JSLHR

Article
Assessment of Stigma Associated With
Stuttering: Development and Evaluation of
the Self-Stigma of Stuttering Scale (4S)
Michael P. Boyle
a
Purpose: To create a psychometrically sound scale that
measures different levels of internalized stigma (i.e., self-
stigma) among adults who stutter and to analyze factor
structure, reliability, and initial construct validity of the scale.
Method: Two-hundred ninety-one adults who stutter were
recruited from Board Recognized Specialists in Fluency
Disorders and the National Stuttering Association. Participants
completed a web-based survey including an experimental
scale called the Self-Stigma of Stuttering Scale (4S), designed
to measure different levels of self-stigma in people who
stutter, along with a series of established measures of self-
esteem, self-efficacy, and life satisfaction.
Results: The experimental scale demonstrated adequate
reliability in internal consistency and temporal stability. Factor
analysis revealed underlying components supportive of a
multidimensional model of stigma. Stigma self-concurrence
and, to a lesser extent, stereotype agreement and stigma
awareness were negatively correlated with self-esteem,
self-efficacy, and life satisfaction, supporting initial construct
validity of the scale.
Conclusion: Speech-language pathologists can identify the
presence of self-stigma in their adult clients who stutter and
help them to alter these beliefs. The 4S can be a means for
researchers and clinicians to achieve these goals.
Key Words: stuttering, stigma, assessment, stereotypes,
psychosocial issues, fluency disorders, psychosocial issues
T
he physical and motoric aspects of stuttering include
involuntary speech disruptions that can make oral
communication challenging and frustrating. In addi-
tion to the more visible physical aspects of stuttering, social,
cognitive, and affective dimensions are critical to consider.
Many recent studies have shown that many people who stutter
(PWS) experience shame and self-consciousness (Ginsberg,
2000); heightened risk for development of many mental health
problems, including social and generalized anxiety disorders,
social phobia, and negative affect (Blumgart, Tran, & Craig,
2010; Iverach, OBrian, et al., 2009; Iverach et al., 2010);
and reduced overall quality of life, including lower social
and emotional functioning (Craig, Blumgart, & Tran,
2009) compared with fluent controls. Importantly, it is clear
that most researchers agree that these findings are likely the
result of living with a chronic communication disorder that
elicits social penalties, including negative listener reactions
and stereotypes, bullying and teasing, and social harm and
rejection, as stuttering does (Craig et al., 2009; Iverach et al.,
2011), rather than reflecting the underlying cause of stut-
tering. In essence, what these authors describe as social
penalties reflects the concept of stuttering being a stigma-
tized disorder. Because it appears possible that stigma may
be relevant to many of the negative psychological conse-
quences experienced by PWS, and because addressing these
issues is important for speech-language pathologists (SLPs),
it seems important to discuss stigma in detail as it relates
to stuttering.
Public Stigma
A stigma is a trait, attribute, signal, or mark that is
devalued among a particular social group. Stigma is also
the outcome of possessing the devalued trait in which the
negative social meanings associated with that trait become
linked to the individual in certain social contexts (Goffman,
1963; Shelton, Alegre, & Son, 2010). Current theoretical
models of stigma identify both public stigma and self-stigma.
Public stigma involves the negative cognitive, affective, and
behavioral reactions of members of the public to individ-
uals with stigmatized conditions in the form of stereotypes,
prejudice, and discrimination (Corrigan & Watson, 2002).
Link and Phelan (2006) described public stigma as involving
a person being labeled, stereotyped, excluded from the non-
stigmatized group, being discriminated against, and losing
a
The Pennsylvania State University, University Park, PA
Correspondence to Michael P. Boyle, who is now at Oklahoma State
University, Stillwater: michael.boyle@okstate.edu
Editor: Jody Kreiman
Associate Editor: Hans-Georg Bosshardt
Received September 1, 2012
Revision received November 28, 2012
Accepted February 4, 2013
DOI: 10.1044/1092-4388(2013/12-0280)
Journal of Speech, Language, and Hearing Research Vol. 56 15171529 October 2013 A American Speech-Language-Hearing Association 1517
status. Importantly, this process happens in the context of a
power imbalance, with the beliefs of the more powerful
group prevailing. Public stigma has negative consequences
for stigmatized individuals, including diminished quality of
life and mental health, as well as restricted opportunities in
employment, education, housing, relationships, and commu-
nity functions (Corrigan, Larson, & Kuwabara, 2010; Major
& OBrien, 2005; Steele, 1997; Steele & Aronson, 1995).
There is an abundance of research that has looked at
public stigma related to stuttering. PWS are often believed to
possess several negative or undesirable personality charac-
teristics, including being introverted, shy, anxious, nervous,
quiet, tense, guarded, fearful, embarrassed, and frustrated
(Kalinowski, Stuart, & Armson, 1996). With a few excep-
tions, these beliefs have been observed in a variety of popu-
lations, including laypeople (Schlagheck, Gabel, & Hughes,
2009), teachers (Lass et al., 1994), employers (Hurst &
Cooper, 1983), college students (Hughes, Gabel, Irani, &
Schlagheck, 2010), and SLPs (Cooper & Cooper, 1996). PWS
are also perceived to be less competent or intelligent than their
fluent counterparts (Silverman & Bongey, 1997; Silverman
& Paynter, 1990), and many members of the public believe
that jobs requiring frequent oral communication are inap-
propriate for PWS (Gabel, Blood, Tellis, & Althouse, 2004).
Historically, PWS have been characterized negatively in films
and television (G. F. Johnson, 1987; J. K. Johnson, 2008)
and in childrens literature (Bushey & Martin, 1988; Logan,
Mullins, & Jones, 2008). PWS are more likely to be bullied
and teased (Blood et al., 2011; Evans, Healey, Kawai, &
Rowland, 2008; Langevin & Prasad, 2012) and less likely to
be perceived by the other sex as attractive and worthy of
a romantic relationship, compared with fluent individuals
(Van Borsel, Brepoels, & De Coene, 2011). In summary, it
appears that there is a public stigma related to stuttering that
may impact vocational, educational, and social dimensions
of life.
