Revue Canadienne D'orthophonie Et Audiologie 2017 Num 41 Vol3

CANADIAN JOURNAL OF SPEECH-LANGUAGE
PATHOLOGY & AUDIOLOGY | CJSLPA

Volume 41, No. 3, 2017
REVUE CANADIENNE D’ORTHOPHONIE

ET D’AUDIOLOGIE | RCOA
Volume 41, No. 3, 2017
Examining the Relationship Between Perceptions of a

Known Person Who Stutters and Attitudes Toward Stuttering
Charles D. Hughes, Rodney M. Gabel, Scott T. Palasik
Performance of Young, Middle-Aged, and Older Adults on Tests of Executive Function

Angela N. Burda, Emily Andersen, Marissa Berryman, Maddisen Heun, Claire King, Tina Kise
Canadian-French Validation of Two Questionnaires That Measure the

Stigma Associated With Hearing Impairment: Initial Development
Claude Vincent, Jean-Pierre Gagné, Tony Leroux, Audrey Clothier,
Marianne Larivière, Frédéric S. Dumont, Martine Gendron
Students’ Evaluation of Audiology Simulation Training

Ahmad A. Alanazi, Nannette Nicholson
Diagnosing Apraxia of Speech on the Basis of Eight Distinctive Signs

Roel Jonkers, Judith Feiken, Ilse Stuive
Development of a Tool to Screen Risk of Literacy Delays in French-Speaking Children: PHOPHLO

Susan Rvachew, Phaedra Royle, Laura M. Gonnerman, Brigitte Stanké,
Alexandra Marquis, Alexandre Herbay
CJSLPA EDITORIAL TEAM
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François Bergeron, Ph.D. Maxime Maheu, M.Sc.S. EDITORIAL ASSISTANTS

Editor-in- Chief
Simona Maria Brambati, Ph.D. Vincent Martel-Sauvageau, Ph.D. Simone Poulin, M.P.O.
David H. McFarland, Ph.D.
Rebecca Wolfe, M.Pub.
Université de Montréal Stéphanie Breau Godwin, M.Sc.S. Laurence Martin, M.P.A.
Sarah Healy, M.Sc.
Rachel Cassie, Ph.D. Christi Miller, Ph.D., CCC-A
Editors
Paola Colozzo, Ph.D., RSLP Monique Charest, Ph.D. Victoria Milloy, M.Sc.S. Translation
University of British Columbia Chantal Desmarais, Ph.D. Laura Monetta, Ph.D. Laurentin Lévesque, René Rivard
Philippe Fournier, Ph.D., FAAA Sheila Moodie, Ph.D. and Simone Poulin, M.P.O.
Lorienne Jenstad, Ph.D, Aud(C), RAUD, RHIP
Soha N. Garadat, Ph.D. Kevin J. Munro, Ph.D.
University of British Columbia
Kendrea L. (Focht) Garand, Ph.D., Mahchid Namazi, Ph.D. LAYOUT AND Design
Josée Lagacé, Ph.D. Olga Novoa
CScD, CCC-SLP, BCS-S, CBIS Flora Nassrallah, M.Sc.
Université d’Ottawa
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Université de Montréal Ellen Hickey, Ph.D. Elizabeth Rochon, Ph.D.
Bonnie Martin-Harris, Ph.D., CCC-SLP, BCS-S Lisa N. Kelchner, Ph.D., CCC/SLP, BCS-S Sig Soli, Ph.D.
Northwestern University Amineh Koravand, Ph.D. Michelle S. Troche, Ph.D., CCC-SLP
Natacha Trudeau, Ph.D. Maureen A. Lefton-Greif, Ph.D., Christine Turgeon, Ph.D.
Université de Montréal CCC-SLP, BCS-S Ingrid Verduyckt, Ph.D.
Andrea MacLeod, Ph.D. Catherine Wiseman-Hakes, Ph.D., CCC-SLP
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ISSN 1913-2018 | www.cjslpa.ca Revue canadienne d’orthophonie et d’audiologie (RCOA)

