RESEARCH PAPER

A life-time of stuttering: How emotional reactions to stuttering impactactivities and participation in older people

GERALDINE BRICKER-KATZ1, MICHELLE LINCOLN1,2 & PATRICIA MCCABE2

1Australian Stuttering Research Centre, The University of Sydney, Sydney, Australia and 2Department of Speech Pathology,

Faculty of Health Sciences, The University of Sydney, Sydney, Australia

Accepted January 2009

AbstractPurpose: The International Classification of Functioning, Disability and Health (ICF) framework has a pragmatic focus onhow impairment impacts the individual’s activities and participation. Stuttering is known to impact communication inyounger adults but this has not been established in older people who stutter. In this study, emotional reactions to stutteringwere investigated in a group 55 years and older who self-reported stuttering since childhood.Method: This was a cross-sectional descriptive design. Twelve participants who self-reported that they still stuttered and inwhom stuttering was confirmed, and 14 controls completed the Fear of Negative Evaluation Scale (FNES), The EndlerMulti-dimensional Anxiety Scales-Trait (EMAS-T) and The Australian Personal Wellbeing Index (PWA-I). Participantswhose stuttering persisted also completed the Overall Assessment of Speakers Experience of Stuttering (OASES).Results: The group who stuttered scored significantly higher on the FNES, with scores in the social phobia range.Responses on the OASES showed that stuttering continues to be a negative experience for this older group. Results for theEMAS-T and PWA-I were within the average range across both participant groups however significant differences existedbetween the groups in the social evaluative and physical danger domains of the EMAS-T, and the satisfaction with healthdomain of the PWA-I.Conclusions: Significant fear of negative evaluation, which is the key feature for social anxiety, was found in the group ofolder people who stuttered with a higher level of trait anxiety in social evaluative domains. The OASES showed that they alsoreacted to stuttering and communication in daily situations with moderate to severe impact scores which showed thatstuttering impacted on speaking activities and by those negative experiences limited communication. Limitedcommunication and restricted participation in the lives of older people have implications for healthy productive ageingand this is discussed.

Keywords: Stuttering, older people, ICF, limitations, restrictions

Introduction

A conceptual framework

Effective communication is vital for people of all

ages. As people grow older efficient and successful

communication is critical to being able to maintain

independence and participate in daily activities

involving personal, social and vocational relation-

ships [1,2]. Integral to the notion of healthy ageing is

the maintenance of involvement with a full range of

activities, staying in the workforce longer, living

independently and being in control of financial,

medical and social activities [2,3]. It has been

suggested that if older people maintain satisfactory

physical and mental health and are supported by

networks of community, family and friends then

sustaining active function and participation are

attainable goals [4,5].

This focus on healthy ageing emerged in syn-

chrony with the evolution of the World Health

Organization’s International Classification for Func-

tioning, Disability and Health (ICF) [6,7]. The ICF

offers a conceptual context to classify and describe

how a disorder like stuttering presents, impacts

and sets up limitations that restrict the person’s

ability to participate fully in life’s activities [7,8].

The application of this framework to stuttering

makes it possible to delineate the many facets of

Correspondence: Geraldine Bricker-Katz, Australian Stuttering Research Centre, The University of Sydney, Sydney, Australia. Tel: þ61-2-9351-9440.

Fax: þ61-2-9351-9763. E-mail: gkat9703@mail.usyd.edu.au

Disability and Rehabilitation, 2009; 31(21): 1742–1752

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2009 Informa UK Ltd.

DOI: 10.1080/09638280902738672

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f Sy

dney

on

03/0

5/15

For

pers

onal

use

onl

y.

the disorder beyond the stuttering behaviors [9,10]

and whilst this has been dealt with extensively for

people who stutter into mid-adulthood [11–14] little

research evidence exists about the nature and

development of the disorder in older people.

The ICF [7] has four categories of description

of the disorder, the first at the physiological and

anatomical levels (Body Functions and Structure; the

impairment category), the second is the activities

of daily living that may be restricted by the

impairment (Activities and Participation), third is

environmental variables that reduce participation

(Environmental Factors), and the fourth concerns

factors intrinsic to the individual (Personal Factors)

that may also restrict participation [7]. The classi-

fication endorses consideration of dynamics be-

tween the individual and their environment that

may preclude them from participation. In people

who stutter this entails identifying and measuring

their speech behaviors (stuttering severity, speech

rate, speech naturalness) and evaluating how the

impairment in their speech restricts them in com-

munication activities such as conversations with

people at work, when shopping, or in other social

situations. At the personal level it involves ap-

praising their emotional responses to their speech

and the restrictions that may arise as a consequence

which compound their ability to be active partici-

pants in communicative interactions of daily living

[15].

There is little information about the stuttering

experience of older people who have stuttered since

childhood. This investigation is a novel exploration

into an age-group whose experience of stuttering has

not received attention. By broadening knowledge of

stuttering in older adulthood a more complete

picture of its development through the lifespan can

be offered.

The impact of stuttering on the lives of people who stutter

People who stutter report a range of feelings in

response to their stuttering and in response to the

real or imagined reactions of other people to their

stuttered speech [8,13,16,17]. Stuttering in younger

adults may predispose people who stutter to anxiety

which can manifest in social anxiety [18–22], fear of

negative evaluation (FNE) [22–24], and consequent

avoidance of speaking situations [19,25]. These

affective, behavioral and cognitive consequences

ultimately impose limitations for these younger

people who stutter in realising their social, educa-

tional and vocational potentials [23,26–28].

