Journal of Fluency Disorders 36 (2011) 86–92

Contents lists available at ScienceDirect

Journal of Fluency Disorders

Stuttering severity and educational attainment

Sue O’Brian a , Mark Jones b , Ann Packman a , Ross Menzies a , Mark Onslow a,∗
a
Australian Stuttering Research Centre, The University of Sydney, PO Box 170 Lidcombe, NSW 1825, Australia
b
The University of Queensland, Brisbane QLD 4006, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: This study investigated the relationship between self-reported stuttering severity
Received 2 September 2010 ratings and educational attainment.
Received in revised form 3 February 2011
Method: Participants were 147 adults seeking treatment for stuttering. At pretreatment
Accepted 3 February 2011
assessment, each participant reported the highest educational level they had attained and
Available online 2 March 2011
rated their typical and worst stuttering severity on a 9-point scale for a range of speaking
situations. These included: (1) talking with a family member, (2) talking with a familiar
Keywords:
person, not a family member, (3) talking in a group of people, (4) talking with a stranger,
Stuttering
Severity (5) talking with an authority figure such as a work manager or teacher, (6) talking on the
Education telephone, (7) ordering food or drink, and (8) giving their name and address.
Results: There was a significant negative relationship between highest educational achieve-
ment and mean self-reported stuttering severity rating for the eight situations.
Conclusions: Future research is needed to investigate how this result should be addressed
in educational institutions.
Educational objectives: The reader will be able to: (1) describe the negative effects of
stuttering through childhood to adulthood; (2) identify some of the negative consequences
associated with stuttering on peer and teacher relationships, and academic performance
at school; and (3) summarise the relationship between stuttering severity and educational
attainment.
© 2011 Elsevier Inc. All rights reserved.

1. Introduction

Verbal communication is a fundamental part of everyday life. It influences the day-to-day interactions with others, around
which all social, educational and occupational networks are established and maintained. Stuttering involves disruptions
to verbal behavior and hence interferes with the process of normal communication. This can affect the development of
relationships, the way an individual functions and quality of life for the short and the long-term (Craig, Blumgart, & Tran,
2009; Craig & Calver, 1991; Klein & Hood, 2004; Klompas & Ross, 2004). In adults, stuttering is often associated with social
maladjustment, under-achievement and qualitative and quantitative impairment of verbal communication (Bloodstein &
Bernstein Ratner, 2008; Craig & Calver, 1991; Crichton-Smith, 2002; Hayhow, Cray, & Enderby, 2002). Around 50% of adults
who stutter qualify for a diagnosis of social phobia (Iverach et al., 2009; Kraaimaat, Vanryckeghem, & Van Dam-Baggen,
2002; Menzies et al., 2008; Stein, Baird, & Walker, 1996). It is known that social phobia in adults is caused, at least in part,
by negative social experiences during the school age years. In this report, we review how these early negative experiences
may affect the educational attainment of people who stutter.

∗ Corresponding author. Tel.: +61 2 9351 9061; fax: +61 2 9351 9392.
E-mail addresses: susan.obrian@sydney.edu.au (S. O’Brian), m.jones@sph.uq.edu.au (M. Jones), ann.packman@sydney.edu.au (A. Packman),
ross.menzies@sydney.edu.au (R. Menzies), mark.onslow@sydney.edu.au (M. Onslow).

0094-730X/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.jfludis.2011.02.006
 S. O’Brian et al. / Journal of Fluency Disorders 36 (2011) 86–92 87