Membres de l’équipe de rédaction de la RCOA
COMITÉ DE RÉVISION DE LA RÉDACTION
RÉDACTEUR EN CHEF François Bergeron, Ph.D. Maxime Maheu, M.Sc.S. ASSISTANTES À LA RÉDACTION
David H. McFarland, Ph.D. Simona Maria Brambati, Ph.D. Vincent Martel-Sauvageau, Ph.D. Simone Poulin, M.P.O.
Université de Montréal Rebecca Wolfe, M.Pub.
Stéphanie Breau Godwin, M.Sc.S. Laurence Martin, M.P.A.
Sarah Healy, M.Sc.
RÉDACTRICES Rachel Cassie, Ph.D. Christi Miller, Ph.D., CCC-A
Paola Colozzo, Ph.D., RSLP Monique Charest, Ph.D. Victoria Milloy, M.Sc.S.
Traduction
University of British Columbia Chantal Desmarais, Ph.D. Laura Monetta, Ph.D. Laurentin Lévesque, René Rivard et
Lorienne Jenstad, Ph.D, Aud(C), RAUD, RHIP Philippe Fournier, Ph.D., FAAA Sheila Moodie, Ph.D. Simone Poulin, M.P.O.
University of British Columbia Soha N. Garadat, Ph.D. Kevin J. Munro, Ph.D.
Kendrea L. (Focht) Garand, Ph.D., Mahchid Namazi, Ph.D. MISE EN PAGE ET
Josée Lagacé, Ph.D.
CScD, CCC-SLP, BCS-S, CBIS Flora Nassrallah, M.Sc. CONCEPTION
Université d’Ottawa
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Bernard Grela, Ph.D. Kathleen Peets, Ed.D.
Karine Marcotte, Ph.D.
Denyse Hayward, Ph.D. Angela Roberts, Ph.D.
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Canadian Journal of Speech-Language Pathology and Audiology (CJSLPA) Volume 41, No. 3, 2017
TABLE OF CONTENTS Table des Matières
Article 1 237 Article 1 237

Examining the Relationship Between Perceptions Explorer la relation entre la perception des individus
of a Known Person Who Stutters and Attitudes envers une personne bègue qu’ils connaissent et
Toward Stuttering leurs attitudes face au bégaiement
Charles D. Hughes, Rodney M. Gabel, Scott T. Palasik Charles D. Hughes, Rodney M. Gabel, Scott T. Palasik
Article 2 253 Article 2 253

Performance of Young, Middle-Aged, and Older Adults La performance des jeunes adultes, des adultes
on Tests of Executive Function d’âge moyen et des aînés à des tests évaluant les
Angela N. Burda, Emily Andersen, Marissa Berryman, fonctions exécutives
Maddisen Heun, Claire King, Tina Kise Angela N. Burda, Emily Andersen, Marissa Berryman,
Maddisen Heun, Claire King, Tina Kise
Article 3 263
Canadian-French Validation of Two Questionnaires Article 3 263
That Measure the Stigma Associated With Hearing Développement initial et validation franco-canadienne
Impairment: Initial Development de deux questionnaires mesurant les stigmates associés
Claude Vincent, Jean-Pierre Gagné, Tony Leroux, à une perte auditive
Audrey Clothier, Marianne Larivière, Frédéric S. Claude Vincent, Jean-Pierre Gagné, Tony Leroux,
Dumont, Martine Gendron Audrey Clothier, Marianne Larivière, Frédéric S.
Dumont, Martine Gendron
Article 4 289
Students’ Evaluation of Audiology Simulation Training Article 4 289
Ahmad A. Alanazi, Nannette Nicholson L’évaluation des étudiants d’une formation en
audiologie utilisant des mises en situation
Article 5 303 Ahmad A. Alanazi, Nannette Nicholson
Diagnosing Apraxia of Speech on the Basis of Eight
Distinctive Signs Article 5 303
Roel Jonkers, Judith Feiken, Ilse Stuive Diagnostiquer l’apraxie de la parole en se basant
sur huit signes distinctifs
Article 6 321 Roel Jonkers, Judith Feiken, Ilse Stuive
Development of a Tool to Screen Risk of Literacy
Delays in French-Speaking Children: PHOPHLO Article 6 321
Susan Rvachew, Phaedra Royle, Laura M. Gonnerman, Développement d’un outil pour dépister le risque de
Brigitte Stanké, Alexandra Marquis, Alexandre Herbay retard dans l’acquisition des habiletés de littératie chez
les enfants francophones : PHOPHLO
Susan Rvachew, Phaedra Royle, Laura M. Gonnerman,
Brigitte Stanké, Alexandra Marquis, Alexandre Herbay
ISSN 1913-2018 | www.cjslpa.ca Revue canadienne d’orthophonie et d’audiologie (RCOA)

KNOWN PERSON AND STUTTERING Canadian Journal of Speech-Language Pathology and Audiology (CJSLPA)
Examining the Relationship Between Perceptions of a Known