Self-Stigma
Whereas public stigma is what the public does to stig-
matized individuals, self-stigma is what stigmatized individuals
do to themselves by internalizing the stereotypes, prejudice,
and discrimination they are exposed to from the public
(Corrigan, Larson, & Rsch, 2009). Stereotypes become
negative beliefs about the self, and prejudice is experienced as
a negative emotional reaction to internalized negative atti-
tudes. These negative cognitive and affective reactions can
lead to self-discriminating behavior in which individuals fail
to pursue work, independent living, meaningful relationships,
or other social opportunities (Corrigan & Watson, 2002).
Corrigan et al. (2009) labeled this lack of confidence in the
ability to achieve life goals the why try effect (e.g., Why
should I try to get work? Someone like me will not be able
to handle a job like that). Self-stigma has been associated
with reduced self-esteemand self-efficacy (Corrigan, Watson,
& Barr, 2006), quality of life (Jacoby & Austin, 2007), social
interaction and adaptation (Berger, Ferrans, & Lashley,
2001), and overall psychological well-being (Kellison, Bussing,
Bell, & Gravan, 2010). Self-stigma is also associated with
increased mental health problems, including helplessness,
depression, and anxiety (Mak, Poon, Pun, & Cheung, 2007;
Yen et al., 2005); impaired physical health status (Barreto
& Ellemers, 2010); and decreased utilization of and adher-
ence to clinical services and treatment (Corrigan, 2004;
Sirey et al., 2001).
Research has shown that PWS are afraid that others
will view them as mentally defective, stupid, strange,
not good enough, a fool, incompetent, freak of
nature, not a whole person, mentally retarded, infe-
rior, socially crippled, not normal, an imbecile, an
idiot, or crazy because of their stuttering (Bricker-Katz,
Lincoln, & McCabe, 2010, Corcoran & Stewart, 1998;
Klompass & Ross, 2004; Plexico, Manning, & Levitt, 2009;
Whaley & Parker, 2000). Beyond mere fear of what others
may think, it has also been demonstrated that some PWS
internalize these negative attitudes and integrate them as part
of their self-concepts, as illustrated by the following quotes:
Absolutely, stuttering has affected my self-esteem, self-
image, self-identity, and the way I see and value myself
(Klompass & Ross, 2004, p. 295), and well, because I
stutter, I dont deserve to say what I was going to say. I think
it kinda brings down my self-worth at times. When I have,
like, when looking for a job, that oh, Im not worthy of that
(Plexico et al., 2009, p. 98). It is also known that a consid-
erable number of PWS have turned down jobs or promotions
because of their stuttering (Hayhow, Cray, & Enderby,
2002; Klein & Hood, 2004) and that many restrict their
participation in any desired activity that involves speaking,
indicating general patterns of participation restriction for
some PWS (Bricker-Katz et al., 2010; Daniels, Hagstrom, &
Gabel, 2006). From this research, it appears clear that stigma
can be internalized among PWS.
A Multidimensional Model of Stigma
Corrigan and colleagues have developed a theoretical
model of self-stigma that is composed of four progressive
levels (Corrigan & Watson, 2002; Corrigan et al., 2010,
2012; Corrigan, Rafacz, &Rsch, 2011; Corrigan et al., 2006).
The first level is called stereotype awareness, in which stig-
matized individuals become aware of the negative stereotypes
associated with their condition that are held by the public
(e.g., I believe that the public thinks that PWS are less
competent). The second level is called stereotype agreement,
in which individuals with a stigmatized condition agree with
and express the same stereotypes about other members of
the stigmatized group that are held by the general public
(e.g., I agree with the public, most people who stutter are less
competent and they make me uncomfortable). The third level
is called self-concurrence, or application, in which individuals
internalize and apply the negative beliefs found in the public
to themselves personally (e.g., Because I stutter, I am less
competent). The final stage is harm, which is represented by
decrements in well-being, including lower self-esteem.
Importantly, Corrigan and colleagues believe this
is a progressive stigma model in which the first two levels
1518 Journal of Speech, Language, and Hearing Research Vol. 56 15171529 October 2013
(awareness and agreement) are necessary but not the most
important factors associated with decrements in well-being.
Rather, the model proposes that self-concurrence has the
strongest implications for lower psychological well-being,
including self-esteem and self-efficacy (Corrigan et al., 2006,
2010, 2011). It would be expected that proximal stages (e.g.,
self-concurrence and harm) have greater associations than
distal stages (e.g., awareness and harm). This progressive
model can be described as trickle-down in nature, such that
awareness would be expected to be higher than agreement,
which would be expected to be higher than self-concurrence.
This multidimensional model of stigma can be applied
to PWS. There is evidence that PWS are aware of the fact
that they may be perceived negatively by the public; this
demonstrates stereotype awareness (Bricker-Katz et al.,
2010; Plexico et al., 2009). There is also evidence that some
PWS hold the same negative views about other PWS that
are held among the general public (Craig, Tran, & Craig,
2003; Kalinowski, Lerman, & Watt, 1987); this indicates
stereotype agreement. However, although PWS may agree
with negative stereotypes about other PWS, or a hypothetical
person who stutters, some studies have shown that many
PWS rate themselves personally in a more positive, non-
stereotypical manner (Fransella, 1968; Kalinowski et al.,
1987) and believe that stuttering is significantly more handi-
capping for the average person who stutters than for
themselves (Klein & Hood, 2004). However, no research to
date has analyzed these components of stigma simultaneously
in PWS.
Purpose of the Current Study
PWS are likely to experience public stigma and may be
at risk for self-stigma. This may be related to many of the
recent troubling findings concerning lower levels of well-
being and quality of life in PWS. It seems important to be
able to measure self-stigma in PWS and determine whether
associations do exist between stigma and important elements
of well-being and, if so, at what levels of stigma. To measure
the stigma associated with stuttering, it was necessary to
create and tailor a scale specifically related to individuals
who stutter, rather than use a more general measure of stigma.