For people who stutter anxiety is frequently

associated with the idea or act of speaking

[21,29,30]. The relationship between anxiety and

stuttering has posed a long-standing conundrum for

clinicians and researchers who have yet to fully

unravel the process that drives the interaction between

the two [29,31,32]. Research has dispelled the notion

that stuttering is of itself an anxiety-based disorder

since it has been demonstrated that people who stutter

are not inherently more anxious than people who do

not stutter [31,32]. However, the consequences of

stuttering can induce an anxiety component to an

already potentially debilitating speech disorder [31].

Trait anxiety is the individual’s inbuilt, possibly

genetically founded level of anxiety [33] while state

anxiety relates to contexts and situations in the

individual’s environment that may trigger anxiety

specific to the external stressor [34,35]. It has been

argued that for people who stutter speaking situations

are the situational stressor [29,30] for state-anxiety.

Contrastively, trait anxiety measures for people who

stutter have not consistently been reported to be

higher than in fluent speakers [32,36].

It has been suggested that the relationship between

trait anxiety and stuttering may change over time with

trait anxiety increasing as people who stutter grow

older having had consistent and enduring exposure to

state anxiety triggered by speaking [32,37].

Integral to the social anxiety experienced by people

who stutter is FNE by others. From a study of 34

younger people who stuttered (19–52 years, mean

32.0 years, SD 10.5) Messenger et al. demonstrated

the significance of FNE in this group [22]. Partici-

pants who stuttered scored significantly higher than

control participants on measures of social evaluation

(SE) and anxiety in new/strange situations (N/S). In

the same study, people who stuttered scored in the

clinically significant range for FNE with measures in

a range similar to that measured in people who are

diagnosed with social phobia [22]. The behavioral

response to such feelings may be avoidance of

speaking situations and this in turn may isolate

people who stutter from participation in social

activities and contexts where verbal interaction is

anticipated [19,38].

Research and the older person who stutters

It has been reported that recruitment of older

people who stutter as research participants is

challenging [39,40] and older people who stutter

are not frequently represented in clinical popula-

tions. Some authors suggest that the disorder

becomes less onerous as people grow older and this

may indicate that the disorder ameliorates with aging

[39,41–45]. Manning et al. [40] investigated the

speech attitude, personality characteristics, and

attitude to treatment of 29 older people who

stuttered (51–82 years, mean age 62 years) through

The ICF and stuttering in older people 1743

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f Sy

dney

on

03/0

5/15

For

pers

onal

use

onl

y.

a biographical survey and other measures. The survey

included questions about stuttering severity in the

participants’ past and how they rated their stuttering

severity at the time of the research. Participants were

also asked about the impact of stuttering on their

social, vocational and educational experiences and

whether their attitude to stuttering had changed in

comparison to when they were younger.

Manning et al.’s [40] overall findings were that for

this older group, stuttering did not limit (handicap)

their communication to the same degree as they

reported it did when they were younger. That is, as

these people grew older their attitude towards

speaking became less negative. Participants felt less

constrained by their stuttering because they ‘felt less

pressure on them to be fluent’ [40, p. 213], and this

appears to have lessened the experience of handicap

for this group despite no reported (or measured)

change in the severity of the stuttering itself.

In younger people who stutter, research has shown

that negative speaking experiences establish negative

attitudes towards communication and that these

attitudes play a role in exacerbating the disorder

[46,47]. The notion that stuttering ameliorates as

people who stutter grow older was thus given some

credence by Manning et al. [40]. Nevertheless, this

requires a more rigorous level of enquiry to clarify

which facets of the disorder might change over time,

and gives added impetus to using the ICF which by

its form allows for such evaluation.

Stuttering and barriers to healthy ageing

The presence of stuttering may be a significant

barrier to healthy and successful ageing. A recent

study [48] reported on the speech characteristics

(ICF Body Function level) of 16 older people who

reported stuttering into adulthood (56–83 years,

mean age 70.4 years). This is the first formal

reported investigation of the impairment in an older

group. Stuttering behaviors were present in 13 of this

older group and this stuttering was characterized by

behaviors typically seen in younger people who

stutter [48]. However, there was no evidence from

that study to support the belief that social anxiety in

speech related situations abates as people grow older.

It is simply unknown whether older people who

stutter continue to avoid speaking situations as

younger people who stutter do [49]. It is possible

that older people who stutter may avoid asking

questions, seeking clarification or participating in

decision making regarding their health and lifestyle.

The complex issues of anxiety, FNE and resultant

social anxiety and avoidance of speaking situations

can take a toll on the quality of life of younger people

who stutter [21,28,50] and to date there are no data

on how stuttering in older people impacts on how

they experience the quality of their life. Identifying

the consequences of stuttering for older people and

highlighting whether they are similar to those

experienced by younger people who stutter is

clinically relevant. From this, appropriate interven-

tions may be framed to meet the needs of older

people who stutter.

Research aims

The aim of this study was therefore to measure and

identify the affective, cognitive and behavioral

responses to stuttering of a group of older people

who stutter and to use these measures to determine

whether stuttering might create barriers to effective

communication for these older people who stutter.

Method

Recruitment of participants

The study reported in this article is one of three

studies investigating stuttering in older people. The

same participants were used across the research as

each project investigated different facets of the

disorder according to the ICF framework [6,7] in

the cohort.

The original recruitment invited people 55 years

and older who stuttered or had stuttered into

adulthood to participate. A second group of similar

aged people who did not stutter or have any history

of stuttering in their lives was recruited as controls

for the current study.

Participants who stuttered were recruited from the

general population in the state of New South Wales,

Australia. Information about the research was

disseminated using press releases in community

newspapers, veterans’ and seniors’ newspapers, and

notices in the university speech pathology clinic.

People over 55 years were invited to participate in the

research if they stutter and/or have stuttered from an

early age into adulthood and had functional English

literacy. Confirmation of self-report was conducted

and is reported in detail in Bricker-Katz et al. [48].