Person Who Stutters and Attitudes Toward Stuttering
Explorer la relation entre la perception des individus envers

une personne bègue qu’ils connaissent et leurs attitudes face
au bégaiement
KEY WORDS Charles D. Hughes

stuttering
Rodney M. Gabel
Scott T. Palasik
familiarity
attitudes
perceptions
Abstract
The focus of this study was to examine the association between familiarity and attitudes toward
stuttering. In total, 152 participants completed a survey consisting of Likert-type questions where
they rated their perceptions of a known person who stutters (PWS). Questions were organized for
analysis into 3 categories, which included perceptions of the quality of the relationship; how the
known PWS copes with stuttering; and perceived impact of stuttering. Participants then completed
a semantic differential scale related to their attitudes toward the known PWS, and were asked
to complete the same scale thinking of an average PWS. Significant positive correlations were
Charles D. Hughes found between ratings of the quality of the relationship with the known PWS and positive ratings
Bowling Green State University,
Bowling Green, Ohio,
of their traits. Furthermore, how important the known PWS was to a participant was positively
USA correlated with ratings of an average PWS as trustworthy and reliable. Perceptions regarding
how the known PWS coped with stuttering were positively correlated with positive ratings of this
Rodney M. Gabel
person’s traits. The most significant negative correlations were observed between perceptions of
University of Toledo,
Toledo, Ohio, how stuttering impacted the known PWS and attitudes toward the known and average PWS. That
USA is, the more participants perceived stuttering impacting the known PWS, the more negative their
perceptions were of the known and average PWS. Findings provide support for encouraging the
Scott T. Palasik
University of Akron,
public to become familiar with individuals who stutter who demonstrate positive management with
Akron, Ohio, stuttering. Furthermore, this study helps clarify inconsistencies reported in the literature related to
USA the impact of familiarity on attitudes toward stuttering.
237 Examining the Relationship Between Perceptions of a Known Person Who Stutters and Attitudes Toward Stuttering Volume 41, No. 3, 2017
Revue canadienne d’orthophonie et d’audiologie (RCOA) KNOWN PERSON AND STUTTERING
Abrégé
Cette étude vise à explorer la relation entre la familiarité des individus envers le bégaiement et
leurs attitudes face à ce trouble de la parole. Au total, 152 participants ont rempli un questionnaire
utilisant des échelles de Likert et leur demandant d’évaluer leurs perceptions envers une personne
bègue qu’ils connaissent. Les questions ont été regroupées en trois catégories pour les analyses :
la perception des individus concernant la qualité de leur relation avec la personne bègue qu’ils
connaissent, la perception des individus quant à l’adaptation de la personne bègue qu’ils
connaissent face au bégaiement et la perception des individus quant à l’impact du bégaiement.
Les participants ont ensuite rempli une échelle sémantique différentielle portant sur leurs attitudes
envers la personne bègue qu’ils connaissent. Ils ont également rempli la même échelle en pensant
à une personne bègue typique. Les résultats montrent que la qualité de la relation des individus
avec la personne bègue qu’ils connaissent est positivement et significativement corrélée avec une
évaluation positive de leurs traits de personnalité. De plus, l’importance d’une personne bègue aux
yeux des participants est positivement corrélée avec une perception que les personnes bègues
typiques sont fiables et dignes de confiance. La perception des participants à propos de la façon
dont la personne bègue qu’ils connaissent s’adapte au bégaiement est positivement corrélée
avec une évaluation positive des traits de personnalité de cette personne. Les résultats montrent
que les corrélations négatives les plus significatives portent sur la relation entre la perception des
participants à propos de la façon dont le bégaiement affecte la personne bègue qu’ils connaissent
et leurs attitudes envers la personne bègue qu’ils connaissent et les personnes bègues typiques.
En d’autres mots, plus les participants perçoivent que le bégaiement affecte la personne bègue
qu’ils connaissent, plus ils perçoivent négativement la personne bègue qu’ils connaissent et les
personnes bègues typiques. Les résultats suggèrent que d’apprendre à connaitre une personne
bègue qui prend en charge son bégaiement de façon positive devrait être encouragé au sein du
public. Cette étude contribue également à clarifier les discordances rapportées dans la littérature
à propos de l’impact de la familiarité des individus envers le bégaiement et leurs attitudes face à ce
trouble de la parole.
pages 237-252 ISSN 1913-2018 | www.cjslpa.ca 238