1.1. The negative effects of stuttering during the school years

Educational institutions, from preschool to university, place a major emphasis on verbal communication skills. Such skills
form an integral part of most classroom activities. As well as the development of social skills, there are requirements to read
aloud, to discuss activities with peers, to ask and answer questions from authority figures and to speak in front of a group.
These activities place excessive demands on those who have a stuttering problem. For example, normal speech rate in adults
is around 250 syllables per minute, but stuttering can significantly reduce this verbal information transfer rate, sometimes
to below 50 syllables per minute. In severe cases, the disruptions of stuttering can last up to 30 s and render the speaker
functionally mute. This, coupled with the frequently associated extraneous body movements, the unpredictable nature of
the disorder, and the fear of negative evaluation by peers can make apparently routine educational activities challenging
and fraught with anxiety.
Stuttering is known to evoke negative peer reactions and to disturb peer interactions as early as the preschool years
(Ezrati-Vinacour, Platzky, & Yairi, 2001; Langevin, Packman, & Onslow, 2009). For example, Langevin et al. provide video
evidence of preschool peers reacting to stuttering with confusion, and interrupting, ignoring and walking away from stut-
tering children. Stuttering children were also observed to have difficulty leading peers in play, participating in pretend play,
resolving conflicts, participating in problem solving discussions, and providing explanations. There is ample documentation
of the distressing effects of early stuttering on affected children (Bernstein-Ratner, 1997; Onslow, Attanasio, & Harrison,
2003; Yairi, 1983). At the end of the preschool years, there is already evidence that these early conditioning experiences
promote negative attitudes to speech and communication (Vanryckeghem, Brutten, & Hernandez, 2005).
Such early negative conditioning experiences extend through the school years. Negative attitudes to speech and commu-
nication are measurable in 6 and 7 year olds (De Nil & Brutten, 1991; Vanryckeghem & Brutten, 1992). For stuttering children,
they worsen progressively during the school years, whereas attitudes to communication in non-stuttering children become
healthier (De Nil & Brutten, 1991). Replicated findings show that primary school children who stutter are more susceptible
to teasing and bullying than others (Langevin, 2009; Langevin, Bortnick, Hammer, & Wiebe, 1998; Langevin & Hagler, 2004),
are perceived negatively by non-stuttering peers (Langevin et al., 2009), and are rejected more often and have more difficulty
establishing peer relationships than those who do not stutter (Davis, Howell, & Cooke, 2002). In addition, a recent study by
Eggers, De Nil, and Van den Bergh (2010) shows that children who stutter have more sensitive temperaments than those
who do not stutter. Young stuttering children are more likely to show higher levels of frustration and anger while being
less able to maintain attention or control emotions and behavior. Such temperaments have been shown to influence the
development of anxiety and other disorders.
During the final years of school, these difficult experiences are exacerbated by the physical, social and emotional changes
of adolescence along with the pressure to conform to group norms and the need for peer acceptance (Heaven, 2001; Spear,
2000). Adolescents who stutter have been shown to have significantly greater fear of speaking in group discussions and
interpersonal conversations––a higher incidence of heightened communication apprehension––than their non-stuttering
counterparts (Blood, Blood, Tellis, & Gabel, 2001). They also perceive their communication competence to be much lower
when talking to strangers. These deficits have in turn been correlated with negative attitudes to school and overall poorer
academic performance (Blood et al., 2001). Not surprisingly, a significant positive relationship has been found between
stuttering severity, communication apprehension, and self-perceived communication competence scores (Blood et al., 2001)
although this finding was not subsequently confirmed in a later study by the same group (Blood, Blood, Tellis, & Gabel, 2003).
Virtually every adult who stutters confirms experiencing the disabling effects of the condition during their school years
(Crichton-Smith, 2002; Hayhow et al., 2002; Hearne, Packman, Onslow, & Quine, 2008; Hugh-Jones & Smith, 1999; Klompas
& Ross, 2004). The majority report that stuttering affected their relationships with teachers and peers, their self-confidence
and their academic performance (Hayhow et al., 2002; Klompas & Ross, 2004; Silverman & Zimmer, 1982). Many feel that
stuttering did not allow them to reach their full academic potential, limiting their educational achievements (Hugh-Jones
& Smith, 1999). Stuttering resulted in excessive anxiety and avoidant behavior, and in extreme cases individuals have
reported leaving school prematurely due to difficulties associated with performing routine speaking activities (Corcoran &
Stewart, 1998; Crichton-Smith, 2002). At the very least, many report difficulties with concentration and learning as a result
of expending lots of energy towards the thought of stuttering or controlling it (Daniels, 2007). As many as 83% confirm being
teased or bullied at school (Hugh-Jones & Smith, 1999) beginning a destructive path of increased anxiety, low self-esteem,
difficulties with schoolwork and reduced educational enjoyment and fulfillment.
According to Van Riper (1982), many people who stutter may strive for lower levels of achievement than their normally
speaking colleagues due to low self-esteem and fear of failure. Certainly, Williams, Melrose, & Woods (1969) and Guitar
(1998) reported that children who stutter, in general, perform slightly below average in school. If effective communication
is an important skill for academic progress and success, then one would expect those who stutter to have reduced academic
success.

