The attitudes, knowledge and beliefs of Arab parents in Kuwait about stuttering

Journal of Fluency Disorders 34 (2009) 44–59

The attitudes, knowledge and beliefs of Arab parentsin Kuwait about stuttering

Maram Al-Khaledi b,c, Michelle Lincoln a,b,∗, Patricia McCabe a,Ann Packman b, Tariq Alshatti c

a Speech Pathology, The University of Sydney, Sydney, Australiab Australian Stuttering Research Center, The University of Sydney, Sydney, Australia

c College for Women, Department of Communication Science and Languages, Kuwait University, Kuwait

Received 8 October 2008; received in revised form 20 February 2009; accepted 20 February 2009

Abstract

An Arabic version of the Public Opinion Survey of Human Attributes Inventory [POSHA-E; St Louis, K. O. (2005), a globalinstrument to measure public attitudes about stuttering. (The ASHA Leader, 22, 2–13)] was administered to 424 Arab parents ofpreschool and school age children in 18 government schools across all six governorates in Kuwait. The survey questions pertainedto and investigated attitudes, knowledge and beliefs towards stuttering as well as comparative attitudes toward several otherconditions. The aim was to identify whether potential barriers existed that might hinder the establishment and conduct of treatmentprograms for stuttering within Kuwait. These potential barriers might be negative stereotypes, misconceptions about stuttering,cultural beliefs as well as lack of awareness of the disorder within Kuwaiti society. The instrument successfully sampled a varietyof beliefs, reactions and emotions that identified cultural beliefs, societal ignorance and confusion about the disorder. It was foundthat although stuttering appears to be a disorder that most people in Kuwait are aware of and familiar with, their level of knowledgeabout stuttering in general and about some specific aspects of the disorder was limited. This indicates a need to disseminatescientific information about stuttering in Kuwait and possibly other Arabic speaking countries.

Educational objectives: Readers will be able: (1) to evaluate the status of speech–language pathology in Kuwait and the MiddleEast and compare it to that in other countries, such as Australia and the United States; (2) to list similarities in the stereotypes andattitudes towards stuttering cross-culturally. Readers will also be able to: (3) discuss the differences in knowledge and attitudesaccording to age, gender and educational level in Kuwait; (4) discuss public awareness and knowledge of stuttering among Arabsin Kuwait specifically.Crown Copyright © 2009 Published by Elsevier Inc. All rights reserved.

Keywords: Stuttering; Attitudes; Arab parents

∗ Corresponding author at: Faculty of Health Sciences, PO Box 170, Lidcombe, 1825, NSW, Australia. Tel.: +61 2 9351 9430;fax: +61 2 9351 730.

E-mail address: [email protected] (M. Lincoln).

0094-730X/$ – see front matter. Crown Copyright © 2009 Published by Elsevier Inc. All rights reserved.doi:10.1016/j.jfludis.2009.02.003

mailto:[email protected]

dx.doi.org/10.1016/j.jfludis.2009.02.003

M. Al-Khaledi et al. / Journal of Fluency Disorders 34 (2009) 44–59 45

1. Introduction

1.1. Speech–language pathology in Kuwait

To date, research in the field of stuttering has been conducted on non-Arab populations. Consequently nothing iscurrently known about the attitudes, knowledge and beliefs of Arabs about stuttering. The Arabic culture has manybeliefs, attitudes and behaviors that are different from Western societies. There are cultural and religious factors thatinfluence and shape people’s attitudes and perceptions of physical handicaps and disorders in general.

Although it is known that stuttering exists in all cultures and societies throughout the world (Bloodstein & BernsteinRatner, 2008), there is very limited data available to assist with establishing and implementing stuttering treatmentservices for culturally and linguistically diverse populations (Shames, 1989). Kuwait is developing rapidly both sociallyand economically. The health sector of the Kuwaiti government is attempting to expand the available speech and hearingtreatment services. Speech treatment facilities are currently available at government clinics, run under the Ministryof Health, as well as school clinics, which are under the umbrella of and the auspices of the Ministry of Education.There are approximately 42 Kuwaiti and non-Kuwaiti speech–language pathologists (SLPs) currently working in boththe government and private sectors within Kuwait. Additionally the College for Women at Kuwait University hascommenced training SLPs with the first cohort of 20 students graduating in 2008.

Anecdotally, it seems there is growing awareness in Kuwait, as well as in the broader Middle East, about treatmentfor most speech disorders including stuttering, that has resulted in a higher demand for speech–language pathologyservices. There are a number of reasons for this growing awareness. First, many more people are seeking medicaladvice and services for any health related issues or concerns. Younger individuals, particularly employees, recognizethat communication is essential for social interaction and that speech disorders such as stuttering can create barriersto leading a normal life. Second, there are more referrals today to SLPs due to the increased awareness of healthprofessionals such as pediatricians, ENT’s, dentists, etc., about speech–language pathology services and their existencewithin the region (although limited). Third, there is an infiltration of speech services in different sectors (health,education, private, etc.) and therefore they are recognized by teachers, counselors and the general public. Finally, thereappears to be a fast growing, younger, well educated generation that seeks the best for themselves and their childrenin all aspects of development including communication.

However, although there has been a rise in awareness about communication disorders in Kuwait, it is possiblethat culturally specific, idiosyncratic, or out dated attitudes, knowledge and beliefs towards disabilities in generaland towards speech impairments perhaps, may exist. For example, in a study by Crab (2007), which looked at theperceptions of Arab caregivers of children with developmental disabilities in the United Arab Emirates, it was foundthat social stigma and negative attitudes within the family setting was an issue of concern for parents. Fathers weredescribed by mothers, as “having stronger feelings of shame and disappointment than mothers, placing the heavy burdenof both supporting and accepting the child’s disability on the mothers” (p. 254). Not only was there discriminationtowards disability, but towards gender as well. Having said that however, we also know that Islamic principles do notdiscriminate against people with disabilities and that Muslims are in fact encouraged to extend care to those in need (ElNaggar Gaad, 2001, p. 199). Many Muslims believe that disability is an “act of God” and that the impairment/handicapshould be accepted. Therefore it is possible that Crabtree’s study reflected to some degree “cultural” attitudes ratherthan religious attitudes. We do not yet know whether similar beliefs and attitudes exist with regards to communicationdifficulties in Arab societies.