It is well documented that various populations report investigation of 204 college-aged students. Boyle et al.
negative attitudes toward stuttering (Cooper & Cooper, examined whether causality, curability, and familiarity
1996; Crowe & Cooper, 1977; Crowe & Walton, 1981; Dorsey had an influence on attitudes toward stuttering and
& Guenther, 2000; Silverman & Bongey, 1997; St. Louis, found that perceived causality was found to be a factor in
2011; Turnbaugh, Guitar, & Hoffman, 1979; Walker, Mayo, & affecting attitudes; however, familiarity was found to be
St. Louis, 2016; Yairi & Carrico, 1992). The impact of these unrelated to attitudes.
attitudes on people who stutter has been highlighted
by Yaruss and Quesal (2004) in their description of the Familiarity having positive effects on attitudes
International Classification of Functioning, Disability and
Other studies have shown familiarity can have a positive
Health model. In this application, Yaruss and Quesal
impact on attitudes toward stuttering. For instance,
describe how negative attitudes have an adverse impact
Klassen (2001) concluded that individuals who knew a
on the quality of life of people who stutter. Therefore, it
PWS demonstrated a positive attitude toward people
is important to explore variables that could potentially
who stutter and proposed that this contact with stuttering
decrease these negative attitudes, in hopes of improving
could improve overall perceptions of people who stutter.
the quality of life of people who stutter.
In another study, Klassen (2002) utilized a semantic
One variable that has been discussed as a way to differential scale to examine responses from 108 individuals
improve attitudes toward certain populations is familiarity. who knew someone who stutters. Klassen’s findings
The benefit of familiarity can be explained through the revealed that individuals who knew someone who stutters
contact hypothesis described by Allport (1954) where he demonstrated more positive attitudes toward stuttering
suggests that, as a method to decrease stigmatization when compared to previous studies of the general
toward a marginalized group, individuals come into contact public toward stuttering. Klassen concluded that these
with an individual in the group in order to obtain a more findings provided support that familiarity with a PWS has a
accurate understanding of the population. Many studies positive impact on attitudes toward stuttering. In addition,
have explored whether or not this contact, or familiarity, has Schlagheck et al. (2009) investigated stereotyping of people
an impact on attitudes toward people who stutter (Arnold who stutter using a mixed method design exploring the
& Li, 2016; Boyle, Blood, & Blood, 2009; Doody, Kalinowski, impact of several variables on attitudes toward stuttering,
Armson, & Stuart, 1993; Gabel, Tellis, & Althouse, 2004; where familiarity was found to have a positive effect. More
Hughes, Gabel, Irani, & Schalgheck, 2010; Klassen, 2001, recently, Arnold and Li (2016) examined the relationship
2002; Schlagheck, Gabel, & Hughes, 2009). Research to between beliefs about people who stutter and behavioural
date has found that familiarity has an inconsistent impact and affective reactions toward stuttering. A database from
on attitudes toward people who stutter. the Public Opinion Survey of Human Attributes – Stuttering
was used, and when filtered for the purposes of their study
Familiarity having no effect on attitudes produced 2,206 participants. Arnold and Li found that
familiarity was related to how participants reacted toward
Some evidence suggests familiarity does not have
people who stutter, and concluded that having the public
an effect on attitudes. For instance, Doody et al. (1993)
become familiar with a PWS has implications related to
examined the perceptions of 106 individuals from rural
improving how others react toward people who stutter.
communities in Newfoundland toward stuttering. They
found that regardless of familiarity, participants viewed a
Statement of the problem
person who stutters (PWS) more negatively versus a non-
stuttering individual. Gabel et al. (2004) reported similar Research exploring the relationship between familiarity
results in their investigation of 195 university students, which and attitudes toward stuttering has produced mixed
concluded that different levels of familiarity did not have a results. Despite the many studies that have examined this
significant positive impact on perceptions toward people relationship, little is known as to the underlying reasons
who stutter. Hughes et al. (2010) found similar results when for the discrepancy. One possible explanation could be
examining how university students perceived the impact that previous studies may not have accounted for the
stuttering has on a person’s life. In their survey, 110 of 146 complexity of knowing another PWS. For example, asking
participants reported knowing at least one PWS; however, questions related to the extent to which a person is familiar
familiarity with a PWS did not have a significant impact with a PWS, and their perceptions of how they are managing
on perceptions. University students’ attitudes toward their stuttering, may add another layer of understanding
stuttering were also explored by Boyle et al. (2009) in their of the impact of familiarity on attitudes toward stuttering.
These factors could add nuances to familiarity that have The questionnaire was composed of three sections, with
not yet been fully explored, and could help clarify the varied the first section consisting of demographic information.
findings observed in the relationship between familiarity and Some of the main questions in this section included level
attitudes toward stuttering. of education, occupation, age, gender, and if participants
knew anyone who stuttered. The second section included
Purpose survey questions related to perceptions toward a known
The purpose of this study was to better understand PWS. If participants reported knowing multiple people
the relationship between familiarity and attitudes toward who stutter, they were asked to complete the questions in
stuttering for both a known and average PWS. The following the second section in regard to the person they knew the
research questions were used to explore whether a best, or in other words, with whom they were most familiar.
relationship exists between perceptions of a known PWS This section asked participants to respond to questions
and attitudes toward the known and average PWS: related to the nature of their relationship and quality of
familiarity with the known PWS, as well as perceptions of
1) Does the quality of relationship with a known PWS their communication ability and stuttering. Participants
relate to attitudes toward the known and average were asked to respond to questions related to quality of the
PWS? relationship with the known PWS and perceptions of their
communication and stuttering on a 5-point Likert scale,
2) Is there a relationship between the perceptions of
indicating their level of agreement from 1 (Strongly Agree)
how a known person manages their stuttering and
to 5 (Strongly Disagree). A total of 11 survey items used this
attitudes toward the known and average PWS?
Likert scale.
3) How do perceptions of how stuttering impacts a
For the third and final section of the survey, participants
known PWS relate to attitudes toward a known and
responded to Woods and Williams’ (1976) semantic
average PWS?
differential scale, which consisted of a total of 25 items on
Methods a 7-point scale. Each item consisted of an adjective located
in the left column with a corresponding antonym (e.g.,
Questionnaire design and procedures trustworthy-untrustworthy) in the right column. To assure
A questionnaire was developed after reviewing previous even distribution of positive and negative adjectives, each
research exploring attitudes toward stuttering. In addition, pair was randomly distributed so that positive and negative
many of the survey questions and procedures were used adjectives were randomly positioned in right and left
and adapted from previous studies (Klassen, 2001, 2002; columns of the scale. Participants rated their perceptions
Turnbaugh et al., 1979; Woods & Williams, 1976). One part on the 7-point scale for all 25 adjectives. Participants first
of the questionnaire included the semantic differential completed the scale with regard to the known PWS, and
scale, which has been utilized in many studies (e.g., Gabel then completed another copy of the scale with respect to
et al., 2004; Klassen, 2001, 2002; Turnbaugh et al., 1979; an average PWS. A definition of stuttering was not included
Woods & Williams, 1976). This method was chosen due in the survey. Thus, participants were required to think of
to the consistency in findings across studies exploring what they believed an average, typical PWS was like when
perceptions of stuttering. Additional items were designed completing the second semantic differential scale. The
specifically for this study to gather data about participants’ word average was used as a way to keep in line with other
demographic information, as well as perceptions of studies that have examined attitudes toward stuttering, in
their experiences with people who stutter according to that they have used a synonym of typical when referring
relationships, familiarity, and behaviours. Though the to a PWS (Doody et al., 1993; Woods & Williams, 1976).
study did not engage in standardization and testing of Furthermore, the Klassen (2001, 2002) studies have
the validity of these items, it was judged that these items incorporated similar procedures when measuring the
would be appropriate for this study. These additional items impact of familiarity on attitudes toward stuttering.
were developed based on a review of published studies
exploring similar research questions related to stuttering Participants
and the impact of a variety of factors on perceptions This study was reviewed and approved by the
of people who stutter (Crowe & Cooper, 1977; Crowe & Human Subjects Review Board at Bowling Green State
Walton, 1981; Doody et al., 1993; Gabel et al., 2004; Klassen, University. In order to take part in the study, the following
2001, 2002; St. Louis, 2011). criteria were met: (1) being above the age of 18; (2) not

