all other schools. ASHA generated a random sample mailing list of 1000 speech–language pathologists who fit the above criteria and created mailing labels for a fee. 2.2. Stimuli 2.2.1. Condition scenarios Participants were given introductions to the three different conditions and answered three sets of similar questions related to the different clinical populations: middle school children with developmental stuttering, middle school children
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with functional articulation disorders, and middle school children with cerebral palsy. These disorders were selected because, as mentioned previously, they are likely to be perceived at different ends of the spectrum of controllability and therefore useful anchors to compare with stuttering (Murphy et al., 2012). Interviews and written feedback from six certified speech–language pathologists in a pilot study regarding the content and comprehensibility of questions in the survey supported this notion and revealed that functional articulation disorders and cerebral palsy were perceived as opposite ends of a continuum with Stuttering being the more difficult section to answer (i.e., controllability and biological attributions of stuttering were more uncertain). The age group of middle school children was selected because it was perceptions of chronic stuttering that were of interest in this investigation and it is known that at middle school age, stuttering is considered a chronic disorder that is unlikely to completely resolve (Yairi & Ambrose, 2013). Using younger children in the stimuli would have made data interpretation difficult because of the high rate of spontaneous recovery in the first several years post onset. Using adults who stutter would have perhaps represented even more chronic stuttering, however, because the sample was school-based SLPs, it was desirable to have children who stutter in the stimuli. Even though it is relatively rare for middle school children to be seen in schools for articulation, it was necessary to keep all age groups consistent across the conditions in order to make a valid comparison. It should be noted that although participants worked in a variety of school settings, they were all asked questions related to middle school children for the reasons described above. Each of the disorders was introduced separately followed by 13 questions for each disorder, which are described in the following section. To account for potential order effects, the disorders were counterbalanced so that each disorder was presented once in the first, second, and third presentation order (i.e., stuttering–articulation disorders–cerebral palsy, cerebral palsy–stuttering–articulation disorders, and articulation disorders–cerebral palsy–stuttering). This arrangement resulted in three different forms of the survey. All questions were asked in the same order within each disorder group. 2.2.2. Measures Single items for each disorder were used to measure perceptions of onset controllability, offset controllability, biological attributions, and non-biological attributions. Nine questions were developed to tap into perceptions of willingness to help, sympathy, and anger for each of the three disorders. In addition, at the end of the survey respondents answered 14 questions pertaining specifically to people who stutter. These items were designed to measure perceptions of blame for stuttering and negative attitudes toward PWS. These questions included items pertaining to negative stereotypes toward PWS as well as negative emotional and behavioral reactions to PWS. All items were selected and adapted for the particular disorders of interest based on an in-depth literature review of studies testing attribution theory with disorders such as mental illness, drug addiction, and obesity (Corrigan et al., 2009, 2000; Crandall, 1994; Ebneter et al., 2011; Phelan, 2002). In addition, a small pilot study of six certified speech–language pathologists obtained feedback about appropriateness and wording of the questions. Wording was altered based on pilot participant feedback to ensure that items would be correctly understood. The first four questions asked of participants were: (1) ‘‘How responsible do you think they were for the onset of their stuttering?’’ (onset controllability); (2) ‘‘How controllable do you think their stuttering is currently?’’ (offset controllability); (3) ‘‘To what extent do you think their stuttering is caused by biological factors (e.g., genes, brain abnormality, etc.)?’’ (biological attributions); and (4) ‘‘To what extent do you think their stuttering is caused by non-biological factors (e.g., personality, stress, environment, emotional trauma, etc.)?’’ (non-biological attributions). The wording was the same across disorders except that the word ‘‘stuttering’’ was replaced with ‘‘articulation disorders,’’ and ‘‘cerebral palsy’’ in the appropriate sections. Willingness to help was assessed with three questions: (1) ‘‘How important is it to give them help and support?’’ (2) ‘‘How enthusiastic would you be about helping them?’’ and (3) ‘‘How committed would you be to helping them?’’ Sympathy was measured with three questions: (1) ‘‘How much do you feel sorry for them?’’ (2) ‘‘How much sympathy do you feel for them?’’ and (3) ‘‘How much concern do you feel for them?’’ Anger was also assessed with three questions: (1) ‘‘How much do you think it would aggravate you to have them as clients?’’ (2) ‘‘How much do you think it would bother you to have them as clients?’’ and (3) ‘‘How much do you think it would anger you to have them as clients?’’ These questions were asked for every disorder with the same wording. Response options for each question in the preceding paragraphs were on a unidimensional scale from 1 to 9 (1 = not at all, 5 = moderately, 9 = very; or 1 = none at all, 5 = moderate amount, 9 = a lot, depending on the wording of the question). The 14 items addressing negative attitudes toward PWS at the end of the survey (shown in Table 3) were developed after a thorough literature review regarding common stereotypes of stuttering (e.g., Cooper & Cooper, 1996; Lass et al., 1989), prejudicial and discriminatory reactions to PWS from the public (Gabel, Blood, Tellis, & Althouse, 2004; Hughes, Gabel, Irani, & Schlagheck, 2010; Hurst & Cooper, 1983) and common misconceptions regarding the controllability of stuttering (Plexico et al., 2010; Quesal, 2010). Response options for these questions were on a scale from 1 to 5 (1 = strongly disagree, 5 = strongly agree). Again, these items were included because of previous research showing that stigmatization (i.e., stereotypes, prejudicial and discriminatory attitudes) increases with higher blame and perceived controllability of the condition (Jorm & Griffiths, 2008; Lincoln et al., 2008). In an attempt to minimize social desirability bias, particular wording in the instructions was adapted from early perceptual research conducted by Yairi and Williams (1970). Instructions included the following wording: ‘‘Please read the following questions about middle school children with developmental stuttering. Circle the number for each question that best represents your feelings. Don’t spend too much time on any question. Respond with the first ideas that occur to you
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because this is a study about how various communication disorders ‘‘strike’’ us, not a study of what we think we ought to say about them.’’ 2.3. Procedure Following the pilot study, the edited version of the questionnaire was delivered to participants via first-class U.S. mail. The materials sent to participants included an information sheet and implied consent form along with the questionnaire, and a prepaid return envelope. Three weeks later, a follow up mailing was sent including all of the materials contained in the first mailing plus a reminder post card expressing the importance of participation for representative results. Follow-up mailings are known to increase response rate substantially for survey studies (Dillman, Smyth, & Christian, 2009). The first mailing resulted in 201 responses, and the second mailing added another 139 for a total of 340 responses (34% response rate). Three percent of the responses were unusable for various reasons including change of address, failure to fill out the scales, and retirement from the schools. This resulted in a final response rate of 330 usable surveys (33%). This response rate is considered reasonable and adequate for mail surveys, particularly for those covering wide geographical regions and received without pre-notification (Kelley, Clark, Brown, & Sitzia, 2003; Sitzia & Wood, 1998). In addition, all but three states in the U.S. were represented and the sample size obtained provided the necessary statistical power to conduct the analyses of interest. 2.4. Data analysis Preliminary analysis included exploratory factor analysis and calculation of Cronbach’s coefficient alpha for constructs with multiple items. Summary statistics including means and standard deviations were conducted for every question for each disorder. Primary analysis included a series of one-way analysis of variance (ANOVA) to compare group mean scores for perceptions of onset controllability, offset controllability, biological attributions, non-biological attributions, willingness to help, sympathy, and anger across the different disorders. Bonferroni adjusted alpha levels of 0.007 per test were used (0.05/ 7) to control for Type I error. Pearson correlation coefficients were calculated to determine if there were relationships between these variables, and to determine if there were relationships between blame, onset and offset controllability, and negative attitudes toward PWS. In addition, Pearson correlation coefficients were used to determine if significant relationships existed between perceptions of PWS and demographic information of the participants (i.e., age, years of experience working as an SLP, number of children who stutter treated over the course of the career, number of children on current caseload, completion of a graduate course in stuttering, and average number of continuing education hours acquired in fluency disorders each year).