1.2. Universality of stereotypes and attitudes toward stuttering

Over the past few decades there has been a vast amount of research on attitudes toward people with differentcommunication disorders such as hypernasality, cleft palate, articulation, and stuttering (Bebout & Arthur, 1992;McKinnon, Hess, & Landry, 1986). Studies exploring the attitudes of listeners towards stuttering, found that due tothe chronic nature of stuttering (Guitar, 2006; Shapiro, 1999; Silverman, 1996), and the negative attitudes of listeners(Ham, 1990; Ruscello, Lass, Schmitt, & Pannbacker, 1994) stuttering could be a stigmatizing condition. Many of thesestudies have described the attitudes of members of a single group towards stuttering (e.g., students, SLPs, parentsand/or teachers; Cooper & Cooper, 1985; Cooper & Rustin, 1985; Crowe & Walton, 1981; Horsley & FitzGibbon,1987; Yeakle & Cooper, 1986). Studies that have specifically investigated the attitudes of “single groups” of non-

46 M. Al-Khaledi et al. / Journal of Fluency Disorders 34 (2009) 44–59

stuttering people across different professions and communities (Doody, Kalinowski, Armson, & Stuart, 1993) haveconsistently found the presence of negative stereotypes towards stuttering and people who stutter (PWS). Researchhas shown that these negative beliefs and stereotypes are held by the general public (Ham, 1990; St. Louis, 2005),teachers (Crowe & Walton, 1981; Yeakle & Cooper, 1986), and college students (Ruscello, Lass, & Brown, 1988;Silverman & Paynter, 1990). Health professionals, including SLPs and SLP students, have also been found to holdnegative stereotypes of stuttering and PWS, which include the belief that PWS are generally quiet, reticent, guarded,avoiding, introverted, passive, self-derogatory, anxious, tense, nervous, and afraid (Cooper & Cooper, 1985; Cooper &Cooper, 1996; Leahy, 1994; Silverman and Bongey, 1997; Snyder, 2001; St. Louis and Lass, 1981; Yairi and Carrico,1992).

Researchers have also examined whether these negative attitudes and stereotypes are affected by direct versus indirectcontact with the stereotyped group (Craig, Tran, & Craig, 2003; Dorsey & Guenther, 2000; McGee, Kalinowski, &Stuart, 1996; Snyder, 2001). Numerous studies dating back to the late 60s and early 70s provide evidence that manypeople develop these negative stereotypes regardless of direct or indirect contact with PWS. One would assume thatthose who have had direct contact with PWS (e.g., family members, acquaintances, clinicians and teachers) wouldhave a more positive outlook towards the disorder; however, it is evident that regardless of direct contact, educationand exposure to stuttering, these negative stereotypes and perceptions remain resistant to change (Craig et al., 2003;Dorsey & Guenther, 2000; McGee et al., 1996; Snyder, 2001). Negative stereotypes have also been reported by parentsof PWS (Crowe & Cooper, 1977; Woods & Williams, 1976), and these negative and resilient attitudes reportedly canimpede children’s progress in treatment (St. Louis & Lass, 1981; Bebout & Arthur, 1992).

Seemingly, negative attitudes to stuttering may develop early in life. There has been indirect evidence suggesting thatfluent preschoolers as young as 3 years recognize stuttering in their peers, and evaluate stuttering negatively as early as4 years (Langevin et al., in press). Langer (1969) for example, found that stuttering severity affected children’s reactionsin different ways. Children reacted negatively to moderate stuttering and showed increasingly negative reactions as thestuttering severity increased.

Starting from a very early age, teasing or bullying has been found to affect the quality of peer interactionswhich impacts the social–emotional development and sometimes academic performance of young children in school(Langevin, 1997). Teasing or bullying is frequently reported by PWS to be one of the worst aspects of stuttering.Somewhere between 49% and 56% of all school age children report being bullied or teased in school at some point.This incidence increases to 81% for children who stutter (Langevin, 2001). Therefore, children who stutter are morelikely to be rejected by their peers and viewed as less popular than children who do not stutter (Davis, Howell, &Cooke, 2002). Consequently, living with stuttering over many years can become associated with problems such asanxiety and distress, feelings of helplessness and lower than desired quality of life (Craig, 1990; Craig & Calver,1991; Fitzgerald, Djurdjic, & Maguin, 1992; Gabel, Colcord, & Petrosino, 2002; Menzies, Onslow, & Packman,1999).

1.3. Procedures for measuring attitudes, knowledge and beliefs about stuttering

Attitudes, knowledge and beliefs about stuttering have been measured using different techniques including telephoneinterviews, the semantic differential technique and self-administered paper and pencil surveys. Various stimuli havealso been used in conjunction with these techniques and have included factual and fictional videos, audio recordingsof PWS or simulated stuttering with hypothetical PWS (Doody et al., 1993; Leahy, 1994; McGee et al., 1996; Panico,Healey, Brouwer, & Susca, 2005; Susca & Healey, 2001).

Telephone interviews (Craig et al., 2003; Ham, 1990) have been used to sample the attitudes, knowledge and beliefsabout stuttering from a wide range of participants. Although this technique has been successful in sampling a variety ofrespondents, the results are limited by the type of questions included. The accuracy of answers provided in interviewshas also been questioned and the possibility raised that respondents may “gild” their responses (Ham, 1990, p. 261).

Semantic differential scale techniques for use with stuttering were developed by Osgood, Succi, and Tannenbaum(1957) and are used to measure five dimensions of attitude towards a speaker, after the presentation of stimulusconditions. These dimensions were: evaluation, potency, activity, understandability and anxiety. The Osgood instru-ment has been used to identify stereotypes and investigate perceptions of adults who stutter, parents of children withcommunication disorders unrelated to fluency, classroom teachers in elementary grades and parents of stuttering chil-dren and non-stuttering children (Woods & Williams, 1976). Other groups studied using the instrument include SLPs


(Turnbaugh, Guitar, & Hoffman, 1979; Woods & Williams, 1976), college students (Gabel, 2006; Woods & Williams,1976) and community members (Doody et al., 1993). The instrument has also been used to measure changes in attitudestowards stuttering using different stimuli (e.g., education, exposure, emotional information and factual information).The disadvantage of using this technique is that it investigates a limited number of attitudes and perceptions of PWS. Inorder to fully understand the attitudes and stereotypes of the respondents, a mixed qualitative and quantitative methodis needed to provide an in depth understanding of attitudes towards PWS (e.g., Panico et al., 2005).