reporting a history of stuttering; and (3) knowing a PWS. totalled 17 participants. Participants reported knowing
Participants were recruited in a variety of settings, which some people who stutter for many years, with 65
included public establishments such as restaurants, participants reporting a relationship lasting between 1
office buildings, and college classrooms. A total of and 10 years, and 49 participants reporting a relationship
326 survey packets were distributed, with 204 surveys lasting longer than 10 years. Thirty-eight participants
returned. From these returned surveys, 21 were deemed reported knowing a PWS for 1 year or less.
incomplete, eight individuals were a PWS, and 23 did not
know anyone who stuttered. Analysis
Survey items. To organize the 11 Likert scale survey
As a result, there were 152 participants who met the
items for analysis, the first and second author discussed
inclusion criteria. It should be noted that this study is
how similar questions could possibly be grouped to form
part of a larger study examining factors that influence
categories. After multiple discussions, a consensus was
attitudes toward stuttering. Results from other parts of reached regarding how to categorize questions. These
the survey can be found in a separate study with these categories are presented in Table 1. The categories
participants using the previously described questionnaire consisted of questions that focused on the quality of
procedures (Hughes, Gabel, & Palasik, 2011). Participants the relationship, coping with stuttering, and the impact
consisted of 65 males and 87 females with a mean of stuttering. The quality of the relationship was chosen
age of 26.39 (SD = 12.16). A variety of relationships with as a name for the category because these questions
people who stutter were reported, with 81 participants asked participants to reflect on how well they knew the
reporting having friends who stutter; 24 reporting having person and how they viewed the relationship. Coping with
classmates/acquaintances who stutter; 13 choosing the stuttering was chosen as the descriptor for the second
other category; eight reporting a co-worker; five reporting category because these questions generally focused
a professor/teacher; three reporting a client, and one on how the person dealt with their stuttering. The last
reporting a student. Finally, a variety of family members category consisted of questions related to the perceived
were reported, which included spouses, aunts/uncles, impact of stuttering on various aspects of the known
cousins, siblings, and parents—which, when combined, person’s life.
Table 1. Categories of Survey Questions
Category Likert-type question (1 = strongly agree, 5 = strongly disagree)

Quality of Familiarity I know this person well.
I have a good relationship with this person.
This person is important to me.
Coping with Stuttering This person is a good communicator.