3. Results 3.1. Participant characteristics Participant characteristics are shown in Table 1. Most participants were female, white, non-Hispanic, with an age range from 25 to 75. Ninety-nine percent of the sample possessed the certificate of clinical competence, with 97% having master’s degrees as highest degree earned, and 3% having a doctorate. Participants were represented from 47 states in the United States. 3.2. Preliminary analysis The nine items created to tap into judgments of willingness to help, sympathy, and anger for children who stutter were factor analyzed to determine if they could be grouped into meaningful variables and validate the structure of the group of items. An exploratory factor analysis with principal components extraction and varimax rotation was conducted to identify factor loadings. The Kaiser (1960) method (retaining factors with eigenvalues greater than 1.0) and scree plot analysis (Cattell, 1966) were used to determine how many factors to retain. Strong factor loadings were considered to be 0.50 or above (Costello & Osborne, 2005; Tabachnick & Fidell, 2001). Three factors were identified and confirmed for the most parsimonious solution accounting for 53.18% of the total variance. These factors were labeled ‘‘willingness to help’’ (a = 0.80), ‘‘anger’’ (a = 0.80), and ‘‘sympathy’’ (a = 0.76). Table 2 shows the list of items, factor loadings, and eigenvalues for these factors. Factor analysis was also conducted with these items for the children with functional articulation disorders and cerebral palsy. The factor structure shown in Table 2 was replicated in both cases with only minor deviations in factor loadings (all primary factor loadings remained above 0.50 with no strong crossloadings). Factor analysis was also conducted on the items designed specifically for PWS created to tap into blame for stuttering and negative attitudes toward PWS. A three factor solution was the most parsimonious accounting for 53.75% of the total variance. Factors were labeled ‘‘dislike’’ (a = 0.79), ‘‘blame’’ (a = 0.68), and ‘‘negative stereotypes’’ (a = 0.73). Table 3 shows the list of items, factor loadings, and eigenvalues for each factor. ‘‘Negative stereotypes’’ represented agreement that PWS have more negative discernable personality traits than people who do not stutter. ‘‘Dislike’’ represented items that assess negative emotional reactions (e.g., being uncomfortable and aggravated talking to PWS) and discriminatory attitudes toward
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Table 1 Participant characteristics. % or M (SD) Gender Female Male Race/ethnicity African American Hispanic American Asian American White, not Hispanic Age Years working as SLP Primary location of work setting Rural (less than 5000 residents) Rural/suburban (5000–50,000 residents) Suburban (50,000–100,000 residents) Urban (more than 100,000 residents) Primary work setting Pre-school Elementary school Middle school/junior high High school Other Estimate of number of clients who stutter in career Children who stutter on current caseload Completed a graduate course in stuttering? Yes No Estimate of average number of continuing education in fluency disorders per year
97 3 4 1 2 92 44.2 (12) 17.1 (10.8) 14 25 32 30 18 39 8 4 31 13.1 (14.9) 1.6 (4.8) 83 17 2.4 (3.9)
Note: Percentages are rounded.
PWS (e.g., desire to avoid interaction with PWS and unwillingness to hire PWS for jobs requiring lots of talking). ‘‘Blame’’ represented beliefs of stuttering being controllable if the PWS would just try harder to be fluent. 3.3. Primary analysis 3.3.1. Comparison of perceived onset controllability, offset controllability, biological attributions, non-biological attributions, willingness to help, sympathy, and anger across disorders Mean ratings for the three disabilities on each variable of interest are shown in Fig. 1. Significant main effects were found for all variables: onset controllability, F(2, 980) = 27.5, p < 0.001, h2 = 0.05 (small effect size); offset controllability, F(2, 965) = 355.1, p < 0.001, h2 = 0.42 (large effect size); biological attributions, F(2, 979) = 117.7, p < 0.001, h2 = 0.19 (large effect size); non-biological attributions, F(2, 977) = 230, p < 0.001, h2 = 0.32 (large effect size); willingness to help, F(2, 979) = 7.3,
Table 2 Factor analysis of items asked about children who stutter. Factor loadings Willingness to helpa 0.806 0.811 0.857 Angerb 0.830 0.816 0.827 Sympathyc 0.879 0.905 0.592 Note: All undisplayed factor loadings
Contents lists available at ScienceDirect
Journal of Communication Disorders
Understanding perceptions of stuttering among school-based speech–language pathologists: An application of attribution theory Michael P. Boyle * Department of Communication Sciences and Disorders, Oklahoma State University, 042 Murray Hall, Stillwater, OK 74078, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 21 December 2013 Received in revised form 13 June 2014 Accepted 28 June 2014 Available online 7 July 2014
Introduction: The purpose of this study was to investigate whether attribution theory could explain speech–language pathologists (SLPs) perceptions of children with communication disorders such as stuttering. Specifically, it was determined whether perceptions of onset and offset controllability, as well as biological and non-biological attributions for communication disorders were related to willingness to help, sympathy, and anger toward children with these disorders. It was also of interest to determine if blame for stuttering was related to perceived controllability of stuttering and negative attitudes toward people who stutter (PWS). Method: A survey was developed to measure perceived onset and offset controllability, biological and non-biological attributions, willingness to help, sympathy, and anger toward middle school children with developmental stuttering, functional articulation disorders, and cerebral palsy. In addition, a scale was developed to measure blame and negative attitudes toward PWS in general. Surveys were mailed to 1000 school-based SLPs. Data from 330 participants were analyzed. Results: Supporting the hypotheses of attribution theory, higher perceived onset and offset controllability of the disorder was linked to less willingness to help, lower sympathy, and more anger across conditions. Increased biological attributions were associated with more reported sympathy. Increased blame for stuttering was linked to higher perceived controllability of stuttering, more dislike of PWS, and more agreement with negative stereotypes about PWS. Conclusions: Educating SLPs about the variable loss of control inherent in stuttering could improve attitudes and increase understanding of PWS. Reductions in blame may facilitate feelings of sympathy and empathy for PWS and reduce environmental barriers for clients. Learning outcomes Readers should be able to: (1) identify the main principles of Weiner’s attribution theory (2) identify common negative perceptions of people who stutter (3) describe how disorders of stuttering, articulation disorders, and cerebral palsy are differentiated in terms of perceived onset and offset controllability, and biological and non-biological attributions (4) describe relationships between perceived onset and offset controllability of disorders and sympathy, anger, and willingness to help. ß 2014 Elsevier Inc. All rights reserved.