Control group participants who did not stutter

were recruited. They were asked to complete all

questionnaires except the OASES. The technique of

Snowball sampling [51] was used to recruit the

control participants from the personal networks of

the researchers. Snowball sampling involved word-

of-mouth requests for suitable participants through

social, vocational and community networks. People

over 55 years who had no history of stuttering or any

other communication disorder, and could indepen-

1744 G. Bricker-Katz et al.

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f Sy

dney

on

03/0

5/15

For

pers

onal

use

onl

y.

dently complete the relevant research questionnaires

in English were eligible to participate.

Participants

There were two groups of participants and Table I

shows the demographic information for each group.

The first group was 12 people over the age of 55

years who volunteered to participate because they

reported stuttering in their speech from childhood

into adulthood and had participated in a previous

study that verified their stuttering by evaluation of

various speech measures [48]. The nine men and

three women had a mean age of 68.8 years

(SD¼ 8.01, range 57.2–80.5). Their mean number

of years of education was 12.6 (SD¼ 4.32, range 7–

20). They described stuttering behaviors consistent

with a diagnosis of stuttering, and also described

consequences of having stuttered speech that were

congruent with a stuttering disorder. None of the

participants had any neurological incident associated

with the onset of the stuttering.

The control group comprised 14 participants, 55

years and older (mean age 69.1, SD¼ 4.18, range

56.1–80.4). The 3 women and 11 men had a mean

number of years of education of 11.7 (SD¼ 2.91,

range 8–16). The completion of demographic

information and at least one questionnaire was a

criterion for using the control participant data.

Thirteen controls completed all the questionnaires,

14 completed the FNES, 13 the EMAS-T and 14 the

PWI-A thereby creating a difference in the number

of control participants across tasks.

Measures of reactions to stuttering in older people

The measurement of an older groups’ reactions to

stuttering involved compiling a range of instruments

that would quantify psycho-affective constructs such

as anxiety, FNE, quality of life and the experience of

stuttering. These are known sequelae of stuttering in

younger adults who stutter [19–22]. The tools

selected measured trait anxiety for social evaluative

contexts, FNE, subjective well being and the

Table I. Demographic Information for Older group who persisted with stuttering, and controls.

Participant CA Gender Years of education Employment status Previous employment Marital status

Older group who persisted with stuttering n¼ 11

Mean 68.8 12.6

SD 8.01 4.32

Range 57.2–80.5 7–20

P2 80.5 M 20 Retired Professional Married

P4 77.9 M 16 Retired Commercial Married

P5 72.1 M 9 Employed Commercial Married

P6 57.2 F 12 Employed Administration Divorced

P7 65.3 M 10 Retired Trade Single

P8 80.11 M 8 Retired Commercial Married

P10 64.7 M 16 Semi-retired Professional Married

P11 59.11 F 12 Semi-retired Commercial Widowed

P12 64.4 F 10 Employed Administration Married

P14 73.7 M 7 Retired Trade Divorced

P15 63.11 F 16 Semi-retired Professional Divorced

P16 64.7 M 15 Employed Trade Married

Controls n¼ 14

Mean 69.1 11.7

SD 4.8 2.91

Range 56.1–80.4 8–16

C1 62.5 M 16 Employed Professional Married

C2 73.11 M 8 Retired Trade Married

C3 57.10 F 10 Retired Military Married

C4 66.3 M 16 Employed Professional Married

C5 64.6 M 10 Employed Commercial Married

C6 65.9 M 10 Semi-retired Trade Married

C7 69.7 M 16 Semi-retired Trade Married

C8 56.1 F 10 Employed Administrative Married

C9 80.0 F 10 Retired Professional Married

C10 80.2 M 9 Retired Commercial Widowed

C11 76.3 M 12 Retired Professional Married

C12 80.4 M 12 Retired Trade Widowed

C13 72.9 M 15 Retired Commercial Married

C14 62.9 M 10 Employed Trade Married

The ICF and stuttering in older people 1745

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f Sy

dney

on

03/0

5/15

For

pers

onal

use

onl

y.

stuttering-specific OASES [10] a relatively new

measure that takes the perspective of the person

who stutters experience of stuttering across all

components of the ICF.

The group of older people who persisted with

stuttering thus completed a trait anxiety measure the

Endler Multidimensional Anxiety Scale-Trait

(EMAS-T) [52]; Fear of Negative Evaluation Scale

(FNES) [53]; the Australian Wellbeing Index (PWI-

A) [54]; and the Overall Assessment of Speakers

Experience of Stuttering, (OASES) [10]. Control

participants completed all measures except the

OASES.

The EMAS-T is a clinical and research tool based

on an interactional model of personality that

proposes that trait anxiety is a multidimensional

emotion occurring when a person reacts to variables

in the environment [55,56]. The EMAS-T includes

measurement of trait anxiety in situations of SE and

N/S, both previously reported to be challenging for

people who stutter [22]. It is a 60-item questionnaire

which measures trait anxiety for SE, physical danger

(PD), N/S and daily routines (DR). The FNES and

the EMAS-T have yielded important data in a

younger group of people who stutter [22], and in

clinical groups who experience social anxiety [57].

Quality of life is a construct of relevance in

stuttering since the disorder can be intractable and

is experienced as a chronic condition, much like

other health conditions such as psoriasis [58] which

are comparable with stuttering in terms of severity,

variability, unpredictability and how the individual

reacts to living with the condition. It is understood

that stuttering can impact significantly on a person’s

life and this impact may or may not override the

person’s overall sense of wellbeing. The PWA-I [54]

is a quality of life tool standardized for Australian

adults which measures the average level of satisfac-

tion with life across seven domains including the

specific life domains of standard of living, personal

health, achievement in life, personal relationships,

personal safety, community connectedness and

future security [59].