This person is a competent speaker.
This person stutters more frequently in some situations than others.
This person appeared to be comfortable in discussing his/her stuttering.
Impact of Stuttering I feel that stuttering has affected this person socially.
I feel that stuttering has affected this person educationally.
I feel that stuttering has affected this person occupationally.
I feel that stuttering has not affected this person in any way.
Semantic differential scale. In preparation for data multiple comparisons with the 25 semantic differential
analysis, each of the 25 items on the semantic differential scale items. The p-value was divided by the number of
scale was scored such that the higher mean scores were semantic differential items (.05 / 25), which equalled an
indicative of a negative trait and a lower mean was indicative alpha level of .002. This alpha level was used for analysis.
of a positive trait. This required that all items be arranged so
the positive adjectives were allotted to the lower number on Results
the 7-point scale, and participants’ reports were adjusted Pearson product-moment correlations between
accordingly. Pearson product-moment correlations were the items related to the three categories (quality of
then conducted for each survey item with the 25 items on relationships, coping with stuttering, and impact of
the semantic differential scale for the known and average stuttering) and the responses on the semantic differential
PWS. For correlations that were significant for the known scales were calculated. Additionally, descriptive statistics
PWS but not for the average PWS, a Fisher z-test was were calculated for each survey item (see Table 2) and
used to transform the correlation statistic to a z-score to for individual semantic differential scale items for the
determine if these associations were significantly different known and average PWS (see Table 3). Findings from
from one another. A Bonferroni adjustment was completed the correlations are presented in relation to the known
with regard to the alpha level (.05) with the 25 semantic and then average PWS. Recall that lower numbers on the
differential items. This correction was made due to the 7-point scale are related to more positive adjectives.
Table 2. Descriptive Statistics for Survey Items
Neither
Mean Strongly Strongly
Item Agree Agree Nor Disagree
(SD) Agree Disagree
Disagree
I know this person well. 2.21 (1.01) 45 47 46 11 3
I have a good relationship with this person. 2.16 (.931) 38 66 35 11 2
This person is important to me. 2.34 (.949) 33 50 55 12 2
This person appeared comfortable

2.81 (.882) 13 32 83 19 5
discussing his/her stuttering.
I feel that stuttering has affected this

2.96 (1.15) 10 58 27 42 15
person socially.
I feel that stuttering affected this person

3.39 (1.06) 3 32 44 48 25
educationally.
I feel that stuttering has affected this

3.43 (1.00) 2 24 59 40 27
person occupationally.
I feel that stuttering has not affected this

3.44 (1.11) 9 23 36 60 24
person in any way.
This person is a good communicator. 2.58 (.903) 10 75 38 27 2
The person is a competent speaker. 2.74 (.919) 8 62 47 32 3
This person stutters more frequently in

2.04 (.805) 36 82 28 4 2
some situations than in others.
N = 152

Table 3. Descriptive Statistics for Semantic Differential Scale Items
Known PWS Average PWS