There have been many scales developed to measure percep-
tions, attitudes, and feelings of adults who stutter (e.g.,
Andrews & Cutler, 1974; Darley & Spriesterbach, 1978;
Erickson, 1969; Ornstein & Manning, 1985; Riley, Riley, &
Maguire, 2004; Woolf, 1967; Yaruss & Quesal, 2006). Despite
the several scales available to measure cognitive and affec-
tive dimensions of stuttering, a validated scale does not yet
exist that measures the self-stigma associated specifically
with stuttering, particularly within the context of the progres-
sive, multidimensional model of stigma presented by Corrigan
and Watson (2002).
The purpose of this study was to create a scale that
measures stuttering within the multidimensional model of
stigma proposed by Corrigan and colleagues (Corrigan et al.,
2011; Corrigan & Watson, 2002) and analyze its psycho-
metric properties in terms of (a) factor structure, (b) internal
consistency, (c) temporal stability, (d) content validity, and
(e) initial construct validity. It was hypothesized that the
scale would demonstrate sound psychometric properties,
including good internal consistency and temporal stability,
and would be composed of three main factors: awareness,
agreement, and self-concurrence. In addition, it was hypoth-
esized that initial construct validity would be supported
through negative correlations between the different dimensions
of self-stigma (i.e., awareness, agreement, and self-concurrence)
and self-esteem, self-efficacy, and life satisfaction. More
specifically, in accordance with the progressive nature of the
self-stigma model, it was hypothesized that self-concurrence
would be most negatively associated with measures of well-
being, with agreement having a smaller association and
awareness having an even smaller association (Corrigan et al.,
2011; Corrigan & Watson, 2002).
It should be noted that the fourth stage of Corrigan
and colleagues (2011) model, harm, was represented by
measuring self-esteem, self-efficacy, and life satisfaction.
These constructs were evaluated using previously validated
measures, rather than creating new items. These constructs
were measured because they are known to be crucial com-
ponents of mental health and well-being (Bandura, 1997;
Crocker, 1999; Pavot & Diener, 1993). Improving well-being
and quality of life is considered by many to be a critical aspect
of working with PWS (Craig et al., 2009; Tran, Blumgart, &
Craig, 2011; Yaruss, 2010). This idea has been reinforced
with the recent findings that reduced mental health among
PWS is associated with avoidance of speaking situations
and failure to maintain benefits of speech modification after
therapy has ended (Iverach, Jones, et al., 2009). The Self-
Stigma of Stuttering Scale (4S) would provide a different way
of measuring the hidden dimensions of the stuttering disorder
that are relevant to well-being and quality of life in PWS.
Method
Participants and Procedure
Participants in this study were 291 adults who stutter
(ages 1883 years), recruited from the National Stuttering
Association (NSA) as well as Board Recognized Specialists
in Fluency Disorders. The survey mode was web based.
Web-based surveys have some advantages over traditional
mail surveys in that they are more efficient in distribution
and data management (Kaplowitz, Hadlock, & Levine,
2004), they are perceived by many survey respondents to be
easier to fill out and less likely to be misplaced, and they can
often reach a larger number of potential respondents
(Kiernan, Kiernan, Oyler, & Gilles, 2005). One drawback
of the web survey is that response rates are not able
to be determined, as the total number of PWS who had
access to the survey is unknown. The web survey used in
this study was created using Qualtrics Survey Research Suite
software Version 28, 206. After approval for the research
was obtained from the NSA Research Committee and the
Institutional Review Board at The Pennsylvania State
University, a series of e-mails was sent to individuals listed
Boyle: Self-Stigma of Stuttering 1519
on the NSA database describing the survey with a link to take
the survey online. In addition, Board Recognized Specialists
in Fluency Disorders were contacted with the request to for-
ward the e-mail to any clients or acquaintances who stutter.
The Dillman (2008) method was used for determining the
number of requests sent to potential respondents as well as
the amount of time between requests. Personalized e-mails
for prenotification, second, third, and final contacts were
sent to the participants. There were 2 days between preno-
tification and the second e-mail containing the survey, ap-
proximately 3 weeks between the second and third contact,
andapproximately 1 month between third and final contacts.
Forty-one individuals, who were obtained by convenience
sampling, completed the survey twice, approximately 2 weeks
apart, in order for us to obtain temporal stability results.
The survey that participants completed was composed of
several different components, including the experimental
scale described in this article (the 4S); three previously existing
measures of self-esteem, self-efficacy, and life satisfaction;
and a section measuring demographic information.
Instruments
The 4S. The general format of the scale was adapted
from the Self-Stigma of Mental Illness Scale (Corrigan et al.,
2006), with the content changed to be relevant for PWS
rather than for individuals with mental illness. The 4S was
designed to assess three major components of self-stigma,
including stereotype awareness (e.g., I think the public be-
lieves that most people who stutter are insecure), stereotype
agreement (e.g., I believe that most people who stutter are
insecure), and self-concurrence (e.g., Because I stutter, I
feel more insecure than people who dont stutter). Responses
were given on a 5-point agreement scale (1 = strongly disagree,
2 = somewhat agree, 3 = neither agree nor disagree, 4 =
somewhat agree, 5 = strongly agree). Scores on each subscale
were averaged, with higher scores representing higher self-
stigma. Positively worded items were reverse scored. The
Appendix shows all 73 items that were included in the first
version of the 4S.
Many strategies were used in order to increase content
validity of the scale as it related specifically to stigma ex-
perienced by PWS. First, potential items were generated on
the basis of an in-depth review of the literature of self-stigma
and psychosocial aspects of stuttering. Potential items were
assigned to bins, or areas, corresponding to different
elements of stigma, and some items were systematically
removed due to redundancy, confusing language, or limited
applicability to PWS (DeWalt, Rothrock, Yount, & Stone,
2007). Second, the inclusion of interviews and discussions
with members of target populations for scale development
has been used extensively (Rao et al., 2009; Sayles et al.,
2008). Eighteen PWS who were attending an annual con-
vention of the NSA were approached and were asked
whether they would be interested in participating in a
research project by answering what they believe people in
the public think about person who stutters, and how they
thought most people in the public felt when talking to a
person who stutters. The content of these discussions was
recorded through handwritten notes taken during the discus-
sion. This was an important step in developing a survey that
was anchored in the experiences of PWS.