Keywords: Stuttering Attribution theory Blame Controllability Stereotypes
* Corresponding author. Tel.: +1 405 744 8946; fax: +1 405 744 8070. E-mail address: [email protected] http://dx.doi.org/10.1016/j.jcomdis.2014.06.003 0021-9924/ß 2014 Elsevier Inc. All rights reserved.
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1. Introduction Stuttering is experienced as an intermittent and unpredictable loss of control over the speech production process (Quesal, 2010; Perkins, 1990). Improving speech fluency can be a beneficial and worthy treatment goal for PWS (Herder, Howard, Nye, & Vanrycheghem, 2006; Nye et al., 2013). However, it is also known that maintenance of these efforts over time and situations is very difficult for PWS, especially in anxiety provoking situations (Craig, 1998). Due to the chronic nature of stuttering, attaining completely normal and lasting fluency may be an unrealistic goal for many PWS, despite the noticeable benefits of learning speech modification strategies for improved fluency (Cooper, 1993). Because stuttering involves a variable loss of control over speech production that can result in social penalties (Blood et al., 2011), PWS experience challenges such as negative communication attitudes and emotions, social anxiety, reduced quality of life, activity limitations and participation restrictions (Bricker-Katz, Lincoln, & Cumming, 2013; Bricker-Katz, Lincoln, & McCabe, 2009; Craig, Blumgart, & Tran, 2009; Daniels, Gabel, & Hughes, 2012; Iverach & Rapee, 2013; De Nil & Brutten, 1991; Plexico, Manning, & Levitt, 2009; Vanryckeghem & Brutten, 1996). In order to increase feelings of control over speech production, improve overall communication skills, and reduce the negative life impact of stuttering in PWS, speech–language pathologists (SLPs) need to be trained to deliver quality services that address cognitive and affective domains, in addition to speech modification (Cooper, 1993; Yaruss, Coleman, & Quesal, 2012). Unfortunately, research has shown that SLPs and students in communication disorders are uncomfortable, unconfident, and often unprepared to work with PWS (Brisk, Healey, & Husk, 1997; Kelly et al., 1997; St. Louis & Lass, 1980; St. Louis & Lass, 1980; St. Louis & Durrenberger, 1993; Tellis, Bressler, & Emerick, 2008). Furthermore, SLPs and classroom teachers tend to hold negative stereotypical views about personality characteristics (e.g., that they are nervous and nonassertive) of PWS regardless of their age (Abdalla & St. Louis, 2012; Cooper & Cooper, 1996; Horsley & FitzGibbon, 1987; Lass, ¨ zdemir, & Tog˘ram, 2013; Ragsdale & Ashby, 1982; Ruscello, Pannbacker, Schmitt, & Everly-Meyers, 1989; Mavis¸, St. Louis, O Turnbaugh, Guitar, & Hoffman, 1979; Woods & Williams, 1976). Stigmatizing attitudes and unfavorable perceptions held by SLPs toward individuals who stutter represent an environmental barrier to optimal service delivery (American Speech-Language-Hearing Association (ASHA), 2007) and may limit therapy gains experienced by PWS. Qualitative data from interviews of PWS suggest that some SLPs can be perceived as judgmental, annoyed, and not understanding of the unpredictable and intermittent loss of control experienced during stuttering and this contributes to the perception of ineffective therapy (Plexico, Manning, & DiLollo, 2010). Furthermore, awareness of negative public perceptions of stuttering is very high among PWS and this is significantly correlated with internalization of negative stigmatizing thoughts (Boyle, 2013). From this evidence, environmental factors (e.g., listener perceptions) do appear to be relevant for the psychological well-being of the individual and the effectiveness of therapy. These negative public perceptions of PWS should be eradicated. 1.1. Attribution theory One potentially useful lens through which to look at negative stigmatizing attitudes toward PWS and their possible mitigation is Weiner’s (1985, 1986) attribution theory. Attribution theory states that the more controllable a stigmatizing condition is perceived, the more anger and blame it will create in the public, and the less willingness to help and sympathy will be demonstrated (e.g., blindness will receive more sympathy and willingness to help, and less anger and blame compared to alcoholism) (Menec & Perry, 1998; Weiner, 1995; Weiner, Perry, & Magnusson, 1988). Attribution theory has been supported in previous research with several different stigmatized conditions and disorders including schizophrenia and depression (Boysen & Vogel, 2008; Jorm & Griffiths, 2008; Lincoln, Arens, Berger, & Rief, 2008), eating and weight disorders (Crandall, 1994; Ebneter, Latner, & O’Brien, 2011), challenging behaviors (Dilworth, Phillips, & Rose, 2011), drug addiction (Corrigan, Kuwabara, & O’Shaughnessy, 2009), autistic behaviors (Ling, Mak, & Cheng, 2010), mental disorders (Mukolo & Heflinger, 2011), and self-harm (Law, Rostill-Brookes, & Goodman, 2009). Two of the most frequently mentioned concepts in attribution theory include dimensions of onset controllability and offset controllability. Onset controllability refers to beliefs about how much the person, compared with external forces (e.g., biological or environmental factors), is responsible for the onset of a specific condition or disability that is stigmatized. Offset controllability refers to beliefs about how much a person is held responsible for the offset, or solution, of the condition. Biological attributions (e.g., genetic and neurological explanations of conditions) are related to less onset