Surveys have also been used to elicit knowledge, attitudes and beliefs. These include the Parental Attitudes TowardStuttering Inventory (PATS; Crowe & Cooper, 1977), the Alabama Stuttering Knowledge Test (ASK; Crowe & Cooper,1977), and the Clinicians Attitude Toward Stuttering Inventory (CATS; Cooper, 1975). The scope of these surveysvaries, with topics ranging from studying parental attitudes and knowledge of stuttering, to sampling a variety ofprofessional views regarding the nature of stuttering, its treatment and SLPs’ competence and effectiveness in workingwith the disorder.

Although these inventories have been widely used and published in peer-reviewed journals, some have never beenformally examined for reliability (e.g., Snyder, 2001). Therefore further studies looking into the validity, reliability,number, quality, relevance and comprehensiveness of the attitude statements in some of these inventories are necessary.

The Public Opinions Survey on Human Attributes (POSHA-E) by St. Louis (2005) is perhaps one of the mostwell developed scales to date. In 1999, an International Project on Attitudes Toward Human Attributes (IPATHA) wasestablished to develop a standardized instrument for measuring international, public attitudes toward stuttering. ThePOSHA-E was subsequently developed by a team, which included SLPs, PWS and an epidemiologist (St. Louis, Lubker,Yaruss, Pill, and Diggs). The inventory is designed to measure the attitudes, knowledge and beliefs toward stutteringamong the general public in different cultural groups. The POSHA-E has been translated into and administered inseveral languages in various countries around the world (e.g., St. Louis, Andrade, Georgieva, & Troudt, 2005), andconsiderable attention has been paid to the validity, reliability and standardization of the instrument. The inventory isunique in that it is designed to elicit attitudes toward stuttering, and other human attribute and reduce response biasby not stating specifically that stuttering (or any of the other attributes) is the targeted attribute. It is also designed tominimize cultural and linguistic bias, by requiring a “back-translation” of the survey, from the language in which it isused back into English. The design of the survey also allows researchers to measure changes in responses that mightbe expected to occur after public awareness campaigns.

1.4. Cultural group studies

Several studies have been conducted that tap into the perceptions and beliefs of different cultural groups in the U.S.(e.g., Bebout & Arthur, 1992; Gabel, 2006; Mayo, Mayo, Jenkins, & Graves, 2004), and in different communities andcultural groups across several countries (St. Louis, 2005). These studies have successfully gathered a wide range ofvaried attitudes and beliefs showing that the negative stereotypes of PWS found in previous studies exist across culturesand even within small rural communities (Doody et al., 1993).

However, while certain stereotypes and beliefs were found to be cross-cultural, others appeared to be culture specific,such as the beliefs that the cause of stuttering is “an act of God”, or that “ghosts, demons or spirits” were responsible andwere found to exist within certain non-Western cultures (St. Louis et al., 2007; St Louis, Roberts, Lukong, & Freese,2008). Mayo et al. (2004) examined cross-cultural knowledge of stuttering among African American and CaucasianAmerican adults using a 21-item survey questionnaire adapted from Van Borsel, Verniers, and Bouvry (1999). Bothgroups had traditional knowledge and understanding of stuttering (e.g., that it is a disorder that begins early in life andsignificantly impacts more males than females). Many respondents from both groups were aware of the overt features ofstuttering, such as the repetitions and blocks, as well as some secondary behaviors, such as eye blinking and extraneousbody movements. Although both cultural groups agreed that a SLP was the appropriate professional to provide therapyand that speech therapy is the most effective means of managing stuttering, more African American than Caucasianparticipants viewed the application of faith through prayer as an effective means of stuttering intervention.

Studies conducted on various ethnic and cultural groups around the world show some cultural groups demonstratecontemporary understanding of stuttering (de Britto Pereira, Rossi & van Borsel, 2008; Xing Ming, Jing, Yi Wen, &Van Borsel, 2001), and that it occurs early in childhood (de Britto Pereira et al., 2008; Mayo et al., 2004; Van Borselet al., 1999; Xing Ming et al., 2001), while other cultures demonstrate less traditional conceptualizations about thedisorder, such as it is “an act of God”, that it has a psychological etiology, that PWS have psychosocial problems


(Mayo et al., 2004) or that the cause of stuttering is emotional (de Britto Pereira et al., 2008). Significant differences interms of current understanding and knowledge about the disorder have also been noted between different age groupsand genders in some cultures (Van Borsel et al., 1999; Xing Ming et al., 2001).

1.5. Importance of parents attitudes

Many factors will contribute to a person who stutters’ ability to manage and cope with their stuttering in socialsituations. Family relationships can either have a positive impact, providing support and positive guidance in assistingthe person who stutters to manage and cope with their stuttering, or they can have a negative impact, hindering thedevelopment of positive management. This also means that the family’s attitudes can either support the managementof stuttering or delay the effective management of the disorder (Yaruss & Quesal, 2004). Ultimately, the familyplays a crucial role in children’s development, and it is therefore critical that clinicians understand and consider thepositive or negative impact the home environment plays in the development of stuttering. We now know that “Wecannot isolate the individual from his environment when we discuss stuttering and we need to observe the interactionbetween the stuttering child and his family in order to understand how the problem develops and manifests itselfand how it is affected by and affects the family” (Bergstrom, 2001, p. 141). An individual’s environment includeshome environment as well as the community in which the person lives. Therefore it is crucial we consider this whenstudying the development of stuttering within any community, especially a culturally diverse community. Since therehas been little to no studies done on the current prevalent attitudes and perceptions of Arabs and Arab communities asa whole, the aim of this study is to determine these attitudes and to help determine how to take action to combat thepresence, if any, of negative attitudes in order to enhance the environment. These attitudes may be negative, stereotypicalbeliefs which can lead to social exclusion or even worse, to racism. This wider social action should facilitate moreeffective work with PWS. Clinicians have an important role in this process, by helping change the environment in whichchildren are raised, so that positive changes can be made to better help them with their stuttering (Bergstrom, 2001). Theclinicians’ role is to promote education of parents and the general public about stuttering, as well as being advocates forPWS.