1.2. The present study

In short, those who stutter are more likely to be teased and bullied, to be socially isolated, have lower self-confidence,
to achieve lower academic grades, and generally to perceive their school years more negatively than their non-stuttering
peers. Such negative experiences are likely to influence whether, and for how long, older children and adults remain in the
88 S. O’Brian et al. / Journal of Fluency Disorders 36 (2011) 86–92

educational system and continue to benefit from it. That is, such experiences are likely to influence their ultimate educational
attainment. It is also the case that increased stuttering severity may compound these issues and be a predictor of educational
success. Although some research has shown a relationship between stuttering severity, communication apprehension and
communication competence (Blood et al., 2001), to date there has been no research to investigate any direct association
between stuttering severity and educational attainment.
The aim of the current study therefore was to investigate the relationship between stuttering severity and educational
achievement. Specifically, we ask the question: is stuttering severity, as measured by self-reported severity ratings, correlated
with educational attainment?

2. Method

2.1. Participants

Participants were 147 adults seeking treatment for stuttering. They were drawn from treatment waiting lists of seven
university-affiliated stuttering treatment clinics in four Australian cities and one New Zealand city. There were 116 men
(78.9%) and 31 women (21.1%) ranging in age from 18 to 73 years (mean = 31.7). One hundred and twenty of the participants
(81.6%) had received treatment for their stuttering previously.

2.2. Procedure

Each participant attended an assessment with a speech-language pathologist (SLP) prior to being offered treatment. At this
assessment, a comprehensive case history was taken and a diagnosis of stuttering confirmed. The case history information
included biographical information such as age, gender, highest educational level attained, whether currently studying, and
previous treatment history. Participants also completed a self-report stuttering severity evaluation.

2.2.1. Educational achievement

Participants circled the highest level of education they had achieved from the following options: (1) did not finish high
school, (2) completed high school, (3) completed some university/college, but not graduated, (4) college diploma, certificate,
or similar, (5) bachelor degree, (6) masters degree (7) doctoral degree (8) Other – please specify.

2.2.2. Self-report stuttering severity

As part of a standard pretreatment assessment battery, participants from the above clinics rated their typical and worst
stuttering severity for each of eight speaking situations using a 9-point scale (1 = no stuttering and 9 = extremely severe stutter-
ing). No other points on the scale were specifically identified as evidence suggests that this appears to make little difference
to reliability (Cullinan, Prather, & Williams, 1963). Typical was defined as “the severity of your speech for the majority of the
day”. A worst stuttering severity was collected in addition to a typical stuttering severity to more adequately capture the
variable nature of stuttering particularly for comparison with post treatment outcomes. The eight situations included: (1)
talking with a family member, (2) talking with a familiar person, not a family member, (3) talking in a group of people, (4)
talking with a stranger, (5) talking with an authority figure such as a work manager or teacher, (6) talking on the telephone,
(7) ordering food or drink, and (8) giving their name and address. Each participant’s ratings were averaged across all eight
situations to give a mean typical severity rating (SR) and a mean worst SR.