The last measure used was a stuttering-specific

instrument the Overall Assessment of the Speakers

Experience of Stuttering, (OASES) [10]. This

measure was chosen because it is uniquely designed

to measure the individual experience of stuttering

using the ICF framework as its conceptual frame-

work and in its design incorporated the dimensions

of the stuttering experience targeted in this research

[7,8,10]. It is a 100-item, four-section questionnaire.

Items in the sections General Information (GI) (20

items) and Reactions to Stuttering (RS) (30 items)

address the ICF impairment level (Body Structure and

Function). The restrictions imposed on communica-

tion (Activities and Participation) are addressed in the

section Communication in Daily Situations (25

items) and Quality of Life (25 items) [10].

Raw scores in the OASES are converted to impact

scores for each category. The lower the score, the less

negative the impact of stuttering. The lowest score

possible is 20 which equates to a mild impact. Impact

scores are calculated for each category and from

these a Total Impact Score is calculated indicating

the overall degree of impact severity that people who

stutter might experience because of their stuttered

speech [10].

Results

Fear of Negative Evaluation Scale [40]

The results of the FNES are shown in Table II. A

two-tailed t-test yielded a significant difference

between the older people who stuttered and the

control group [t(17)¼ 3.46, p¼ 0.0029] indicating

that the group of older people whose stuttering had

persisted had significantly higher FNE than controls.

Seven of the 11 participants (64%) in the group of

older people with persistent stuttering scored higher

than 18 on the FNES, whilst no controls scored

higher than 18.

EMAS-T [52]

Mean T-scores for the two groups on all four

domains of the test were within the average range

of T-scores [52]. However t-tests between the two

groups showed significance for the domains of social

evaluative anxiety and PD in older people who

stuttered. The results on the EMAS-T are shown in

Table III.

Personal Wellbeing Index (Quality of Life measure)

Scores on the PWI-A were obtained for older people

with persistent stuttering (n¼ 12), and control

Table II. Descriptive statistics for older people who stuttered and

controls on the FNES.

FNES

Older group who persisted

with stuttering (n¼ 11) Controls (n¼14)

Mean 17.64 3

Median 23 3

Mode 2 3

SD 10.65 2.76

Range 2–28 0–11

Two-tailed t-test assuming unequal variances.

Significant [t(17)¼ 2.1, p¼ 0.002].

1746 G. Bricker-Katz et al.

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f Sy

dney

on

03/0

5/15

For

pers

onal

use

onl

y.

participants (n¼ 14). Table IV shows descriptive

statistics for each domain of the PWI-A for the two

groups.

The group means showed that the group of older

people with persistent stuttering had a Subjective

Wellbeing Index (SWBI) of 71 which is slightly

below the normative range of 73.4 – 76.7 for the age

groups represented [57,60]. It is known that there is

a decrease in life satisfaction on the PWI-A as age

increases [59]. The age-specific normative means

decline from 73.4 to 72.3 for ages 55–60 years and

76þ age groups, respectively [59].

Group scores for each domain of life satisfaction

showed that the older people with persistent stutter-

ing scored within the normal range for Satisfaction

with Standard of Living, Safety, Sense of Commu-

nity and Future Security. The group means for

Achievement in Life and Personal Relationships

were below the normed aggregated individual data

but within the normal range for group data [57,60].

Control participants scored at the normative level

across all the domains.

A two tailed t-test for samples of unequal variances

was applied to the Satisfaction with Health measures

and showed significant difference between older

people with who had persisted with stuttering and

controls [t(18)¼ (2.41; p¼ 0.026]. Thus, older

people who stuttered were significantly less satisfied

with their health than controls.

OASES

Individual participant scores for the OASES are

available in Appendix. Table V shows descriptive

statistics for older people who persisted with stutter-

ing. Impact ratings across the categories were in the

moderate to moderate-to-severe impact range on

the OASES. The highest impact score was 59.6

in the category RS which showed that this older

group are cognitively focused on their speech,

experience discomfort when observing reactions of

listeners when they are talking and stuttering, and

experience their stuttering as impacting on how they

feel, think and behave in relation to speaking [10].

The lowest impact score for this group was QOL

(mean score 45.9) and whilst this also showed a

moderate impact rating it was at the lower end of the

moderate range which is 45.0–59.9 [10].

The pilot data for the OASES was drawn from

173 people who stutter with an age range of 18–70

years (mean and SD were not provided) [10].

Distribution of these scores approximated a normal

distribution with the mean at 50 equating to a

moderate impact score [10]. This means that the

average person who stutters will fall at the 50

percentile in their responses on the OASES. This

group of older people who persisted with stuttering

responded at or above the 50 percentile [10]. The

mean scores of the group of older people who

persisted with stuttering were higher than 50 for

RS, CDS and TI. Thus, the older group showed

that they experience stuttering as restricting com-

munication and thus limiting their capacity to fully

participate in life activities that involve speech.

Mean scores were in the range of 45.9–59.6,

median scores were in the range of 46.4–62.4 and

the large SD showed that variance was high.

A Pearson correlation between the Quality of Life

measure on the OASES and the SWBI of the

Personal Wellbeing Index (PWA-I) was weak

[r¼ (0.24].

Discussion

Older people whose stuttering persisted scored

significantly higher for FNE than controls. Variance

in the FNES scores in the older stuttering group was

fairly large, indicating that there are some in the

group who reported high FNE whereas others scored

in a lower range. This suggests that FNE is not

consistently higher for all older people who stutter

Table III. Descriptive statistics for two groups on the EMAS-T.