Utilizing experts as content reviewers is common in
survey development (Berger et al., 2001; Vogel, Wade, &
Haake, 2006). A potential list of items was submitted to three
experts for review. Expert status was based on (a) publication
records in peer-reviewed journals regarding survey develop-
ment in psychosocial aspects of stuttering (e.g., social stigma
related to stuttering; cognitive and affective dimensions of
stuttering) as well as (b) being a person who stutters or a
person who has recovered from stuttering. The experts served
as content reviewers to evaluate how well each item tapped
the concept of self-stigma related to stuttering in terms of
clarity and relevance, and they gave suggestions for potential
changes. Then, a pilot study was conducted with 22 PWS.
Pilot testing and obtaining feedback on a new survey is com-
monly done in the refinement stage of survey development
(Rao et al., 2009; Sayles et al., 2008). Participants were self-
selected members of the NSA. These participants were queried
on the language, comprehensibility, format, and relevance of
items. They then provided written feedback to the author via
e-mail regarding their thoughts about the survey, and revi-
sions were made on the basis of that feedback.
The Rosenberg Self-Esteem Scale (RSES). The RSES
(Rosenberg, 1965) was used to measure self-esteem. This
scale has 10 items measuring overall self-worth. Five items
are positively worded (e.g., I feel I have a number of good
qualities), and five items are negatively worded and reverse
scored (e.g., I feel I do not have much to be proud of ).
Responses are measured on a 4-point scale (4 = strongly agree,
3 = agree; 2 = disagree; 1 = strongly disagree), and the score
is the sum of the responses, which can range from 10 to 40,
with higher scores representing higher self-esteem. The RSES
has been shown to be a reliable (a = .88), unidimensional,
and valid scale that is frequently used in self-esteem research
(Corrigan et al., 2006; Rsch et al., 2006).
The General Self-Efficacy Scale (GSES). The GSES
(Schwarzer & Jerusalem, 1995) was designed to assess gen-
eral feelings of self-efficacy, or belief in the ability to cope
with daily hassles and adapt to stressful life experiences. The
scale contains 10 items (e.g., I am confident that I could deal
efficiently with unexpected events) and is measured on a
4-point response scale (1 = not at all true, 2 = hardly true, 3 =
moderately true, 4 = exactly true). The final score is obtained
by adding the response to each item, with a range from 10
to 40, with higher scores indicating higher levels of general
self-efficacy. The GSES demonstrates adequate psycho-
metric properties, including unidimensionality, internal
consistency (Cronbachs coefficient alphas [as] ranged from
.76 to .90 in a series of studies), and construct validity, and
has been used extensively in research measuring self-efficacy
(Luszczynska, Gutierrez-Dona, & Schwarzer, 2004).
The Satisfaction With Life Scale (SWLS). The SWLS
is a cognitively driven measure of global life satisfaction
containing five items (e.g., In most ways my life is close
to ideal). Responses are measured on a 7-point scale
1520 Journal of Speech, Language, and Hearing Research Vol. 56 15171529 October 2013
(1 = strongly disagree, 2 = disagree, 3 = slightly disagree,
4 = neither agree nor disagree, 5 = slightly agree, 6 = agree,
7 = strongly agree). Scores are calculated by summing the
responses for each item and range from 5 to 35, with higher
scores representing higher life satisfaction. The SWLS has
been shown to demonstrate unidimensionality, good reli-
ability (a = .87), and construct validity (Pavot & Diener,
1993) and has been used frequently in research measuring life
satisfaction (Pavot & Diener, 2008).
Data Analysis
Statistical analyses were conducted to evaluate the
psychometric properties of the 4S. To determine the under-
lying factor structure of the 4S, exploratory factor analysis
using the principal components method of extraction was
conducted. Principal components analysis was used as the
factor extraction method because it is an optimal approach
for reducing data, especially from a scale with many items
(Floyd & Widaman, 1995). Decisions regarding how many
factors to retain were guided by the widely used criteria of
the Kaiser (1960) method in conjunction with scree plot
analysis (Cattell, 1966). Several rounds of factor analysis were
conducted for each of the theoretical subcomponents (i.e.,
awareness, agreement, and self-concurrence) of the scale
and for the overall scale. A range of different factors was
extracted in each analysis to examine the interpretability
of each factor. Orthogonal analysis and varimax rotation
were used because the goal was to detect a clear pattern of
factor loadings, and the factors were believed to be inde-
pendent. Although the first version of the 4S contained
73 items, more than half of these items were eliminated from
the scale following factor analysis, yielding a 33-item scale.
Internal consistency was assessed using a. Temporal stability
was assessed with Pearson productmoment correlations
between participant scores on the original administration of
the survey and scores obtained during a retest that occurred
approximately 2 weeks later. Initial construct validity was
measured by performing multiple regression analyses and
observing correlations between the different levels of self-
stigma and self-esteem, self-efficacy, and life satisfaction.
Results
Participant Characteristics
Four hundred forty-six people opened the link to
the online survey that was conducted after the pilot study.
However, many responses could not be included in the final
analysis, including 64 responses from people who did not
stutter, 11 from people under age 18, and 80 from people who
did not complete any section of the survey beyond the first
few screening questions. Therefore, the total number of
responses from PWS age 18 or older included for data anal-
ysis was 291. The sample consisted of 178 males (61%),
97 females (33%), and 16 individuals (6%) who did not
specify. The average age was 39.70 (SD=15.89), with a range
from 18 to 83. Participants consisted of 33 (12%) African
Americans; six (2%) Asian Americans; 11 (4%) Hispanic
Americans; 207 (74%) White, non-Hispanics; and 20 (7%)
participants who specified other for ethnicity. Two hun-
dred forty-seven (88%) of the participants had received or
were currently receiving speech therapy, 32 (11%) had not,
and 13 (1%) did not answer.