Semantic Differential Item
mean (SD) mean (SD)
1. Sociable-unsociable 2.44 (1.45) 4.06 (1.34)
2. Trustworthy-untrustworthy 2.20 (1.44) 2.66 (1.20)
3. Passive-aggressive 4.29 (1.46) 4.76 (1.26)
4. Secure-insecure 3.54 (1.72) 5.08 (1.27)
5. Introverted-extroverted 3.66 (1.41) 4.84 (1.19)
6. Intelligent-dull 2.76 (1.44) 3.47 (1.22)
7. Withdrawn-outgoing 2.81 (1.59) 4.59 (1.23)
8. Hesitant-daring 3.46 (1.42) 4.80 (1.25)
9. Intelligent-unintelligent 2.77 (1.63) 3.01 (1.28)
10. Composed-anxious 4.09 (1.58) 4.72 (1.24)
11. Sincere-insincere 2.45 (1.28) 2.90 (1.32)
12. Likable-unlikable 2.06 (1.32) 2.64 (1.25)
13. Shy-bold 3.89 (1.63) 5.36 (1.36)
14. Calm-nervous 4.28 (1.52) 5.26 (1.26)
15. Pleasant-unpleasant 2.36 (1.30) 3.13 (1.30)
16. Reliable-unreliable 2.95 (1.76) 2.88 (1.31)
17. Employable-unemployable 2.39 (1.59) 2.88 (1.33)
18. Fearless-fearful 3.80 (1.34) 4.55 (1.08)
19. Friendly-unfriendly 2.02 (1.19) 2.99 (1.23)
20. Open-guarded 3.25 (1.66) 4.49 (1.45)
21. Competent-incompetent 2.70 (1.48) 3.26 (1.31)
22. Excited-frustrated 3.59 (1.39) 4.66 (1.28)
23. Sensitive-insensitive 2.84 (1.32) 2.86 (1.28)
24. Self conscious-self assured 4.07 (1.61) 5.11 (1.39)
25. Relaxed-tense 3.90 (1.45) 4.93 (1.26)
N = 152
Quality of relationship a known PWS, the more they perceived an average PWS to
Known PWS. Correlation results for quality of be reliable and trustworthy.
relationship survey items with the 25-item semantic Correlation comparisons. Recall that, as part of the
differential scale of the known and average PWS can be
analysis, a Fisher z-test transformation was conducted
observed in Table 4. Findings show a significant positive
for correlations that were found to be significant for the
relationship between all three quality of relationship
known PWS but not the average PWS on Likert scale items.
survey items and certain traits. For example, the more
Results of the Fisher z-test found significant differences
participants reported knowing someone who stutters, the
between correlations for quality of relationship survey
more they perceived that person as sociable. In addition,
items and attitudes toward the known and average
the more participants perceived a good relationship with
PWS. More specifically, the association with how well
the known PWS, the more they viewed that person as
participants knew the known PWS was significantly
trustworthy. Finally, the more participants viewed their
stronger than the average PWS related to how social they
relationship with the known PWS as important, the more
viewed the person (Z = 3.06, p = .002). Furthermore, the
they perceived that person as sociable, trustworthy,
association with how important participants viewed the
sincere, reliable, and relaxed.
relationship with the known PWS was significantly stronger
Average PWS. Two significant positive correlations were for the known PWS compared to the average PWS, in
observed between how important participants viewed regard to being social (Z = 2.35, p = .018) and relaxed (Z =
the relationship with the known PWS and two semantic 2.33, p = .019). That is, these associations did not transfer
differential scale items. More specifically, the more to people who stutter in general, but were found to be
importance participants assigned to their relationship with significantly stronger for the known person.
Table 4. Correlations for Semantic Differential Scale Items and Quality of Relationship for Known and Average PWS
Semantic Differential I know this I have a good This person is

Scale Item person well. relationship with important to me.
this person.
Known AVG Known AVG Known AVG
Sociable-unsociable .275* -.072 .241 -.003 .256* -.011
Trustworthy-untrustworthy .165 .076 .251* .140 .297* .249*
Passive-aggressive .227 .041 .189 .114 .191 -.007
Secure-insecure .109 -.034 .126 -.062 .113 -.105
Introverted-extroverted .119 .039 .133 .018 .135 -.081
Intelligent-dull .126 -.074 .178 -.010 .192 .050
Withdrawn-outgoing .198 -.032 .183 -.028 .215 -.004
Hesitant-daring .098 -.044 .053 -.056 .079 -.075
Intelligent-unintelligent .110 .081 .091 .005 .124 .124
Composed-anxious -.115 .089 -.014 .057 -.046 .053
Sincere-insincere .115 .006 .126 .019 .263* .053
Likeable-unlikable .050 .034 .111 -.017 .206 .049

Shy-bold .126 -.026 .094 -.057 .143 -.079
Calm-nervous .060 .013 .101 -.060 .150 -.070
Pleasant-unpleasant .128 .109 .142 -.013 .238 .060
Reliable-unreliable .128 .099 .235 .124 .267* .261*
Employable-unemployable .051 .156 .041 .128 .103 .248
Fearless-fearful .129 -.107 .107 -.085 .144 -.050
Friendly-unfriendly .134 .135 .117 .083 .211 .134
Open-guarded .106 .014 .128 -.021 .147 -.013
Competent-incompetent .095 .003 .065 .068 .140 .103
Excited-frustrated .066 -.061 .057 -.069 .101 -.045
Sensitive-insensitive .055 .104 .081 .119 .133 .142
Self conscious-self assured .064 .011 .027 -.019 .049 .011
Relaxed-tense .159 -.020 .179 -.070 .261* -.003
N = 152, *p < .002
Coping with stuttering