SLPs have advocated the inclusion of significant others in the treatment of PWS. Family oriented therapy programshave been developed that directly involve family members in the therapy process for PWS (Guitar, 2006). The rationalefor including family members is to help facilitate effective communication for the person who stutters in the homeenvironment. Family involvement in therapy has proven to be an effective tool in achieving communication success(Mallard, 1998).

1.6. Purpose and implications of the study

We know that stuttering exists worldwide (Bloodstein & Bernstein Ratner, 2008) among different cultures. To datesome attention has been given in the literature to identifying and comparing the attitudes, knowledge and beliefs ofdifferent cultural groups, but as discussed previously, nothing is known about the Arab population regarding this issue.

The present study aims to collect information about the attitudes, knowledge and beliefs about stuttering of Arabparents. Questioning the perceptions and knowledge of Arab parents may shed some light on their level of awarenessand knowledge about the nature of stuttering and their level of involvement with the disorder. It may also help improveour understanding of the relationship between parental behaviors and children’s stuttering within an Arab culture andtherefore help determine whether Western treatment approaches may be applicable or effective for this population.Another important outcome would be to determine which aspects of the disorder and its treatment are appropriatefor focus in therapy sessions and in future educational programs. Therefore, to help better understand the societalprejudices, attitudes and knowledge of Arab parents about stuttering, the major questions posed in the study are: (a)what are the attitudes, knowledge and beliefs of Arab parents of preschool and school age children in Kuwait aboutstuttering, (b) what are their perceptions of PWS, (c) do the perceptions of parents and their attitudes, knowledge andbeliefs about stuttering have a negative influence on their participation or willingness to seek treatment for stuttering,and (d) do Arab parents know that successful treatment for stuttering is available from SLPs?

The outcomes are important to SLPs working in Kuwait and the Middle East, as well as to those clinicians inWestern countries working with PWS and families of PWS from Arab backgrounds. This is because attitudes towardsspeech and language disorders are important to the clinicians’ work. The attitudes of the client, the client’s family,


and the client’s community toward the causes, effects, and treatment of the disorder can be significant factors in thetherapeutic process (Bebout & Arthur, 1992).

2. Method

2.1. Participants

Arab (both Kuwaiti and non-Kuwaiti) parents (n = 424) of preschool and school aged children were recruited fromdifferent governorates around Kuwait. Parents included in the study had to be Arabic speakers, with Arabic as theirfirst language at home. Of the 424 participants, 62% were women and 38% were men. Participants were categorizedinto two age groups (39 years and under, and 40+ years) and two educational levels (up to secondary school plus othernon-bachelor qualifications, and bachelors plus higher degrees). The data were collapsed from six age groups and nineeducational levels because of small sample sizes in some categories. The researchers attempted to control for genderby sending out three labeled surveys to parents, asking for each parent to complete a survey, with the third to be givento another parent they know; however twice as many female respondents as males took part in the study.

2.2. Survey instrument

An adapted version of The Public Opinions Survey of Human Attributes (POSHA-E) Inventory (St. Louis, 2005)was used to measure attitudes, knowledge and beliefs towards stuttering and PWS as well as comparative attitudestoward several other human conditions. The survey is a paper-and-pencil questionnaire that takes between 20 and40 min to complete and is composed of five components.

The POSHA-E was chosen for this study because according to Pavot, Diener, Colvin, and Sandvik (1991), thescales used have good internal consistency, with Cronbach alpha coefficients ranging from .79 to .90 for the differentscales within the POSHA-E. Ideally, the Cronbach alpha coefficient of a scale should be above .70 (DeVellis, 2003).This therefore establishes the POSHA-E’s scales’ internal consistency and reliability. The survey consisted of fivecomponents, listed below (a–e):

(a) Instructions: This was the first page of the survey, in which a one-page set of instructions was given to therespondents on how to complete the survey.

(b) Demographics: The survey consisted of a two-page demographic section which contained questions about age,gender, marital status, residence and citizenship, work situation, family’s yearly income, religion, education, andnative and other languages spoken.

(c) General section about eight human attributes: A general section in the survey compares stuttering to eight otherhuman “anchor” attributes including left handedness, mental illness, obesity, alcohol addiction, multilingualism,epilepsy, HIV/AIDS and wheelchair use. Respondents recorded their impressions of each attribute on a scalein which response choices were “very positive”, “somewhat positive”, “neutral”, “somewhat negative”, “verynegative”, and “unsure”.

The general section questions were pertaining to: (i) Overall impression of a person with a specific attribute, (ii)how respondents would feel if he/she had one of the attributes, (iii) the amount of knowledge respondents haveabout the attributes, and (iv) their social contact with people with the attributes listed.

(d) Detailed sections containing two of the eight human attributes, stuttering and obesity. The section on obesity, wasused to minimize response bias of respondents who are likely to respond differently knowing that the primary intentof the survey was to determine public opinion about stuttering. Due to the ethical requirement to inform participantsof the purpose of the study before acquiring informed consent, participants may have been aware that the researchwas focused on stuttering despite the inclusion of the section on obesity. Questions about each human attributewere four pages in length. Responses were provided about the following: (i) the characteristics of PWS/obesity, (ii)the causes of stuttering/obesity, (iii) who should help PWS/people who are obese, (iv) general knowledge questionsabout stuttering/obesity (prevalence among sexes and races, curing the disorder), (v) actions of parents, (vi) degreeof concern if various persons stuttered/were obese, and (vii) respondent’s feelings and actions when talking witha PWS/a person who is obese.


(e) Comments: The final page required the respondents to indicate how and where the questionnaire was obtained,whether this was the first survey of this type they have completed on knowledge and attitudes towards stutteringand obesity, and finally, how long it took for them to complete the survey.

Respondents either circled numbers (from −2 to +2), or “yes”, “no” and “unsure” responses for multiple statementsunder each major heading. Scores reported are therefore the total for each statement.