EMAS-T

domains

Descriptive

statistics

Older group

who had

persisted with

stuttering (n¼ 12)

Controls

(n¼13)

SE Mean 54.7 49

Median 50.5 48

Mode 49 48

SD 8.44 4.28

Range 46–71 42–58

PD Mean 55.9 45.9

Median 55.5 45

Mode 55 43

SD 6.99 5.8

Range 45–70 36–60

N/S Mean 53.7 50.5

Median 56 51

Mode 64 51

SD 12.4 6.23

Range 29–69 41–60

DR Mean 49.6 50.2

Median 49 50

Mode 46 50

SD 9.00 9.6

Range 34–67 35–67

1t-Test: two sample assuming unequal variances; [t(20)¼ 2.08,

p¼0.02] showing significant trait anxiety for social evaluative

situations in older people who stutter.2t-Test: two sample assuming unequal variances; [t(21)¼ 2.07,

p¼0.0008] showing significant trait anxiety for physical danger in

older people who stutter.

The ICF and stuttering in older people 1747

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f Sy

dney

on

03/0

5/15

For

pers

onal

use

onl

y.

but some older people who stutter may experience

such negative reactions and the consequences arising

from this warrant further consideration.

Group scores across all domains of the EMAS-T

were within the normal range for both groups.

However, statistical significance was shown between

Table V. Descriptive statistics for OASES scores showing mean, standard deviation and range for group scores for group of older people who

had persisted with stuttering (n¼9).

Mean age

General

information

Reactions to

stuttering

Communication in

daily situations Quality of life

Total impact

score

Group of older people who had persisted with stuttering

Mean 68.8 50.9 59.6 57.0 45.9 53.9

Median n/a 55 60 60.7 46.4 62.4

SD 8.01 17.9 18.9 15.1 17.0 15.3

Range 57.2–80.5 20–73.8 20–78.7 28.8–76 20–75.6 20–66.8

Table IV. Descriptive statistics for two groups on the PWA-I.

PWA-I

Descriptive

statistics

Older group

who had persisted

with stuttering

Controls

(n¼14)

Norms based on aggregated

individual data

(PWA-I-Survey 12) [59]

Std living Mean 85.0 82.85 77.28

Median 80 85

Mode 100 90

SD 15.7 13.82

Range 50–100 30–100

Health Mean 48.33 74.28 75.09; two-tailed t-test for

unequal variances controls;

older group who stuttered significant

[t(18)¼2.41; p¼0.026]

Median 60 80

Mode 70 80

SD 32.42 19.88

Range 0–90 30–100

Achievement in life Mean 60 65.71 74.19

Median 65 70

Mode 70 90

SD 20.44 25.63

Range 20–90 0–90

Personal relationships Mean 72.5 80.71 79.81

Median 80 90

Mode 80 90

SD 20.5 15.91

Range 30–100 40–90

Safety Mean 71.66 82.85 77.63

Median 80 90

Mode 90 90

SD 26.60 13.82

Range 30–100 50–100

Sense of community Mean 75.0 75 70.52

Median 75 80

Mode 60 80

SD 17.83 12.86

Range 50–100 50–90

Future security Mean 73.33 75.71 70.49

Median 80 80

Mode 100 80

SD 23.09 17.41

Range 40–100 40–100

Subjective Wellbeing Index Mean 70.0 76.93 75.02

Median 70.71 74.99

Mode 70 71.42

SD 14.06 10.31

Range 40–91 75–100

1748 G. Bricker-Katz et al.

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f Sy

dney

on

03/0

5/15

For

pers

onal

use

onl

y.

controls and older people who stuttered in both the

social evaluative and PD domains. Younger people

who stutter also show heightened anxiety measures

on the domains of SE and N/S on the EMAS-T [22].

Overall, the results on the FNES together with

significance on the SE domain of the EMAS-T for

older people who stutter indicated that social anxiety

remains a clinical concern for this group.

The significant difference between the groups on

the domain of PD is interesting in relation to

significance found between the groups in the

Satisfaction with Health domain on the PWA-I. This

finding may be anomalous; however, the older

people who stuttered reported health concerns that

may or may not be age-related. Anxiety about PD

may be related to awareness of vulnerability in

physical health but there is no accounting for this

result in terms of the stuttering issues at this stage.

FNE is an intrinsic component of social anxiety

that some people who stutter develop in contexts

where they might speak and stutter [61,62]. The

discomfort experienced by people who stutter in

situations where they have difficulty achieving fluent

speech makes their responses to these contexts

appreciable and essentially non-pathological. How-

ever, the persistence of these responses over time and

through life may change the normalcy of the

reactions by restricting participation and function

beyond the severity of the impairment itself. The

measures obtained on the FNES from the older

group who had persisted with stuttering are in the

range of people with social phobia [53]. This

indicates a need to further examine how such

thoughts impact on activities and participation in

older people who stutter. If these fears are like those

experienced by people with social anxiety then

further exploration of the consequences for older

people who stutter should be pursued as social

anxiety and social phobia may lead to avoidance of

contact with others resulting in isolation and restric-

tion [2,3]. For older people who stutter it is salient to

establish what barriers they face in effecting daily

interactions so that relevant strategies can be devel-

oped to support their communication needs.

Whilst both groups showed trait anxiety measures

within the normal range on the EMAS-T there was a

significant difference between groups on the social

evaluative domain. This corroborates the evidence

from the FNES as well as existing evidence that

suggests that anxiety experienced by people who

stutter is situational specific [21,29,30]. Further

research with older people who stutter might include

measures of state anxiety as well as physiological

measures of anxiety since these were not measured in

the current study.