2.3. Data analysis

SAS version 9.2 for Windows (SAS Institute, Cary, NC) was used for the analysis. The highest educational level achieved
by each participant was represented by an ordinal numeric variable ranging from 1 (did not finish high school) to 7 (doctoral
degree). Due to the 28 participants who classified themselves as students at the time of assessment, we have used censored
linear regression to determine the linear association of stuttering severity with highest education achievement (7 categories).
In this analysis the dependent variable is highest education level achieved and the independent variables are typical SR and
worst SR assessed in two separate univariable models. Any current student’s highest education level was censored because
there was good reason to believe they had not yet reached their highest education achievement at the time they were
assessed. Censoring in this case allows classification of the student’s highest education achievement as at least their level at
the time of assessment.
For example a student may have attained an undergraduate degree in which case their score was 5 however as they were
still studying they could ultimately have achieved a score of 6 or 7. Censoring in this case allowed for classification of the
student’s highest education achievement to be a score of 5 or greater at the time of assessment. The estimated co-efficient
for stuttering severity then provided a measure of linear association with highest education achievement and the resulting
p-value indicated the level of evidence against the null hypothesis of no linear relationship.
The potentially confounding effect of age on highest education achievement was also assessed in the regression models.
 S. O’Brian et al. / Journal of Fluency Disorders 36 (2011) 86–92 89

Table 1
Severity (typical and worst SR) by highest educational qualification for 144 (typical) and 145 (worst) participants.

Predictor variable N Coefficient Standard error T-value p-value

Typical SR 144 −0.19 0.09 −2.1 0.035

Worst SR 145 −0.21 0.09 −2.3 0.024

8
6
Typical severity rating

4
2
0

0 2 4 6 8
Highest educational achievement category

Fig. 1. Scattergram of the number of participants achieving each educational level and their corresponding typical severity. A linear regression line is
shown.
10
8
Worst severity rating
6
4
2

0 2 4 6 8
Highest educational achievement category

Fig. 2. Scattergram of the number of participants achieving each educational level and their corresponding worst severity. A linear regression line is shown.

3. Results

There were some missing data due to some participants failing to provide either a typical or a worst self-report stuttering
severity rating. In total, typical self-report severity data were analyzed for 144 participants, worst self-report severity data
were analyzed for 145 participants. Table 1 and Figs. 1 and 2 show a negative relationship between highest educational
achievement and typical SR (co-efficient −0.19, p = 0.035) as well as between highest educational achievement and worst
90 S. O’Brian et al. / Journal of Fluency Disorders 36 (2011) 86–92

SR (co-efficient −0.21, p = 0.024). Coefficients in a regression model are not interpreted in the same way as correlation coef-
ficients. Correlation coefficients are usually bounded to range from −1 to 1 whereas regression coefficients are unbounded.
These results therefore suggest a significant linear trend in the direction of lower stuttering severity associated with higher
educational achievement. Specifically, as educational classification increases by 1 unit then average severity decreases by
around 0.2 units. We found no evidence of association between age in years and highest education achievement (p > 0.4 for
both models).