1
Factor Structure
Item elimination. Significant loadings were considered
to be .40 or above in the initial stages of analysis (Clark &
Watson, 1995). Items 6, 12, 13, 14, 19, 24, 25, 26, 42, 49, 50,
63, and 64 were eliminated because of questionable relevance
to theoretical constructs of interest; Items 9, 18, 23, 33,
and 51 were eliminated because they loaded highly on
multiple and less relevant factors; Items 31 and 32 did not
load highly on any factor items; and Items 7, 17, 27, 43, 54,
56, 59, 66, 69, and 70 were eliminated due to redundancy
with other items in their section of the scale. In addition, two
pairs of items37 and 38, as well as 35 and 36appeared
to be doublet factors, which are considered conceptually
weak (Chesney, Neilands, Chambers, Taylor, & Folkman,
2006) and were thus eliminated. Item 71 was eliminated
because it was believed that this item would be poor in dis-
criminating PWS from people who do not stutter. Finally,
Item 1 was eliminated because it was heavily skewed, with
85% of the respondents giving the same response.
Reanalysis post initial item elimination. A factor anal-
ysis was conducted on the entire 4S after elimination of the
items described in the previous paragraph. Power for this
analysis was sufficient because the minimum number of cases
needed was exceeded, based on the recommendation of
having more responses than 5 times the number of items
being analyzed (Floyd &Widaman, 1995). Because analyzing
the total 4S measures a more general construct, including
many more items than any of the preceding analyses, a
criterion of .35 was used in determining factor loadings. It is
justified to move loading criteria slightly downward for
analyses with more items measuring wider constructs (Clark
& Watson, 1995). Using this criterion, only Items 2 and 57
did not load on any factor, and these items were eliminated.
Final factor analysis. A final factor analysis was con-
ducted on the remaining 33 items. Scree plot analysis in
combination with the Kaiser (1960) method indicated that
a three-factor solution was the most parsimonious, with
eigenvalues 6.59, 4.06, and 2.72 accounting for 40.5% of the
total variance. After varimax rotation, 12 items loaded onto
the first factor labeled stigma self-concurrence, 14 items
loaded onto the second factor labeled stigma awareness,
and seven items loaded onto the third factor labeled stereo-
type agreement. Factor loadings for the revised version of
the scale are shown in Table 1.
Most of the items had their highest loading on the
expected factor and much lower loadings on the other factors.
All items except 53 and 62 loaded higher than any other on
their respective factors. Items 52 and 58 loaded significantly
on two factors, which is a common occurrence in factor
1
Percentages are rounded.
Boyle: Self-Stigma of Stuttering 1521
analysis. These items were retained because there was a strong
theoretical justification for keeping them within a certain
factor based on the existing literature and the stigma model
used in this study. The results suggested that most items on
the 4S were capturing unique aspects of stigma related to
stuttering in the domains of stigma awareness, stereotype
agreement, and stigma self-concurrence. Note that two of the
factor labels are different from the labels given by Corrigan
et al. (2006), which specified stereotypes only. The factors
in this study related to awareness and self-concurrence con-
tained more than stereotypes, making the more general term
stigma a more appropriate label.
Correlations were small between factors of awareness
and agreement (r = .03), awareness and self-concurrence
(r = .06), and agreement and self-concurrence (r = .12).
DeVellis (2012) recommended that cross-factor correlations
smaller than .15 should be considered orthogonal to main-
tain the simplicity of uncorrelated factors. This justifies the
use of principal components extraction and varimax rotation
on the factors. Raw scores on stigma self-concurrence were
significantly correlated with stigma awareness scores (r = .20)
and stereotype agreement scores (r = .27); however, stigma
awareness scores were not significantly related to stereotype
agreement scores (r = .06).
Reliability: Internal Consistency and
Temporal Stability
Two different types of reliability measures, internal
consistency and temporal stability, were assessed in this
study. To assess internal consistency, coefficient alpha (a)
values were calculated for the 4S and its subscales. Table 2
contains a measures that provide evidence of internal
consistency reliability, as they are all between .70 and .89,
Table 1. Factor analysis of the final version of the Self-Stigma of Stuttering Scale (4S).
Variable
Factor 1:
Stigma
self-concurrence
Factor 2:
Stigma
awareness
Factor 3:
Stereotype
agreement
52. Because I stutter, I feel more nervous than people who dont stutter. .484 .101 .436
53. Because I stutter, I feel just as confident as people who dont stutter. .443 .182 .556
55. Because I stutter, I feel less capable than people who dont stutter. .490 .096 .339
58. Because I stutter, I feel less sociable than people who dont stutter. .480 .070 .429
62. Because I stutter, I feel less assertive than people who dont stutter. .379 .157 .381
63. Because I stutter, I stop myself from taking jobs that require lots of talking. .702 .008 .123
64. Because I stutter, I stop myself from accepting promotions at work. .772 .043 .097
65. Because I stutter, I stop myself from selecting the career I really want. .773 .060 .089
67. Because I stutter, I stop myself from going for higher education opportunities. .730 .112 .123
68. Because I stutter, I stop myself from talking to people that I know well. .629 .011 .042
72. Because I stutter, I stop myself from participating in social events. .772 .111 .082
73. Because I stutter, I stop myself from taking part in discussions. .837 .087 .038
3. Most people in the public believe that people who stutter are insecure. .058 .470 .057
4. Most people in the public believe that people who stutter are self-confident. .114 .445 .296
5. Most people in the public believe that people who stutter are friendly. .071 .516 .160
8. Most people in the public believe that people who stutter are capable. .001 .706 .073
10. Most people in the public believe that people who stutter are outgoing. .097 .463 .304
11. Most people in the public believe that people who stutter are mentally healthy. .058 .581 .127
15. When talking to a person who stutters, most people in the general public feel patient. .057 .613 .107
16. When talking to a person who stutters, most people in the general public
feel annoyed.
.089 .502 .082
20. When talking to a person who stutters, most people in the general public
feel comfortable.