Parts of the POSHA-E were modified to account for societal context and accuracy of translation. For example inthe demographics section of the survey, the question “My family’s income compared to others in my country” waschanged to “My family’s yearly income is. . .”. Incomes fall roughly within three ranges in Kuwait, and asking parentsto indicate where their family’s income falls among those three ranges was thought to be a more accurate indicator oftheir socio-economic status. Other questions modified include the statement “I would want to be a person who. . .”,which was changed to “If I had the following attribute, I would feel. . .”. When the original statement was translated, itgave a negative connotation and appeared that it would have caused response bias. Also some irrelevant questions inthe demographics section were omitted from the final version of the survey as they were not significant to the study.For example, questions pertaining to education such as “Starting at age 6, I have completed total years of full-timeeducation” and other questions such as “I would rate the following aspects of my life now as.” The changes made tothe questions were to ensure the accuracy and applicability of the questions when translated into Arabic and thereforeensure maintenance of the reliability and validity properties of the survey.

Four questions were also added from the Van Borsel et al. (1999) survey to expand the scope of the questionnaire.The questions included pertained to: (a) the prevalence of stuttering among ethnic groups, (b) gender differences inprevalence of stuttering, (c) if parents believed stuttering could be cured, and (d) which professional to seek if they hada 4-year-old child that stuttered.

The instrument was translated into Arabic by the first author, and checked by independent linguists at KuwaitUniversity and the Kuwaiti Public Authority of Applied Education and Training. The Inventory was also translatedback into English (as specified by St. Louis’s method) by another linguist at the Public Authority of Applied Educationand Training in Kuwait to ensure accuracy and reliability of the translation.

2.3. Procedure

The research was approved by the Human Research Ethics Committee at the University of Sydney, as well as bythe Ministry of Education in Kuwait who then facilitated recruitment of participants from schools across Kuwait’s sixgovernorates.

A total of three schools were randomly selected from each of the six Kuwaiti governorates, and one classroom wasselected randomly from each school. This sampling strategy was used to ensure a wide sample range that includesparents of different educational backgrounds and different socioeconomic composites. Questionnaires and informationsheets were distributed to parents who were invited to participate in the study. Parents were given a set of threequestionnaires and information sheets, two to be filled out by both parents of the child and one to be given out to afriend or relative with preschool or school age children. Completed questionnaires were placed in sealed envelopes,and sent back to the child’s teacher to be collected by the researcher.

2.4. Data analysis

All the data from the questionnaires were coded first and then entered into an SPSS database. Data were analyzedusing SPSS (version 10 and 13.1). General descriptive statistics such as frequency distribution cross-tabulations aswell as Chi-square (χ2) tests were used to explore patterns and preliminary associations between age, sex, educationallevel and attitudes, knowledge and beliefs about stuttering. Only p-values ≤.05 were considered to be statisticallysignificant.

3. Results

A total of 1158 surveys were distributed in 18 schools across the 6 governorates. Of these, 762 (65%) were returned.However, 338 were blank or incomplete and therefore excluded. A total of 424 (37%) returned and completed surveys


Table 1Distribution of respondents by age and gender.

Gender 39 Years and under n (%) 40+ Years n (%) Total n (%)

Male 67 (25%) 93 (61%) 160 (38%)Female 197 (75%) 59 (39%) 256 (62%)Total n (%) 264 (63%) 152 (37%) 416 (100%)

Table 2Distribution of respondents by gender and education level.

Gender Up to secondary school and other qualifications n (%) Bachelors and higher degrees n (%) Total n (%)

Male 68 (45%) 92 (34%) 160 (38%)Female 84 (55%) 177 (66%) 261 (62%)Total n (%) 152 (36%) 269 (64%) 421 (100%)

were used in the analysis. Table 1 shows the age and sex distribution of the respondents. Female respondents (62%)were almost twice the number of male respondents (38%) with most (85%) being Kuwaiti, and only 15% non-Kuwaitiresidents (not citizens). A large majority (93%) of the respondents were married, 6% were divorced/separated and1% were widowed. The majority of the participants surveyed were well educated, with a bachelor’s degree or higher(Table 2). The average time taken to complete the POSHA-E survey was estimated at 23.5 min.

3.1. Survey outcomes

The major headings listed above in the methods section under survey instrument are grouped and linked togetherunder subheadings below.

3.1.1. General section statementsIn the general section of the survey, questions pertained to: (a) the overall impression of a person with a specific

attribute, (b) how the respondent would feel if he/she had one of the attributes, (c) the amount of knowledge therespondent has about each of the attributes, and (d) the type of action taken if the respondent was talking to a personwith one of the attributes. For the purpose of this study, specific statements pertaining to stuttering were of interest andwere analyzed. Placing stuttering among eight other human “anchor” attributes, which were also being investigated inthis section, controlled for response bias. The results of the four statements were compared according to differencesbetween age groups, gender, and education level using non-parametric χ2 test for independence.

Statement 1, “My overall impression of a person who has a stuttering disorder” and Statement 3, “The amount I knowabout people who have a stuttering disorder”, showed no significant association with any of the variables considered.

However, a significant association was noted between age and Statement 2, “If I was a person who has a stutteringdisorder, I would feel. . ..”, χ2 (5, N = 416) = 12.71, p = .026. An independent samples t-test was conducted to comparethe strength of opinion scores for the two age groups. Results showed a significant difference in the scores betweenthe younger age group 39 years and under (M = −.72, S.D. = 1.80) who had a more negative opinion (i.e., feeling moreupset) than the older age group 40+ years (M = −.37, S.D. = 1.80), t (414) = −1.93, p = .05 (two-tailed). The magnitudeof the differences in the means (mean difference = −.355, 95% CI: −.71 to .007) was small (eta squared = .008).

Statement 4, “If I were talking to a person who stutters, I would. . .” had six different actions to choose from,describing what a respondent would do to complete the statement. Interestingly, a significant association was onlynoted between the variable gender and action 3, “look away from the person”, showing a highly significant association.χ2 test for independence indicated a strongly significant association between gender and the action statement, χ2 (2,N = 424) = 9.76, p = .008, Cramer’s V = .152. Many (43%) of the males felt they would not look away from the person,while the females were somewhat divided on the issue (Table 3).

A significant association was found however between education level and statement 4, action 2 “make a jokeabout stuttering”, χ2 (2, N = 421) = 10.43, p = .005, Cramer’s V = 0.15 and action 5 “fill in the person’s words”, χ2 (3,N = 421) = 11.88, p = .008, Cramer’s V = 0.16. A majority (61%) of respondents with education level of up to secondary


Table 3Percentage distribution of respondents for statement 4, action 3 according to gender.