4. Discussion

Results of this study indicate a significant inverse relationship between stuttering severity and educational attainment.
Overall, this is not a surprising result given the many studies that have reported the negative impact of stuttering during
the school years. It is well-documented that experiences in the formative years influence the way a person’s personality and
attitudes develop as well as the way they continue to deal with everyday life. It is self-evident that the negative effects of
stuttering on school life may therefore influence a person’s choices as they progress through life.
Although a relationship was established, there is no way to determine causality from these data. In other words, does
significant stuttering in some way impede or restrict progression through the educational system or is there some other fac-
tor associated with completion of higher levels of education that is also responsible for those people having less severe
stuttering? It may be, for example, that those who do well in the education system are also more motivated to seek
treatment or are better able to control their stuttering. Information obtained from previous qualitative studies would
certainly support the former explanation. If this is the case, and stuttering does in fact affect academic performance
and progression, then at the very least teachers need to be aware of how they can best assist children in the classroom
environment.
Self-reported typical and worst stuttering severity ratings were used in this analysis as these data had been routinely
collected, along with educational data, for a large number of adults. Such ratings are practical, reliable with little or no
training, can easily be self-administered and are able to quantify the speech of adults over time and for many different
situations (Aron, 1967; Naylor, 1953; O’Brian, Packman, & Onslow, 2004a; O’Brian, Packman, Onslow, & O’Brian, 2004b;
Sherman, 1955; Young, 1969a,b). They are also assumed to take into consideration not only stuttering frequency but also
the type and duration of stutters along with associated behaviors. Of-course there are also some limitations to self-report
severity rating measures. These include lack of objectivity, compared for example with a percentage of stuttered syllables
measure, and lack of comprehensiveness in measuring all aspects of stuttering compared for example with the Stuttering
Severity Instrument (SSI-4) (Riley, 2009). However neither of these measures could reasonably have been self-administered
by the client across many different situations or over time. However, a strength of self reported severity is that it is a holistic
measure, and not obtained from a small speech sample.
There are some limitations to this study. First, participants were all adults seeking treatment for stuttering and not
necessarily representative of the adult stuttering population as a whole. Second, the study was necessarily cross-sectional.
It explored the relationship between stuttering severity and educational attainment when these participants were assessed
for treatment. It needs to be noted that 28 (18%) of the participants classified themselves as students at the time of data
collection and a number of others were young adults. Therefore it is possible that any of these could potentially progress to
higher levels of education later in life. However the analysis method did take account of this possibility for the students by
censoring the highest education achievement for these participants.
Nonetheless, we do not think these limitations are sufficient to alter the conclusion that there is a significant inverse
relationship between stuttering severity and educational attainment. This finding highlights the need for further research
into the relationship between stuttering severity and educational achievement and how this apparent inequity should be
addressed in educational institutions.

Acknowledgements

This research was supported by Program Grant #402763 from the National Health and Medical Research Council of
Australia.
CONTINUING EDUCATION
Multiple-choice questions
QUESTIONS

1. Evidence has shown negative peer reactions to stuttering in people as young as

(a) Preschool-age children
(b) School-age children
(c) Adolescents
(d) Adults
 S. O’Brian et al. / Journal of Fluency Disorders 36 (2011) 86–92 91

2. What percentage of adults who stutter are diagnosed with social phobia?
(a) 0%
(b) Around 25%
(c) Around 50%
(d) 100%
3. Children who stutter
(a) Perform slightly below average in school
(b) Perform slightly above average in school
(c) Perform about average in school
(d) Only have difficulty with speaking tasks
4. Stuttering severity
(a) Shows no relationship to educational attainment
(b) Shows an inverse relationship to educational attainment
(c) Shows a positive relationship to educational attainment
(d) Cannot be correlated with educational attainment
5. An association between stuttering and educational attainment means that
(a) Those who do well at school are more likely to seek treatment for their stuttering
(b) Those who do well at school are better able to control their stuttering
(c) Severe stuttering leads to problems progressing through the educational system
(d) Causality cannot be determined

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Sue O’Brian is a Senior Researcher at the Australian Stuttering Research Centre. She has extensive experience in the field of stuttering treatment and
research. Her current interests include the effectiveness of early stuttering intervention in community settings, development of treatments for adults
who stutter and stuttering measurement.

Mark Jones works as a statistician for the Centre for Healthcare Related Infection Surveillance and Prevention, Queensland Health, and is also an
Adjunct Senior Lecturer with the School of Population Health, The University of Queensland. He has a strong interest in stuttering treatment research,
clinical trials, and biostatistics.

Ann Packman is a Senior Research Officer at the Australian Stuttering Research Centre. She has worked for more than 30 years in the area of stuttering
as a clinician, teacher and researcher. One of her current interests is theories of the cause of stuttering.

Ross Menzies is a clinical psychologist with an interest in the origins and management of anxiety. He has developed cognitive behavior therapy
packages for the treatment of obsessive compulsive disorders and published theories of the origins of phobias. He is currently the director of the
Anxiety Clinic at The University of Sydney

Mark Onslow is the Director of the Australian Stuttering Research Centre. He is an Adjunct Professor at the University of Canterbury, New Zealand,
and an Honorary Professor at the University of Queensland, Australia.