.055 .576 .160
21. When talking to a person who stutters, most people in the general public
feel anxious.
.002 .541 .071
22. When talking to a person who stutters, most people in the general public
feel embarrassed.
.038 .535 .033
28. Most people in the general public believe that people who stutter should avoid
speaking in front of groups of people.
.052 .698 .020
29. Most people in the general public believe that people who stutter should have other
people speak for them.
.049 .657 .140
30. Most people in the general public believe that people who stutter should avoid jobs
that require lots of talking.
.050 .666 .068
40. I believe that most people who stutter are nervous. .007 .139 .630
41. I believe that most people who stutter are self-confident. .005 .047 .641
44. I believe that most people who stutter are capable. .113 .071 .397
45. I believe that most people who stutter are incompetent. .071 .018 .416
46. I believe that most people who stutter are insecure. .047 .043 .677
47. I believe that most people who stutter are outgoing. .052 .021 .613
48. I believe that most people who stutter are shy. .075 .124 .494
Note. Factor loadings after varimax rotation. Boldface values represent primary loadings associated with each factor.
1522 Journal of Speech, Language, and Hearing Research Vol. 56 15171529 October 2013
which are included in the acceptable to very good range
described by Nunnally (1978).
To assess temporal stability, testretest correlations
were calculated between responses to the original question-
naire and a follow-up questionnaire sent out 2 weeks later.
Forty-one participants completed the scale a second time.
Table 2 displays the testretest correlations for the 4S and
its subscales. Testretest correlation for the overall 4S was
.80. Correlations for the subscales ranged from .55 to .82.
It should be noted that testretest coefficients for the sub-
sections of stereotype agreement and stigma awareness were
below .70. Streiner and Norman (2003) stated that it is dif-
ficult to determine a precise cutoff point for acceptable test
retest reliability because it largely depends on what is being
measured and how long of a gap there is between test and
retest. That said, those authors recommended comparing the
coefficient that was obtained with those obtained from other
instruments measuring similar constructs. The testretest
values obtained for the 4S are comparable to other stigma
questionnaires taken 2 weeks apart by adults with a wide
variety of disorders. These studies have revealed testretest
correlations for specific subscales in the range of .55.90
and overall correlations for the total scale in the range of
.71.92 (Berger et al., 2001; Boyd Ritsher, Otilingam, &
Grajales, 2003; Corrigan et al., 2006; Kellison et al., 2010).
Construct Validity
Construct validity was evaluated by analyzing hypoth-
esized relationships between measures representing certain
variables (DeVellis, 2012). In this study, stigma self-concurrence
was hypothesized to be negatively related to self-esteem, self-
efficacy, and life satisfaction, with stereotype agreement
having a smaller relationship to these measures and stigma
awareness having an even smaller relationship. Because
some of the awareness, agreement, and self-concurrence
scores were significantly correlated, it was of interest to know
the extent of the associations between these levels of stigma and
self-esteem, self-efficacy, and life satisfaction after shared
variance was partialed out of the analysis. Table 3 shows
multiple regression analyses with self-esteem, self-efficacy, and
life satisfaction as dependent variables and stigma awareness,
stereotype agreement, and stigma self-concurrence as inde-
pendent variables. Scores on stereotype agreement and
stigma self-concurrence were shown to be separately and
significantly associated with self-esteem, self-efficacy, and
life satisfaction. However, stigma awareness was not a
significant predictor with agreement and self-concurrence
in the model.
The correlations between these variables support the
hypotheses and construct validity of the 4S. Effect sizes for
correlations in this study use Cohens (1992) widely used
standards (.1.3 = small, .3.5 = medium, >.5 = large). With
a = .05, and all levels of stigma included in the regression
model, stigma self-concurrence had a large negative corre-
lation with self-esteemand had medium negative correlations
with self-efficacy and life satisfaction. Stereotype agreement
had smaller but statistically significant correlations with
self-esteem, self-efficacy, and life satisfaction. Stigma aware-
ness had small and nonsignificant relationships with self-
esteem, self-efficacy, and life satisfaction. The notion that
self-stigma is a multilevel and progressive construct was
supported through mostly stronger correlations at prox-
imal (e.g., self-concurrence and self-esteem decrement) rather
than distal (e.g., stigma awareness and self-esteem decre-
ment) stages.
Stigma Scores
To score the 4S and its subscales, the participants
responses were averaged, yielding a number between 1 and 5.
Table 2. Reliability statistics for the 4S and subscales.
Variable Cronbachs Testretest correlation
Overall 4S .87 .80
Stigma awareness .84 .62
Stereotype agreement .70 .55
Stigma self-concurrence .89 .82
Note. The time between test and retest was approximately 2 weeks
for 41 individuals who stutter.
Table 3. Multiple regression analysis with components of self-stigma predicting self-esteem, self-efficacy, and life satisfaction.
Dependent variable Independent variable B SE t p R
2
Self-esteem
Stigma awareness .042 .048 .040 .879 .380 .45
Stereotype agreement .170 .044 .179 3.833 <.001
Stigma self-concurrence .382 .031 .588 12.345 <.001
Self-efficacy
Stigma awareness .027 .042 .035 .644 .520 .23
Stereotype agreement .172 .039 .244 4.403 <.001
Stigma self-concurrence .169 .027 .351 6.22 <.001
Life satisfaction
Stigma awareness .070 .141 .027 .497 .619 .23
Stereotype agreement .272 .131 .115 2.085 .038
Stigma self-concurrence .705 .091 .433 7.720 <.001
Note. R
2
values represent variance accounted for with all three independent variables in the model.
Boyle: Self-Stigma of Stuttering 1523
For statistical purposes, participants were considered to have
high levels of self-stigma if their average score was above 3
and low levels of self-stigma if average scores were below 3.