In the older group of people who stuttered, the

measures on the OASES in the sections RS and

Communication in Daily Situations were within the

same range as a sample of younger people who

stutter [10]. These findings also supported the

results on the FNES showing that for some the

experience of speaking generates fear and apprehen-

sion, and mirrored similar findings on the FNES for

a group of younger adults who stutter [22]. Whilst it

is known that such cognitions in younger people who

stutter impact on education, vocational choice and

personal relationships [27,28,60], it is not known

which facets of life activities are impacted for older

people who stutter. The concern that there may be a

higher incidence of social anxiety in all adults who

stutter [19,21,22] is supported by this research, and

since there is strong evidence to show the severe

consequences of social anxiety in younger adults

[63,64] it is logical to consider that future research

determine how social anxiety in older people who

stutter limits their capacity to be active, participate

and function in the contexts of the stage of life that

they have reached [2].

The OASES results can be interpreted in the

language of the ICF as limitations to function/activity

and to participation. Older participant’s experience

of stuttering showed a moderate impact on their

ability to communicate in daily situations. This range

was similar to the level of impact experienced by

other adults who stutter [10]. These older people

had reactions to stuttering in the moderate to severe

range which indicates that stuttering invoked fear

about speaking and speaking situations and this

limited their ability to communicate without con-

straint. The scores on the OASES quality of life

category showed that the group of older people who

stuttered experienced stuttering as impacting less

negatively on their overall sense of wellbeing in

comparison to their responses on the other categories

[8,10].

The OASES has limitations [65]. The scoring

does not indicate a zero or ‘no impact’ level which

may have reflected how some respondents experi-

ence some facets of their stuttering. Other limitations

relate to the fact that respondents may omit certain

items and therefore inter-respondent or intra-re-

spondent comparison is not feasible [65].

For both groups quality of life across all seven

domains measured on the PWA-I was within the

normal range for their age group [54]. Subjective

wellbeing was lowest for the older group with

persistent stuttering but this was not significantly

lower than for the control group however their

significantly lower results on the measure of Satisfac-

tion with Health is interesting. Research into the

relationship between stuttering as a chronic disorder

and health is suggested [64].

This research highlights stuttering as a disorder

that can endure for the lifespan and that meeting the

The ICF and stuttering in older people 1749

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f Sy

dney

on

03/0

5/15

For

pers

onal

use

onl

y.

needs of older people who stutter merits attention

through further research. Older people who stutter

have persistent reactions to their stuttering that

suggest that the disorder may impact throughout

the lifespan with similar affective, behavioral and

cognitive affects as in younger people. There is every

reason to examine which parameters of their lives are

impacted by their FNE, apprehension about both

speaking and speaking situations, and how this then

limits their capacity to participate in daily activities.

Further, we should find out from older people who

stutter what they perceive their communication

needs to be as they face the life changes that come

with growing older.

Limitations in this research were those of sample

size and the nature of the sample. However this was

an exploratory study with a previously un-re-

searched cohort. A larger sample recruited ran-

domly from the population would add to the

robustness of findings and make possible finer

statistical examination. There would also be value

in gathering data from younger adults who stutter

for a prospective longitudinal study of the interac-

tion of stuttering and ageing. Establishing compara-

tive data using earlier measures from participants

would advance knowledge about stuttering through

the lifespan. Further research which examines the

needs of older people who stutter with a view to

exploring possible treatment issues is also clinically

relevant.

Ultimately, the aim of this study was to examine

the findings of affective, cognitive and behavioral

measures applied to an older group of people who

stutter. These measures would possibly highlight

the pivotal emotional reactions of this older group

to their stuttering. By finding that social anxiety is

a significant for this group re-states what we know

about younger people who stutter but it is possible

to see how older people may be limited in activities

and life participation because of these fears.

Stuttering still engenders fear of speaking situations

where older people who stutter fear they might be

negatively evaluated by others because of their

stuttering. Such social anxiety leads to avoidance of

social situations and in the case of people who

stutter avoidance of situations where they may be

required to speak. In older age this could have

negative consequences leading to social isolation

and may prevent adequate management of health

and financial matters [66]. It seems that stuttering

may endure longer in the lifespan than has

previously been established and that it is a lifespan

disorder for some is certain. It is therefore reason-

able to further examine the experience of stuttering

in older people so that they may receive interven-

tion and clinical understanding to meet their

needs.

Declaration of interest: The authors report no

conflicts of interest. The authors alone are respon-

sible for the content and writing of the paper.

References

1. Lubinski R, Welland RJ. Normal aging and environmental

effects on communication. Semin Speech Lang 1997;18:107–

125.

2. Worrall LE, Hickson LM. Communication disability in aging:

from prevention to intervention. Clifton Park, NY: Delmar

Learning; 2003.

3. Shadden BB, editor. Communication behavior and aging: a

sourcebook for clinicians. Baltimore: Williams & Wilkins;

1988.

4. Drennan V, Iliffe S, Haworth D, Tai SS, Lenihan P, Deave T.

The feasibility and acceptability of a specialist health and

social care team for the promotion of health and independence

in ‘at risk’ older adults. Health Soc Care Community

2005;13:136–144.

5. Sims J, Kerse NM, Naccarella L, Long H. Health promotion

and older people: the role of the general practitioner in

Australia in promoting healthy ageing. Aust N Z J Public

Health 2000;24:356–359.

6. World Health Organisation. International classification of

impairments, activities and participation. Geneva: World

Health Organisation; 1999.

7. World Health Organisation. International classification of

functioning, disability and health. Geneva: World Health

Organisation; 2001.

8. Yaruss JS, Quesal R. Stuttering and the international

classification of functioning, disability, and health (ICF): an

update. J Commun Disord 2004;37:35–52.

9. Leahy MM. Changing perspectives for practice in stuttering:

echoes from a Celtic past, when wordlessness was entitled to

time. Am J Speech-Lang Pathol 2005;14:274–284.