Statement 4, action 3 “If I were talking to a person who stutters, I would look away from the person” Gender

Males (%) Females (%)

Yes 28 72No 43* 57Unsure 26 74*

* Significant difference (p < .01) between the responses for both genders.

Table 4Percentage distribution of respondents for statement 4, action 2 according to education level.

Statement 4, action 2 “If I were talking to a personwho stutters, I would make a joke about stuttering”

Education level

Up to secondary school and/ornon-bachelor degrees (%)

Bachelors and/orhigher degrees (%)

Yes 61* 39No 35 65Unsure 17 83*

* Significant difference (p < .01) between the responses for both education levels.

Table 5Percentage distribution of respondents for statement 4, action 5 according education level.

Statement 4, action 5 “If I were talking to a person whostutters, I would fill in the persons’ (stutterer’s) words”

Education level

Up to secondary school and/ornon-bachelor degrees (%)

Bachelors and/or higherdegrees (%)

Yes 44 56*

No 28 72*

Unsure 28 72

* Significant difference (p < .01) between the two education levels.

school and/or non-bachelor degrees felt they would make a joke about stuttering when talking to a person who stutters.However, a large majority (83%) of those with higher degrees felt unsure if they would make a joke (Table 4).

Table 5 shows that for action 5 “fill in the person’s (stutterer’s) words” respondents who had lower education levelfelt they would “fill in a person’s words” if talking to a PWS, while respondents with higher degrees felt they wouldnot fill in a person’s words.

Clearly, education has some impact on the respondents actions towards PWS. The more educated an individual is,the more likely he/she will not fill in a person’s words or lean more towards not making a joke about the stuttering. Also,females appear to hesitate on how to react when talking to a person who stutters with a majority feeling unsure if theyshould look away or not. The results of these statements in association with the variable gender using simple frequencyanalysis shows that the majority of males (87%) as well as females (85%) reported they would “wait patiently duringa person’s stuttering”. Overall, this indicates that the general public is empathetic and sensitive towards PWS.

3.1.2. Acquaintance with PWS and overall impressionThe majority of respondents (72.5%) reported having met or come across a person who stutters, and of those 27%

reported having a relative who stuttered. One-third (35%) of respondents had “neutral overall impressions” aboutstuttering. However, two thirds of parents (68%) reported they would feel “upset” if they had a stuttering disorder.

3.1.3. Knowledge questions3.1.3.1. Causes of stuttering and parental actions. As shown in Table 6, although most parents seemed somewhataware of the disorder, their knowledge appeared to be generally limited, with 33% of the respondents indicating they


Table 6Rating for statement on parental action.

If I had a 4-year-old that stutters, I would. . . n (%)

Wait and do nothing 20 (5)Consult a doctor/pediatrician 131 (31)Consult a speech–language pathologist 264 (62)Other 9 (2)

knew “a little” about stuttering. While 43% of parents thought stuttering is genetic, in line with the recent literature (Coxet al., 2005), there also seems to be some confusion around the causes of the disorder, with many attributing stutteringto psychological or emotional factors. Sixty-six percent believed that it is due to “parents overreacting to mistakes inchildren’s speech”, an indication of an old Johnsonian theory (Bloodstein & Bernstein Ratner, 2008) that has long beenrefuted. It was reassuring to find that many parents reported they would seek/consult a SLP if their 4-year-old childstuttered.

3.1.4. Attitudes and beliefs about stutteringTable 7 summarizes parents’ attitudes and beliefs about stuttering. Many parents reported they would be concerned

if they stuttered or if any of their family members did, with half of the respondents believing that PWS “should notwork in influential jobs (teachers, doctors, lawyers, politicians)”.

There was evidently poor knowledge about the prevalence of the disorder. Parents were “unsure” about the prevalenceof stuttering among males and females or its presence in other races such as Africans, Asians as well as the white race.Many, unfortunately, held stereotypical beliefs about PWS believing they are “shy or fearful”. However, overall themajority had positive attitudes and more importantly there was no indication of strong stigmatizing attitudes associatingstuttering with reduced intelligence.

Although a majority reported they would “wait patiently during the person’s stuttering episode”, many reportedthey would “fill in the person’s words, and that they would tell the person to “slow down” or “relax”, indicating someinconsistency with the responses to statements.

4. Discussion

This study investigated the attitudes, knowledge and beliefs about stuttering of 424 Arab parents of preschool andschool age children, using The Public Opinion Survey of Human Attributes Inventory (POSHA-E; St. Louis, 2005), anArabic version of the POSHA-E was administered to parents of children in 18 government schools across Kuwait. Theaim of this study was to determine the attitudes, level of knowledge and current beliefs of parents in Kuwait possessabout stuttering and PWS as negative opinions about stuttering and PWS appear to exist cross-culturally (Bebout &Arthur, 1992; de Britto Pereira et al., 2008; Mayo et al., 2004; St. Louis et al., 2005; Van Borsel et al., 1999; XingMing et al, 2001).

The results of the current study suggest that stuttering is a disorder that most people in Kuwait are aware of andhave had some exposure to. A majority reported knowing a person who stutters, whether it was a friend, acquaintanceor family member. Therefore the exposure of a large majority of respondents to PWS may partly account for their“neutral” (35%) overall impression of the disorder.

In terms of how a person would feel if he/she had the stuttering disorder (general section), it was evident that theyounger age group (39 years and under) had strongly negative feelings in response to if they stuttered. The mean scoresof the younger age group differed significantly from the older age group indicating that the younger generation wouldfeel more “upset”, if they had stuttering. The older age group, (40+ years) also indicated they would feel upset buttheir mean scores were significantly lower. This acceptance by older people could be explained by the fact that oldergenerations have grown to accept certain disabilities due to previously limited medical or professional support. As aresult, perhaps, people have learned to accept what they are given or born with in terms of health conditions. Youngergenerations, however, have more knowledge about medical advances and what is available in their region and in theworld. Therefore, they may be less likely to accept a disability such as stuttering and may know that there are options,solutions and help to overcome this.


Table 7Ratings for stuttering statements.

Items from detailed stuttering section % Rated yes % Rated no % Rated unsure

People who stutter. . .Are nervous or excitable 34 39 27Are shy or fearful 73 18 8Are easy to talk to 56 29 14Should have jobs that require lots of talking 48 35 17Should have jobs that require good judgment 47 24 29Will probably recover from their stuttering 80 7 13Have lower-than-average intelligence 9 71 20Can communicate effectively 67 15 17Can interact with people socially 81 7 12Can get a job 90 2 7Can do well at work 89 3 8Can lead a normal life 90 4 5Should work in influential jobs (teachers, doctors, lawyers, politicians) 21 50 29

I believe stuttering is caused by. . .