This scoring was based on the observation that a score of
exactly 3 represented the theoretical midpoint of neither
agreeing nor disagreeing with stigma, scores higher than 3
represented agreeing with stigma, and scores lower than 3
represented disagreeing with stigma. These average scores
should be interpreted in terms of absolute self-stigma rather
than relative self-stigma. The mean for stigma awareness was
3.61 (SD = 0.54), with 86% of participants demonstrating
high stigma awareness. The mean for stereotype agreement
was 2.56 (SD = 0.61), with 19% of participants agreeing
highly with these stigmatizing views as they apply to other
PWS. The mean for stigma self-concurrence was 2.70
(SD=0.92), with 39%of participants demonstrating high levels
of self-concurrence. It is important to note that the sample of
PWS in this study was limited, and so the scores presented
here should not be interpreted as normative data for a rep-
resentative sample of all PWS. In summary, the results show
that a large proportion of the participants were highly aware
of stigma related to stuttering, but a relatively small pro-
portion agreed highly with negative stereotypes about other
PWS. Still, compared with participants who agreed highly
with negative stereotypes related to other PWS, a substan-
tially larger proportion of participants applied highly nega-
tive stigmatizing attitudes to themselves personally.
Discussion
This study focused on the development of the 4S, the
first scale to measure the self-stigma associated with stut-
tering. Findings suggest that psychometric properties of the
scale are adequate for research and clinical purposes. Spe-
cifically, reliability measures indicate that the 4S has accept-
able to very good internal consistency and acceptable
temporal stability. The scale is made up of three constructs:
stigma awareness, stereotype agreement, and stigma self-
concurrence. Initial construct validity was supported in that
self-stigma was negatively related to self-esteem, self-efficacy,
and life satisfaction, with larger associations observed among
later stages of stigma (e.g., stigma self-concurrence was more
strongly related to self-esteem than was mere awareness of
stigma), supporting the progressive model of stigma described
in this study (Corrigan et al., 2011). The 4S is relevant for SLPs
who work with PWS because it can be administered in a re-
latively brief period of time (about 35 min) and can assess
multiple levels of stigma that appear to be valuable for under-
standing the beliefs of PWS. It can also help in determining
the need for client counseling on certain stigma-related issues
pertaining to stuttering.
Clinicians may want to assess self-stigma during initial
assessment and throughout the duration of treatment to
track whether clients possess altered self-stigmatizing atti-
tudes. In addition, the awareness portion of the scale may be
helpful in evaluating clients perceptions of public attitude
change regarding PWS. It has been established that address-
ing well-being and quality of life are relevant and important
goals for SLPs working with PWS through decreasing
activity limitations, participation restrictions, and barriers
created by contextual factors (American Speech-Language-
Hearing Association, 2007; Yaruss, 2010). PWS who self-
concur or agree with stigmatizing attitudes about stuttering
will likely experience these problems (Klompass & Ross,
2004; Plexico et al., 2009). SLPs working with PWS can target
reducing these limitations, constrictions, and barriers by
addressing self-stigma with the assistance of the 4S. For
example, the use of cognitive therapies and self-help and
mutual aid programs may help clients decrease stereotype
agreement and stigma self-concurrence by challenging
harmful beliefs that may limit their quality of life.
In general, the findings support previous research
demonstrating negative associations between internalized
stigma and self-esteem (Berger et al., 2001; Corrigan et al.,
2006), as well as self-efficacy (Rsch et al., 2006; Watson,
Corrigan, Larson, &Sells, 2007), found in various populations
and extends these associations to PWS. Results support the
notion that self-stigma in PWS has multiple components (i.e.,
awareness, agreement, self-concurrence) similar to what has
been proposed for individuals with mental illness (Corrigan
et al., 2006); however, the content of the stigma is different
between the groups. The findings (see Table 3) also partially
support the progressive model of self-stigma (Corrigan et al.,
2011) and provide little support for the claim that mere
awareness of negative perceptions of PWS from the public
may be functional in influencing stutterers self-concept as
well as their actual behavior (Turnbaugh, Guitar, &Hoffman,
1979, p. 44). Assessing awareness of stigma alone is not suf-
ficient to understand its impact. Of greater relevance is PWS
agreeing with the stigma and, even more so, applying the stigma
and hurtful beliefs to themselves personally. When internaliza-
tion of stigma extends beyond mere awareness into agreement
and finally self-concurrence, PWS may be in danger of ex-
periencing increasingly lower levels of well-being.
Results of the study partially supported the trickle-
down expectation of the progressive model. Awareness
scores were higher than agreement scores; however, agree-
ment scores were lower than self-concurrence scores. It
appears that PWS are harder on themselves than on other
PWS. These findings differ from previous research studies
that suggested that PWS had more negative views about
other PWS than they did about themselves (Fransella, 1968;
Kalinowski et al., 1987). A speculative explanation for these
discrepancies is that over recent years, many more PWS are
coming together through technologies, such as social media
andonline support networks, that were not previously available.
This increased sense of community and access to other PWS
may be decreasing stereotype agreement among PWS. The
findings that agreement scores were lower than self-concurrence
scores and that awareness was more highly correlated with self-
concurrence than agreement seem to imply that the progressive
nature of self-stigma expressed by Corrigan et al. (2011)
may not be generalized to PWS without some modification.
Although it appears true that there are various levels of self-
stigma in PWS, it does not appear that agreement with
stereotypes for other stigmatized group members must be a
1524 Journal of Speech, Language, and Hearing Research Vol. 56 15171529 October 2013
prerequisite for applying that stigma to oneself personally.
Additional research is needed to investigate the framework of
the self-stigma model more deeply.
Limitations and Future Directions
There are some limitations to consider in this study.
First, participants were recruited from either professionals
or self-help networks, meaning that most participants have
sought help or external support for their stuttering. It is
reasonable to believe that PWS with no history of treatment
or support groups may have responded differently to self-
stigma items. Also, even though many different ethnicities
were represented in this study, the majority of participants
were Caucasian; therefore, the 4S requires further evaluation
in larger populations of different ethnicities. Furthermore,
it is not known how responders differed from nonresponders
and whether those differences have implications for the
results found in this study.