and offset controllable deficits whereas non-biological attributions are related to higher perceived onset and offset controllability (Phelan, 2002, 2005). Physically based conditions (e.g., paraplegia, blindness, Alzheimer’s disease) are generally perceived as having more biological attributions and therefore less onset and offset controllability than disorders that are perceived as mental-behavioral (e.g., drug abuse, obesity, mental illness) (Corrigan et al., 2000; Weiner et al., 1988). Applying this model to speech–language pathology, it has been noted that disorders such as cerebral palsy are perceived as being more onset and offset uncontrollable whereas disorders like functional articulation disorders are on the opposite end of the continuum in terms of being perceived as more controllable (i.e., more amenable to change) (Murphy, Quesal, & Yaruss, 2012). These disorders would then theoretically serve as useful anchors and points of comparison to other disorders on the continuum of controllability and biological attributions. It should be noted that some research studies have not entirely supported Weiner’s attribution theory (Jones & Hastings, 2003). In some cases higher offset controllability is
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associated with increased willingness to help (Willner & Smith, 2008). Other findings indicate that uncontrollable biological and genetic attributions may negatively impact perceptions of prognosis and recovery potential (Lam & Salkovskis, 2007; Lincoln et al., 2008; Phelan, 2002, 2005). 1.2. Attributions for stuttering To date there have been no studies conducted that analyze perceptions of controllability or biological attributions of stuttering among school-based SLPs toward children who stutter, however previous research shows that misunderstandings about the etiology of stuttering are common. Studies have shown that only 7% of the public believes that stuttering has neurogenic causes, and 45% believed that stuttering had psychogenic causes (Van Borsel, Verniers, & Bouvry, 1999). Among school teachers in the U.S., 55.6% agreed that stuttering is caused by underlying psychological problems and 48.5% disagreed that most stuttering is caused by underlying physical problems (Yeakle & Cooper, 1986). Other studies have similarly supported the notion that the majority of listeners (as much as over 80%) believe that the etiology of stuttering is an emotional problem, and far less believe in neurological or genetic causes (Abdalla & St. Louis, 2012; de Britto Pereira, Rossi, & Van Borsel, 2008; St. Louis, 2011; Xing Ming, Jing, Yi Wen, & Van Borsel, 2001). Boyle, Blood, and Blood (2009) found that providing university students with psychological explanations of stuttering resulted in more negative stereotypes and more social distance toward PWS compared with genetic explanations. Overall, the findings of previous research indicate that misunderstandings and lack of knowledge about stuttering etiology and controllability may be contributing to negative attitudes toward PWS. 1.3. Purpose of the current study Given the importance of addressing environmental factors in the treatment of stuttering (American Speech-LanguageHearing Association (ASHA), 2007), and the possibility that unfavorable attitudes toward children who stutter from SLPs are related to inaccurate perceptions of the controllability of stuttering, it was desired to investigate perceptions of onset and offset controllability, and biological and non-biological attributions for the disorder of stuttering. Specifically, following Weiner’s model, this investigation sought to answer the following two questions involving the disorders of stuttering, functional articulation disorders, and cerebral palsy: (1) How do perceptions of stuttering compare to perceptions of cerebral palsy and functional articulation disorders in terms of perceived onset controllability, offset controllability, biological attributions, and non-biological attributions among school-based SLPs? (2) Are there correlations between the previously mentioned variables and sympathy, willingness to help, and anger across these three disorders? In addition, two questions were asked specifically pertaining to stuttering: (1) Is blame for stuttering related to perceived onset and offset controllability and negative attitudes toward PWS? (2) Are there relationships between SLPs’ responses and age, years of experience working as an SLP, number of children who stutter treated over the course of the career, number of children on current caseload, completion of a graduate course in stuttering, and average number of continuing education hours acquired in fluency disorders each year? Answers to these questions would help establish how onset and offset controllable stuttering is perceived to be among SLPs relative to other speech disorders and whether these variables are important to consider for the reduction of environmental barriers faced by PWS. The idea that stuttering represents a variable loss of control is important for SLPs to understand because an overestimation of controllability of stuttering might perpetuate feelings of self-blame, guilt, shame, frustration, inadequacy, and discouragement among clients who stutter (Cooper, 1993; Plexico et al., 2010; Quesal, 2010). It was hypothesized that stuttering would be perceived as less onset and offset controllable than functional articulation disorders but more onset and offset controllable than cerebral palsy for school-age children. It was also hypothesized, following Weiner’s (1985) attribution model that onset and offset controllability would be negatively correlated with biological attributions and positively correlated with non-biological attributions. In addition, higher onset and offset controllability were expected to be related to more anger, less sympathy, and less willingness to help. Finally, it was hypothesized that blame for stuttering would be related to higher perceived onset and offset controllability, and negative attitudes toward PWS. 2. Methods 2.1. Participants Participants in this study came from a simple random sample of ASHA certified speech–language pathologists whose professional titles were listed as clinical service providers. Participants had their place of employment listed as educational facilities including pre-elementary, elementary school, secondary school, combined school settings, and all other schools. ASHA generated a random sample mailing list of 1000 speech–language pathologists who fit the above criteria and created mailing labels for a fee. 2.2. Stimuli 2.2.1. Condition scenarios Participants were given introductions to the three different conditions and answered three sets of similar questions related to the different clinical populations: middle school children with developmental stuttering, middle school children
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with functional articulation disorders, and middle school children with cerebral palsy. These disorders were selected because, as mentioned previously, they are likely to be perceived at different ends of the spectrum of controllability and therefore useful anchors to compare with stuttering (Murphy et al., 2012). Interviews and written feedback from six certified speech–language pathologists in a pilot study regarding the content and comprehensibility of questions in the survey supported this notion and revealed that functional articulation disorders and cerebral palsy were perceived as opposite ends of a continuum with Stuttering being the more difficult section to answer (i.e., controllability and biological attributions of stuttering were more uncertain). The age group of middle school children was selected because it was perceptions of chronic stuttering that were of interest in this investigation and it is known that at middle school age, stuttering is considered a chronic disorder that is unlikely to completely resolve (Yairi & Ambrose, 2013). Using younger children in the stimuli would have made data interpretation difficult because of the high rate of spontaneous recovery in the first several years post onset. Using adults who stutter would have perhaps represented even more chronic stuttering, however, because the sample was school-based SLPs, it was desirable to have children who stutter in the stimuli. Even though it is relatively rare for middle school children to be seen in schools for articulation, it was necessary to keep all age groups consistent across the conditions in order to make a valid comparison. It should be noted that although participants worked in a variety of school settings, they were all asked questions related to middle school children for the reasons described above. Each of the disorders was introduced separately followed by 13 questions for each disorder, which are described in the following section. To account for potential order effects, the disorders were counterbalanced so that each disorder was presented once in the first, second, and third presentation order (i.e., stuttering–articulation disorders–cerebral palsy, cerebral palsy–stuttering–articulation disorders, and articulation disorders–cerebral palsy–stuttering). This arrangement resulted in three different forms of the survey. All questions were asked in the same order within each disorder group. 2.2.2. Measures Single items for each disorder were used to measure perceptions of onset controllability, offset controllability, biological attributions, and non-biological attributions. Nine questions were developed to tap into perceptions of willingness to help, sympathy, and anger for each of the three disorders. In addition, at the end of the survey respondents answered 14 questions pertaining specifically to people who stutter. These items were designed to measure perceptions of blame for stuttering and negative attitudes toward PWS. These questions included items pertaining to negative stereotypes toward PWS as well as negative emotional and behavioral reactions to PWS. All items were selected and adapted for the particular disorders of interest based on an in-depth literature review of studies testing attribution theory with disorders such as mental illness, drug addiction, and obesity (Corrigan et al., 2009, 2000; Crandall, 1994; Ebneter et al., 2011; Phelan, 2002). In addition, a small pilot study of six certified speech–language pathologists obtained feedback about appropriateness and wording of the questions. Wording was altered based on pilot participant feedback to ensure that items would be correctly understood. The first four questions asked of participants were: (1) ‘‘How responsible do you think they were for the onset of their stuttering?’’ (onset controllability); (2) ‘‘How controllable do you think their stuttering is currently?’’ (offset controllability); (3) ‘‘To what extent do you think their stuttering is caused by biological factors (e.g., genes, brain abnormality, etc.)?’’ (biological attributions); and (4) ‘‘To what extent do you think their stuttering is caused by non-biological factors (e.g., personality, stress, environment, emotional trauma, etc.)