Genetic inheritance 43 33 24Environmental pressure 60 23 16Parents overreacting to mistakes in child’s speech 66 19 15Trying to talk or think too fast 55 37 18Psychological or emotional factors 82 9 8An act of God 66 19 15

I believe stuttering should be helped by. . .

The family of the person who stutters 86 8 6A psychologist, psychiatrist, or counselor 79 12 8A speech–language pathologist 86 5 8The family of the person who stutters 86 8 6

I believe. . .Stuttering occurs more in males than in females 28 25 47Stuttering can be cured 86 4 10Stuttering occurs only in the white race 3 56 41Stuttering occurs in Africans, Asians and other ethnic groups as well as in the white race 37 20 43

If the following people stuttered, I would be concerned. . .

My child’s teacher 71 23 7My husband or wife 52 41 7My son 77 19 4My daughter 77 20 3Me 73 20 6

If I were talking with a person who stutters, I would. . .

Try to make an issue of the stuttering 6 87 7Tell the person to “slow down” or “relax” 55 35 10Fill in the person’s words 50 42 7Wait patiently during his/her stuttering 86 7 7

If I were talking with a person who stutters, I would feel. . .Pity 55 36 9Comfortable or relaxed 26 51 23

The majority of Kuwaitis reported behaving sensitively towards PWS. Many males (43%) reported they would notlook away while females generally felt unsure (74%), if they would look away while talking to a person who stutters.Also, education level seems to play a role in people’s attitudes and reactions. Sadly most respondents within the lowereducation group (61%) reported they would make a joke when talking to a PWS. The more educated group (bachelorsand higher degree level) were undecided, leaning towards not making a joke about stuttering when talking to a PWS.In another statement “If I were talking to a person who stutters, I would..” the less educated group of respondents


reported they would “fill in the person’s words” (44%) while respondents with higher education felt divided and unsureon whether to do so or not. It appears education level and to a lesser extent gender may have some impact on a person’sperception of how to act when speaking to PWS.

In line with the recent literature (Cox et al., 2005), 43% of Arab parents correctly attributed the cause of stutteringto genetics. However, many respondents (66%) also believed that stuttering is “an act of God”, which is consistentwith previous findings on the attitudes of different cultural groups toward the cause of stuttering (Fain, 1990; St. Louis,2005). A majority (82%) of Arab parents also attributed the cause to psychological or emotional factors, indicatingwhat seems to be public confusion around the causes of the disorder. In any case, respondents appeared optimistic, withmany believing that stuttering could be cured effectively (86%). Knowledge and beliefs about what causes stutteringmay have an impact on whether or not one would seek help and treatment for the problem and where or who to seekhelp from. The importance of increasing public awareness about stuttering is evident and ultimately will require aconsiderable amount of attention.

Subjectively, we know that in Islam and in the Arabic culture generally, physical and mental impairments and otherdisabilities (i.e., impairments a person is born with) are generally accepted by the individual with the disorder as wellas by his/her family and society as a whole. These impairments are not considered a “punishment” by God, and onecannot question why he/she was given this impairment and should accept the impairment. Many respondents heldmostly positive attitudes towards the disorder believing that PWS can lead normal lives, raise a family, get a job and dowell at work. Respondents did not appear to discriminate against or stigmatize PWS, and in fact regarded them as notbeing different. They also felt that PWS are easy to talk to and did not associate stuttering with reduced intelligence.Although a considerable number of parents ascribed the cause of stuttering to psychological factors, as mentionedpreviously, this did not affect their impressions and attitudes towards PWS. This could possibly mean that stuttering isan accepted disorder, which people are open-minded about and are empathetic towards.

Negative attitudes towards stuttering and PWS, however, were also represented in the POSHA-E survey, and wereattributed to the personality and capabilities of PWS. Respondents viewed PWS as “shy and fearful” which is consistentwith previous research (Blood, 1999; Shapiro, 1999). Many respondents reported they would feel anxious if a PWS wasplaced in a significant position such as a teacher, doctor, lawyer or politician. This reveals that the Kuwaiti communityis not fully accepting of stuttering although it generally has positive attitudes towards the disorder and PWS, as notedpreviously. The findings, therefore, question whether complete social integration and acceptance occur for PWS.

Many respondents not only believed that stuttering could be cured but also that a SLP would be the professionalto provide help for stuttering (86%). It was also found that 62% of parents reported they would consult a SLP iftheir 4-year-old child stuttered. This finding, also present in the Belgian study (Van Borsel et al., 1999) and the Rio deJaneiro study (de Britto Pereira et al., 2008), could possibly indicate the developing appreciation of the speech–languagepathology profession on an international level, including in Kuwait. This could also be a possible indication of responsebias from the parents since they had an idea of what the study was about and who was conducting it.

The earliest literature has shown that the attitudes and knowledge of parents are significant aspects in the developmentand treatment of stuttering (Johnson, 1955; Van Riper, 1973). More recent literature points to attitudes of clients, clients’families as well as the clients’ community towards the causes, effects and treatment of speech and language disordersas important to the SLPs’ work and vital to the therapeutic process (Bebout & Arthur, 1992).

Although a considerable number of respondents held views that were in line with current knowledge about stuttering,many demonstrated limited knowledge in some aspects of the disorder. The findings suggest that the general knowledgeof the layperson in Kuwait on stuttering is limited. For example, knowledge questions pertaining to the prevalenceof the disorder, whether stuttering is more frequent in males than in females, or whether it occurs among other racessuch as Africans, Asians, etc., clearly suggested there was some public confusion surrounding the disorder. Some ofthe results of this study are similar to those of other comparable studies conducted in other countries and culturesincluding Belgium, Brazil, Shanghai and China (Bebout & Arthur, 1992; de Britto Pereira et al., 2008; Mayo et al.,2004; Van Borsel et al., 1999; Xing Ming et al., 2001), as well as Bulgaria, Cameroon, Canada, Denmark, Nepal,Nicaragua, Macedonia, South Africa, Turkey and the U.S. (St. Louis et al., 2005). These studies suggest that there ispoor or limited community knowledge in every culture regarding stuttering. This knowledge is vital to have in orderto ensure the well-being of individuals that have the disorder within the community.