An element of subjectivity is unavoidable in the in-
terpretation of the results of factor analyses. Therefore, there
may be other ways of interpreting the factors that arose in
this study. Future research with different populations of
PWS will be helpful in confirming the factor structure found
in this study. It is also important to remember that the ob-
servational design of this study does not permit conclusions
of causal relationships. Although the results are suspected
to mean that self-stigma leads to diminished well-being as a
consequence, it is possible that there are mediating constructs
or that lower well-being leads to increased self-stigma. The
latter interpretation seems less likely, as it has been shown that
baseline self-esteem is not a long-term predictor of self-stigma,
but self-stigma is a long-term predictor of self-esteem (Link,
Struening, Neese-Todd, Asmussen, & Phelan, 2001). Finally,
the theoretical model of self-stigma proposed by Corrigan
and Watson (2002) was used in this study as a guide for item
selection to answer the specific research questions posed.
Therefore, there may be other items related to the stigma as-
sociated with stuttering that could be relevant, depending on
different models or conceptualizations of stigma.
There are many new areas of research to be investi-
gated. First, it will be important to examine how self-stigma
varies with demographic information (e.g., age, gender) as
well as variables such as treatment experience and support
group involvement. Continued analysis of construct validity
of the 4S with measures related to shame, hope, and em-
powerment will be important to consider. It will also be
important to look at the relationships between self-stigma
of stuttering and other important aspects of well-being in
PWS such as positive affect. The scale should also be ad-
ministered to PWS who are not part of treatment or support
groups to determine whether their stigma levels are higher
than those reported in this study. Tracking 4S score changes
across different treatment protocols for stuttering may also
be a valuable area for future research. Finally, most research
related to stigma and stuttering has used self-report mea-
sures. Future investigations may benefit from applying
other assessment methods to analyze connections between
well-being and stigma, including observational or behavioral
data, or physiological measures.
Conclusion
The 4S is a psychometrically sound measure of self-
stigma in PWS. This scaletogether with other measures of
cognitive, affective, and social dimensions of stutteringis
likely to provide information regarding clients need for
cognitive change and the possibility of relapse following
treatment. Looking at multiple layers of stigma through
instruments such as the 4S can contribute to our understand-
ing of processes that have implications for well-being and
quality of life among PWS and can help to develop effective
treatment strategies for altering negative beliefs. Regardless
of the negative reactions PWS may encounter from the
public, which might be unavoidable at times, the extent to
which they agree with and internalize harmful self-stigmatizing
beliefs is modifiable and open to change. The 4S is intended
to be a tool used by researchers and service providers to
identify and document these types of changes in individuals
who stutter.
Acknowledgments
This research was conducted as part of the authors 2012
doctoral dissertation in the Department of Communication Sciences
and Disorders at The Pennsylvania State University. Parts of this
research were presented at the 2012 annual convention of the Amer-
ican Speech-Language-Hearing Association in Atlanta, GA. Special
thanks to my mentor and primary advisor, Gordon Blood, for all his
support, reviews, helpful feedback, and suggestions throughout this
study. Thanks to committee members Ingrid Blood, Robert Prosek,
and James Herbert for their reviews, suggestions, and comments.
Thank you to Rodney Gabel, Kenneth St. Louis, and Robert Quesal
for their reviews on an early version of the scale used in this study.
Thanks to Frank Germann and Daisy Phillips for their statistical
consulting. Thank you to the National Stuttering Association and
the Board Recognized Specialists in Fluency Disorders who helped
greatly with participant recruitment for this study. Thank you to
all of the participants in this research.
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Boyle: Self-Stigma of Stuttering 1527
Appendix (p. 1 of 2)
Items in the first version of the Self-Stigma of Stuttering Scale (4S).
Most people in the general public believe that people who stutter areI
1. nervous
2. shy
3. insecure
4. self-confident
5. friendly
6. confused
7. intelligent
8. capable
9. incompetent
10. outgoing
11. mentally healthy
12. embarrassed
13. not trying hard enough to stop stuttering
14. not concerned enough to stop stuttering
When talking to a person who stutters, most people in the general public feelI
15. patient
16. annoyed
17. frustrated
18. confused
19. surprised
20. comfortable
21. anxious
22. embarrassed
23. pity for the person who stutters
24. unsure how to react to stuttering
25. that they should help the person who stutters
26. that they should give advice to the person who stutters
27. not bothered by stuttering
Most people in the general public believe that people who stutterI
28. should avoid speaking in front of groups of people
29. should have other people speak for them
30. should avoid jobs that require lots of talking
31. are likely to be hired for jobs that require lots of talking
32. are likely to be promoted at work
33. are able to do their job effectively
Most people in the general public would want toI
34. avoid having a conversation with a person who stutters
35. be friends with a person who stutters
36. introduce a person who stutters to friends
37. avoid dating a person who stutters
38. avoid having a romantic relationship with a person who stutters
39. work with a person who stutters
I believe that most people who stutter areI
40. nervous
41. self-confident
42. confused
43. intelligent
44. capable
45. incompetent
46. insecure
47. outgoing
48. shy
49. optimistic
50. stressed
1528 Journal of Speech, Language, and Hearing Research Vol. 56 15171529 October 2013
Appendix (p. 2 of 2)
Items in the first version of the Self-Stigma of Stuttering Scale (4S).
Because I stutter, I feelI
51. less adequate than people who dont stutter
52. more nervous than people who dont stutter
53. just as confident as people who dont stutter
54. just as secure as people who dont stutter
55. less capable than people who dont stutter
56. less competent than people who dont stutter
57. just as intelligent as people who dont stutter
58. less sociable than people who dont stutter
59. just as outgoing as people who dont stutter
60. more confused than people who dont stutter
61. just as ambitious as people who dont stutter
62. less assertive than people who dont stutter
Because I stutter, I stop myself fromI
63. taking jobs that require lots of talking
64. accepting promotions at work
65. selecting the career that I really want
66. asking for promotions at work
67. going for higher education opportunities
68. talking to people I know well
69. talking to people I dont know well
70. starting conversations with other people
71. speaking in front of a group of people
72. participating in social events
73. taking part in discussions
Boyle: Self-Stigma of Stuttering 1529