10. Yaruss JS, Quesal RW. Overall assessment of the speaker’s

experience of stuttering (OASES): documenting multiple

outcomes in stuttering treatment. J Fluency Disord

2006;31:90–115.

11. Bloodstein O. A handbook on stuttering. San Diego: Singular;

1995.

12. Conture EG. Stuttering: its nature diagnosis and treatment.

Needham Heights, MA: Allyn & Bacon; 2001.

13. Manning W. Clinical decision making in fluency disorders.

San Diego: Singular; 2001.

14. Guitar B. Stuttering: an integrated approach to its nature and

treatment. Philadelphia: Lippincott Williams & Wilkins; 2006.

15. Finn P, Howard R, Kubala R. Unassisted recovery from

stuttering: self-perceptions of current speech behavior, atti-

tudes, and feelings. J Fluency Disord 2005;30:281–305.

16. DiLollo A, Manning WH, Neimeyer RA. Cognitive anxiety as

a function of speaker role for fluent speakers and persons who

stutter. J Fluency Disord 2003;28:167–185; quiz 185–186.

17. Kalinowski JS, Saltuklaroglu T. Stuttering. San Diego, CA:

Plural Publishing, Inc; 2006.

18. Stein MB, Baird A, Walker JR. Social phobia in adults with

stuttering. Am J Psychiatry 1996;153:278–280.

19. Mahr G, Torosian T. Anxiety and social phobia in stuttering. J

Fluency Disord 1999;24:119–126.

20. Yaruss JS, Quesal RW, Tellis C, Molt L, Reeves L, Caruso

AJ, McClure J, Lewis F. The impact of stuttering on people

attending the NSA convention. Abstr Third World Congr

Fluency Disord 2000;25:223–223.

21. Kraaimaat FW, Vanryckeghem M, Van Dam-Baggen R.

Stuttering and social anxiety. J Fluency Disord

2002;27:319–331, I–III.

1750 G. Bricker-Katz et al.

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f Sy

dney

on

03/0

5/15

For

pers

onal

use

onl

y.

22. Messenger M, Onslow M, Packman A, Menzies R. Social

anxiety in stuttering: measuring negative social expectancies. J

Fluency Disord 2004;29:201–212, I–III.

23. Hayhow R, Cray A-M, Enderby P. Stammering and therapy

views of people who stammer. J Fluency Disord 2002;27:1–16.

24. Collins KA, Westra HA, Dozois DJA, Stewart SH. The

validity of the brief version of the fear of negative evaluation

scale. J Anxiety Disord 2005;19:345–359.

25. James SE, Brumfitt SM, Cudd PA. Communicating by

telephone: views of a group of people with stuttering

impairment. J Fluency Disord 1999;24:299–317.

26. Craig AR, Calver P. Following up on treated stutterers:

studies of perceptions of fluency and job status. J Speech

Hearing Res 1991;34:279–284.

27. Rice M, Kroll RM. Workplace experiences of people who

stutter. J Fluency Disord 1997;22:140–147.

28. Crichton-Smith I. Communicating in the real world: accounts

from people who stammer. J Fluency Disord 2002;27:333–351.

29. Ezrati-Vinacour R, Levin I. The relationship between anxiety

and stuttering: a multi-dimensional approach. J Fluency

Disord 2004;29:135–148.

30. Craig A, Tran Y. Fear of speaking: chronic anxiety and

stammering. Adv Psychiatr Treat 2006;12:63–68.

31. Menzies R, Onslow M, Packman A. Anxiety and stuttering:

exploring a complex relationship. Am J Speech-Lang Pathol

1999;8:3–10.

32. Craig A, Hancock K, Tran Y, Craig M. Anxiety levels in

people who stutter: a randomized population study. J Speech

Lang Hearing Res 2003;46:1197–206.

33. Lau JYF, Eley TC, Stevenson J. Examining the state-trait

anxiety relationship: a behavioural genetic approach. J

Abnorm Child Psychol 2006;34:18–26.

34. Spielberger CD. Anxiety; current trends in theory and

research: I. New York, NY: Academic Press; 1972.

35. Endler NS. Stress, anxiety and coping: The multidimensional

anxiety scales. Canadian Psychol 1997;38:136–153.

36. Craig A. An investigation into the relationship between anxiety

and stuttering. J Speech Hearing Disord 1990;55:290–294.

37. Craig A, Tran Y. The epidemiology of stuttering: the need for

reliable estimates of prevalence and anxiety levels over the

lifespan. Adv Speech-Lang Pathol 2005;7:41–46.

38. Ezrati-Vinacour R, Levin I. Anxiety and coping strategies in

people who stutter. Abstr Third World Congr Fluency Disord

2005;25:220–220.

39. Shames GH, Beams HL. Incidence of stuttering in older age

groups. J Speech Hearing Disord 1956;21:313–316.

40. Manning W, Daily D, Wallace S. Attitude and personality

characteristics of older stutterers. J Fluency Disord

1984;9:207–215.

41. Yairi E, Clifton NF Jr. Disfluent speech behavior of preschool

children, high school seniors, and geriatric persons. J of

Speech Hearing Res 1972;15:714–719.

42. Manning W, Shirkey EA. Fluency and the aging process. In:

Beasley DS, Albyn-Davis G, editors. Ageing: communication

processes and disorders. New York: Grune & Stratton; 1980.

43. Manning W, Monte K. Fluency breaks in older stutterers:

implications for a model of stuttering throughout the life-

cycle. J Fluency Disord 1981;6:35–48.

44. Peters HFM, Starkweather WC. Development of stuttering

throughout life. J Fluency Disord 1989;14:303–321.

45. Silverman FH. Stuttering and other fluency disorders. Long-

Grove, IL: Waveland Press Inc; 2004.