?’’ (non-biological attributions). The wording was the same across disorders except that the word ‘‘stuttering’’ was replaced with ‘‘articulation disorders,’’ and ‘‘cerebral palsy’’ in the appropriate sections. Willingness to help was assessed with three questions: (1) ‘‘How important is it to give them help and support?’’ (2) ‘‘How enthusiastic would you be about helping them?’’ and (3) ‘‘How committed would you be to helping them?’’ Sympathy was measured with three questions: (1) ‘‘How much do you feel sorry for them?’’ (2) ‘‘How much sympathy do you feel for them?’’ and (3) ‘‘How much concern do you feel for them?’’ Anger was also assessed with three questions: (1) ‘‘How much do you think it would aggravate you to have them as clients?’’ (2) ‘‘How much do you think it would bother you to have them as clients?’’ and (3) ‘‘How much do you think it would anger you to have them as clients?’’ These questions were asked for every disorder with the same wording. Response options for each question in the preceding paragraphs were on a unidimensional scale from 1 to 9 (1 = not at all, 5 = moderately, 9 = very; or 1 = none at all, 5 = moderate amount, 9 = a lot, depending on the wording of the question). The 14 items addressing negative attitudes toward PWS at the end of the survey (shown in Table 3) were developed after a thorough literature review regarding common stereotypes of stuttering (e.g., Cooper & Cooper, 1996; Lass et al., 1989), prejudicial and discriminatory reactions to PWS from the public (Gabel, Blood, Tellis, & Althouse, 2004; Hughes, Gabel, Irani, & Schlagheck, 2010; Hurst & Cooper, 1983) and common misconceptions regarding the controllability of stuttering (Plexico et al., 2010; Quesal, 2010). Response options for these questions were on a scale from 1 to 5 (1 = strongly disagree, 5 = strongly agree). Again, these items were included because of previous research showing that stigmatization (i.e., stereotypes, prejudicial and discriminatory attitudes) increases with higher blame and perceived controllability of the condition (Jorm & Griffiths, 2008; Lincoln et al., 2008). In an attempt to minimize social desirability bias, particular wording in the instructions was adapted from early perceptual research conducted by Yairi and Williams (1970). Instructions included the following wording: ‘‘Please read the following questions about middle school children with developmental stuttering. Circle the number for each question that best represents your feelings. Don’t spend too much time on any question. Respond with the first ideas that occur to you
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because this is a study about how various communication disorders ‘‘strike’’ us, not a study of what we think we ought to say about them.’’ 2.3. Procedure Following the pilot study, the edited version of the questionnaire was delivered to participants via first-class U.S. mail. The materials sent to participants included an information sheet and implied consent form along with the questionnaire, and a prepaid return envelope. Three weeks later, a follow up mailing was sent including all of the materials contained in the first mailing plus a reminder post card expressing the importance of participation for representative results. Follow-up mailings are known to increase response rate substantially for survey studies (Dillman, Smyth, & Christian, 2009). The first mailing resulted in 201 responses, and the second mailing added another 139 for a total of 340 responses (34% response rate). Three percent of the responses were unusable for various reasons including change of address, failure to fill out the scales, and retirement from the schools. This resulted in a final response rate of 330 usable surveys (33%). This response rate is considered reasonable and adequate for mail surveys, particularly for those covering wide geographical regions and received without pre-notification (Kelley, Clark, Brown, & Sitzia, 2003; Sitzia & Wood, 1998). In addition, all but three states in the U.S. were represented and the sample size obtained provided the necessary statistical power to conduct the analyses of interest. 2.4. Data analysis Preliminary analysis included exploratory factor analysis and calculation of Cronbach’s coefficient alpha for constructs with multiple items. Summary statistics including means and standard deviations were conducted for every question for each disorder. Primary analysis included a series of one-way analysis of variance (ANOVA) to compare group mean scores for perceptions of onset controllability, offset controllability, biological attributions, non-biological attributions, willingness to help, sympathy, and anger across the different disorders. Bonferroni adjusted alpha levels of 0.007 per test were used (0.05/ 7) to control for Type I error. Pearson correlation coefficients were calculated to determine if there were relationships between these variables, and to determine if there were relationships between blame, onset and offset controllability, and negative attitudes toward PWS. In addition, Pearson correlation coefficients were used to determine if significant relationships existed between perceptions of PWS and demographic information of the participants (i.e., age, years of experience working as an SLP, number of children who stutter treated over the course of the career, number of children on current caseload, completion of a graduate course in stuttering, and average number of continuing education hours acquired in fluency disorders each year).