Public and perhaps parental ignorance are major contributing factors to the mental and emotional complexitiesof stuttering (Blood, 1999). Therefore targeting and correcting the stereotypical misconceptions present among Arabparents in Kuwait, such as “PWS are shy and fearful”, “PWS should not work in influential jobs” or that the causes of


stuttering includes “parents overreacting to mistakes in child’s speech”, is crucial for clinicians to provide successfultherapy to PWS. This is because the attitudes and beliefs that parents have regarding stuttering may generally reinforceor hinder the applicability and effectiveness of treatment, but more importantly, the applicability and effectiveness ofany new Western therapeutic approaches that might be introduced in the near future. Parental perspectives drawn fromthis study are therefore valuable in adding information to help guide clinicians in choosing the appropriate treatmentapproach, as well as in guiding the parent–child interaction in therapy. For example parent’s beliefs that stutteringis caused by “parents overreacting to mistakes” in their child’s speech may be problematic if a clinician attempts toimplement a direct intervention for stuttering such as The Lidcombe Program (Onslow, Harrison, & Packman, 2003)which involves speech correction by parents.

Involving family members in the therapeutic process can be an important element of treatment. However, it is crucialthat clinicians have an accurate understanding of the experiences that a person who stutters has with their family intheir everyday environment in order to successfully involve family members in treatment. The results of this study mayalso have implications for clinicians working with parents of children who stutter from Kuwait or Arab backgroundsoutside of Kuwait. It is possible that parents persist with the same attitudes, knowledge and beliefs even though theyare no longer living Kuwait.

Future research could involve investigating a PWS’ experiences in societal contexts as well as in the home. Thispotentially will confirm or refute the perceptions reported in this paper and further guide clinicians in educating andcounseling parents and the general public and correcting any misinformation. Ultimately, this information could alsobe an important component of therapy, and may help guide parents to early intervention and clinicians in providingintervention.

5. Conclusion

Previous studies have established that knowledge about stuttering tends to be poor in the general population (e.g.,St. Louis, 2005). Therefore the dissemination of scientific information on stuttering, and perhaps the impact of thedisorder on PWS is warranted. Given that the profession of speech–language pathology is relatively new in Kuwaitand that SLPs are beginning to develop and provide stuttering assessment and treatment services, it is imperative thatthis information is available to the community, so that individuals are able to seek help appropriately. These steps willultimately help in the integration of PWS into society and will contribute to their well-being.

The current results will be incorporated into follow up comparative studies and previous POSHA-E studies, andfuture research aimed at addressing any prevailing issues within the Arabic culture/society. The outcomes of thisstudy give impetus to future educational campaigns within schools for students and in the health care systems toeducate other health professionals and the general public. Ultimately this will increase awareness about stutteringand speech–language pathology services, as well as ensure a healthy and supportive environment for PWS and theirfamilies, in order to encourage them to seek help as early as possible.

CONTINUING EDUCATION

Multiple-choice self-assessment CE questions with answers

Multiple Choice Questions

1. Research has shown that negative stereotypes about stuttering(a) Are resistant to change despite exposure to people who stutter(b) Are found among speech–language pathologists only(c) Are affected by direct contact only(d) Exist among most people except by parents of people who stutter(e) Develop later in life

2. Attitudes, knowledge and beliefs about stuttering have been measured using(a) Telephone interviews(b) Surveys(c) Semantic differential techniques


(d) Stimuli such as educational videos(e) All of the above

3. The Public Opinions Survey on Human Attributes (POSHA-E)(a) Measures the attitudes of speech–language pathologists toward stuttering(b) Measures the attitudes, knowledge and beliefs among the general public(c) Does not allow researchers to measure changes in responses(d) Lacks validity and reliability(e) All of the above

4. Public opinion about stuttering is important because(a) Attitudes, knowledge and beliefs about stuttering can influence treatment outcomes(b) It may influence referral rates(c) It may influence acceptance of assessment and treatment services(d) It promotes the speech–language pathology profession(e) All of the above

5. Cultural group studies have been(a) Conducted on cultural groups within the U.S. only(b) Able to gather a limited range of attitudes and beliefs(c) Able to show that negative stereotypes exist cross-culturally(d) Able to show that no cultural groups demonstrate up to date knowledge of stuttering(e) (a) and (c)

Acknowledgments

The authors would like to thank and acknowledge the permission of Dr. Kenneth St. Louis to use the POSHA-Esurvey in this study, as well as his input and guidance. The authors would also like to acknowledge the assistance ofthe school principles and teachers at the government schools in Kuwait for their assistance in distributing the surveysamong parents, and the parents that took part in the study. We would also like to thank the following people for theircontribution and support: Mrs. May Mutawa at the Department of English, Public Authority of Applied Education andTraining, Dr. Khawla Alqinae and Dr. Fauzia Abdulla at the Department of Communication Sciences and Languages,as well as Dr. Emad-Aldeen Ali, Mr. Ahmad Abu-Agwa, and Ms. Seham Ali at the Department of Statistics, Facultyof Science.

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Maram Al Khaledi is a PhD student from Kuwait studying at the University of Sydney. She is also a teaching assistant at the Department ofCommunication Science and Languages, College for Women at Kuwait University. She has previously completed a Masters in Speech LanguagePathology at The University of Queensland.

Michelle Lincoln is an Associate Professor in the Discipline of Speech Pathology at The University of Sydney. Michelle lectures and researches inthe area of stuttering. Her particular area of interest is treatment efficacy for stuttering.

Patricia McCabe is a Lecturer in the Discipline of Speech Pathology at The University of Sydney. Patricia lectures and researches in the area ofmotor speech disorders. Her particular areas of interest are childhood apraxia and stuttering.

Ann Packman is an Associate Professor at the Australian Stuttering Research Centre at The University of Sydney. Ann has been involved extensivelyin stuttering research over many years.

Tariq Alshatti is the head of the Department of Communication Science and Languages, College for Women at Kuwait University. Tariq lecturesin speech pathology and is engaged in a wide range of research activities.

Documents

The attitudes, knowledge and beliefs of Arab parents in Kuwait about stuttering