46. Huinck WJ, Langevin M, Kully D, Graamans K, Peters

HFM, Hulstijn W. The relationship between pre-treatment

clinical profile and treatment outcome in an integrated

stuttering program. J Fluency Disord 2006;31:43–63.

47. Lewis KE. Research on communication attitude and stutter-

ing in adults: a critical analysis. J Dev Phys Disabil 1997;9:47–

58.

48. Bricker-Katz G, Lincoln M, McCabe P. The persistence of

stuttering behaviours in older people. Disabil Rehabil

2008;19:1–13.

49. Davis S, Shisca D, Howell P. Anxiety in speakers who persist

and recover from stuttering. J Commun Disord 2007;40:398–

417.

50. Corcoran J, Stewart M. Stories of stuttering: a qualitative

analysis of interview narratives. J Fluency Disord

1998;23:247–264.

51. Maxwell DL, Satake E. Research and statistical methods in

communication sciences and disorders. Clifton Park, NY:

Thomson Delmar Learning; 2006.

52. Endler NS, Edwards JM, Vitelli R. Endler Multidimensional

anxiety scales: manual. Los Angeles, CA: Western Psycholo-

gical Services; 1991.

53. Watson D, Friend R. Measurement of social-evaluative

anxiety. J Consult Clin Psychol 1969;33:448–457.

54. International Wellbeing Group. Personal wellbeing index-

adult: (PWI-A) (English). Melbourne: Australian Centre on

Quality of Life, Deakin University; 2005.

55. Endler NS, Parker JDA, Bagby RM, Cox BJ. Multidimen-

sionality of state and trait anxiety: factor structure of the

Endler multidimensional anxiety scales. J Pers Soc Psychol

1991;60:919–926.

56. Endler NS, Kocovski NL, Macrodimitris SD. Coping,

efficacy, and perceived control in acute vs. chronic illnesses.

Pers Individ Dif 2001;30:617–625.

57. Teachman B, Allen J. Development of social anxiety:

social interaction predictors of implicit and explicit fear

of negative evaluation. J Abnorm Child Psychol 2007;35:63–

78.

58. Crowe BT, Davidow JH, Bothe AK. Quality of life

measurement: Interdisciplinary implications of stuttering

measurement and treatment. In: Bothe AK, editor. Evi-

dence-based treatment of stuttering: empirical bases and

clinical applications. Mahwah, NJ: Erlbaum; 2004. pp 173–

198.

59. Cummins RA. Australian unity wellbeing index survey 14.1:

fifth anniversary special report – summarising the major

findings. Deakin University and Australian Unity Limited;

2006.

60. Gabel RM, Blood GW, Tellis GM, Althouse MT. Measuring

role entrapment of people who stutter. J Fluency Disord

2004;29:27–49.

61. St Clare T, Menzies RG, Onslow M, Packman A, Block S.

Unhelpful thoughts and beliefs about stuttering: development

of a measure. Int J Lang Commun Disord 2008;25:1–14.

62. Cream A, Onslow M, Packman A, Llewellyn G. Protection

from harm: the experience of adults after therapy with

prolonged-speech. Int J Lang Commun Disord

2003;38:379–395.

63. Stopa L, Clark DM. Social phobia and interpretation of social

events. Behav Res Ther 2000;38:273–283.

64. Kessler RC. The impairments caused by social phobia in the

general population: implications for intervention. Acta Psy-

chiatr Scand 2003;108(s417):19–27.

65. Eadie TL, Yorkston KM, Dudgeon BJ, Deitz JC, Baylor CR,

Miller RM, Amtmann D. Measuring communicative partici-

pation: a review of self-report instruments in speech language

pathology. Am J Speech Lang Pathol 2006;15:307–320.

66. Findlay RA. Interventions to reduce social isolation amongst

older people: where is the evidence? Ageing Soc 2003;23:647–

658.

The ICF and stuttering in older people 1751

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f Sy

dney

on

03/0

5/15

For

pers

onal

use

onl

y.

Appendix: Individual OASES responses

Section 1:

General information

Section II:

Reactions to

stuttering

Section III:

Communication in

daily situations

Section 1V:

Quality of life Total impact score

Group of older people who had persisted with stuttering (n¼9)

CA I.S I.R I.S I.R I.S I.R I.S I.R I.S I.R

P2 80.5 55 Mod. 55 Mod. 60.7 Mod–severe 27.2 Mild 52.70 Mod.

P5 72.1 33 Mild–mod. 51.6 Mod. 37.6 Mild–mod. 46.4 Mod. 44.4 Mild–mod.

P6 57.2 63 Mod.–severe 71.4 Mod.–severe 56.7 Mod. 61.7 Mod.–severe 63.4 Mod.–severe

P7 65.3 73.8 Mod.–severe 60 Mod.–severe 69.1 Mod.–severe 52 Mod. 62.4 Mod.–severe

P8 80.11 20 Mild 20 Mild 28.8 Mild 20 Mild 20 Mild

P11 59.11 44 Mild–mod. 47.3 Mod. 53.6 Mod. 36.8 Mild–mod. 45.6 Mod.

P12 64.4 71.6 Mod.–severe 78.7 Severe 65.6 Mod.–severe 42.4 Mild–mod. 64.80 Mod.–severe

P14 73.7 41 Mild–mod. 74 Mod.–severe 65 Mod.–severe 75.6 Severe 65.3 Mod.–severe

P16 64.7 57 Mod. 78.6 Severe 76 Severe 51.2 Mod. 66.8 Mod.–severe

I.S, impact score; I.R., impact rating; GI, general information; RS, reactions to stuttering; CDS, communication in daily situations; QOL,

quality of life.

1752 G. Bricker-Katz et al.

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f Sy

dney

on

03/0

5/15

For

pers

onal

use

onl

y.