3. Results 3.1. Participant characteristics Participant characteristics are shown in Table 1. Most participants were female, white, non-Hispanic, with an age range from 25 to 75. Ninety-nine percent of the sample possessed the certificate of clinical competence, with 97% having master’s degrees as highest degree earned, and 3% having a doctorate. Participants were represented from 47 states in the United States. 3.2. Preliminary analysis The nine items created to tap into judgments of willingness to help, sympathy, and anger for children who stutter were factor analyzed to determine if they could be grouped into meaningful variables and validate the structure of the group of items. An exploratory factor analysis with principal components extraction and varimax rotation was conducted to identify factor loadings. The Kaiser (1960) method (retaining factors with eigenvalues greater than 1.0) and scree plot analysis (Cattell, 1966) were used to determine how many factors to retain. Strong factor loadings were considered to be 0.50 or above (Costello & Osborne, 2005; Tabachnick & Fidell, 2001). Three factors were identified and confirmed for the most parsimonious solution accounting for 53.18% of the total variance. These factors were labeled ‘‘willingness to help’’ (a = 0.80), ‘‘anger’’ (a = 0.80), and ‘‘sympathy’’ (a = 0.76). Table 2 shows the list of items, factor loadings, and eigenvalues for these factors. Factor analysis was also conducted with these items for the children with functional articulation disorders and cerebral palsy. The factor structure shown in Table 2 was replicated in both cases with only minor deviations in factor loadings (all primary factor loadings remained above 0.50 with no strong crossloadings). Factor analysis was also conducted on the items designed specifically for PWS created to tap into blame for stuttering and negative attitudes toward PWS. A three factor solution was the most parsimonious accounting for 53.75% of the total variance. Factors were labeled ‘‘dislike’’ (a = 0.79), ‘‘blame’’ (a = 0.68), and ‘‘negative stereotypes’’ (a = 0.73). Table 3 shows the list of items, factor loadings, and eigenvalues for each factor. ‘‘Negative stereotypes’’ represented agreement that PWS have more negative discernable personality traits than people who do not stutter. ‘‘Dislike’’ represented items that assess negative emotional reactions (e.g., being uncomfortable and aggravated talking to PWS) and discriminatory attitudes toward
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Table 1 Participant characteristics. % or M (SD) Gender Female Male Race/ethnicity African American Hispanic American Asian American White, not Hispanic Age Years working as SLP Primary location of work setting Rural (less than 5000 residents) Rural/suburban (5000–50,000 residents) Suburban (50,000–100,000 residents) Urban (more than 100,000 residents) Primary work setting Pre-school Elementary school Middle school/junior high High school Other Estimate of number of clients who stutter in career Children who stutter on current caseload Completed a graduate course in stuttering? Yes No Estimate of average number of continuing education in fluency disorders per year
97 3 4 1 2 92 44.2 (12) 17.1 (10.8) 14 25 32 30 18 39 8 4 31 13.1 (14.9) 1.6 (4.8) 83 17 2.4 (3.9)
Note: Percentages are rounded.
PWS (e.g., desire to avoid interaction with PWS and unwillingness to hire PWS for jobs requiring lots of talking). ‘‘Blame’’ represented beliefs of stuttering being controllable if the PWS would just try harder to be fluent. 3.3. Primary analysis 3.3.1. Comparison of perceived onset controllability, offset controllability, biological attributions, non-biological attributions, willingness to help, sympathy, and anger across disorders Mean ratings for the three disabilities on each variable of interest are shown in Fig. 1. Significant main effects were found for all variables: onset controllability, F(2, 980) = 27.5, p < 0.001, h2 = 0.05 (small effect size); offset controllability, F(2, 965) = 355.1, p < 0.001, h2 = 0.42 (large effect size); biological attributions, F(2, 979) = 117.7, p < 0.001, h2 = 0.19 (large effect size); non-biological attributions, F(2, 977) = 230, p < 0.001, h2 = 0.32 (large effect size); willingness to help, F(2, 979) = 7.3,
Table 2 Factor analysis of items asked about children who stutter. Factor loadings Willingness to helpa 0.806 0.811 0.857 Angerb 0.830 0.816 0.827 Sympathyc 0.879 0.905 0.592 Note: All undisplayed factor loadings