Known PWS. Complete results of the correlations for the known person’s stuttering produced significant
known and average PWS related to coping with stuttering negative correlations, revealing that the more participants
can be found in Table 5. Significant positive correlations perceived the person’s stuttering as varying across
were found between perceptions of how the known PWS situations, the more they perceived that person as
was comfortable in discussing their stuttering and ratings anxious, nervous, and self-conscious.
on semantic differential scale items for the known PWS.
More specifically, the more participants perceived the Average PWS. Although some correlations were noted
as approaching the level of significance, no statistically
known PWS as being comfortable discussing stuttering,
significant correlations were noted between any semantic
the more they perceived the person as sociable, open,
differential scale items for the average PWS and survey
and relaxed. Many significant positive correlations were
items related to coping with stuttering. More specifically,
found between both questions related to viewing the
perceptions of how the known PWS coped with stuttering
known PWS as a good or competent communicator
were not found to be significantly related to attitudes
and semantic differential scale items. For example, the
toward the average PWS.
more participants perceived the known PWS as a good
communicator, the more they rated them as being Correlation comparisons. Significant differences were
sociable, trustworthy, secure, extroverted, intelligent, found for correlations between the known and average
outgoing, daring, sincere, bold, calm, pleasant, fearless, PWS related to how good a communicator the known
friendly, open, excited, self-assured, and relaxed. PWS was perceived. These significant differences were
Furthermore, the more participants rated the known noted for the following traits: sociable (Z = 3.94, p < .001);
PWS as a competent speaker, the more they perceived intelligent (Z = 2.89, p = .003); outgoing (Z = 2.52, p = .011);
them as sociable, trustworthy, secure, extroverted, daring (Z = 2.69, p = .007); intelligent, as compared to
intelligent, outgoing, daring, bold, competent, self- unintelligent (Z = 2.33, p = .019); bold (Z = 2.17, p = .030);
assured, and relaxed. Perceptions of the variability of calm (Z = 2.20, p = .027); pleasant (Z = 2.94, p = .003);
and relaxed (Z = 2.09, p = .036). In regard to perceptions discussing stuttering openly, significant differences
of competence, significant correlation differences were found between known and average PWS ratings
were found related to being sociable (Z = 3.27, p = .001), of being social (Z = 2.78, p = .005), open (Z = 2.49, p =
extroverted (Z = 2.39, p = .016), outgoing (Z = 2.68, .012), and relaxed (Z = 2.88, p = .004). In other words,
p = .007), daring (Z = 3.59, p < .001), and bold (Z = 2.93, these perceptions related to coping with stuttering
p = .003). For perceptions of the variability of stuttering, were found to be stronger in association to a known
significant differences in correlations were found with the PWS and did not relate to perceptions of people who
trait of being composed (Z = -2.10, p = .035). In regard to stutter in general.
Table 5. Correlations for Semantic Differential Scale Items and Coping With Stuttering for Known and Average PWS
Semantic Differential This person This person This person This person
Scale Item is a good is a competent stutters appeared to be
communicator. speaker. more frequently in comfortable in
some situations discussing his/her
than others. stuttering.
Known AVG Known AVG Known AVG Known AVG
Sociable-unsociable .483* .070 .427* .077 -.004 -.014 .253* -.063
Trustworthy-untrustworthy .371* .221 .255* .195 .050 .007 .161 .208
Passive-aggressive .118 .084 .181 -.062 -.219 -.181 -.070 .030
Secure-insecure .296* .093 .258* .063 -.149 -.159 .073 -.046
Introverted-extroverted .262* .148 .268* -.002 -.116 -.118 .113 -.042
Intelligent-dull .470* .173 .341* .228 -.100 -.120 .244 .040
Withdrawn-outgoing .374* .101 .347* .051 -.041 -.145 .196 .001
Hesitant-daring .333* .035 .353* -.047 -.161 -.077 .166 .072
Intelligent-unintelligent .434* .192 .341* .227 -.028 -.077 .163 .083
Composed-anxious .169 .120 .243 .145 -.278* -.042 .130 -.079
Sincere-insincere .264* .126 .187 .142 .175 .004 .218 .063
Likeable-unlikable .221 .058 .073 .101 .135 .008 .203 .009
Shy-bold .329* .090 .299* -.031 -.067 -.128 .156 .024
Calm-nervous .270* .022 .193 .043 -.284* -.128 .140 .034
Pleasant-unpleasant .257* -.077 .045 .079 .069 -.018 .117 -.082
Reliable-unreliable .079 .153 .062 .150 .169 .023 -.023 .043
Employable-unemployable .195 .146 .135 .208 .029 -.014 .096 .037

Fearless-fearful .257* .118 .220 .027 -.134 .163 .090 .007
Friendly-unfriendly .286* .078 .163 .178 .179 -.080 .212 .052
Open-guarded .283* .084 .204 -.056 -.062 .074 .296* .017
Competent-incompetent .191 .106 .315* .174 -.023 .078 .194 .073
Excited-frustrated .337* .184 .237 .148 .003 -.160 .217 .006
Sensitive-insensitive .083 -.005 .004 -.020 -.032 .127 .230 .041
Self conscious-self assured .350* .154 .327* .158 -.279* -.170 .117 .109
Relaxed-tense .415* .197 .369* .185 -.133 -.207 .312* -.011
N = 152, *p < .002
Impact of stuttering
noted for perceptions of how stuttering affected the
Known PWS. Table 6 displays the results of the known person educationally with untrustworthy and
correlation analysis between semantic differential unintelligent. In addition, responses for stuttering affecting
scale items for the known and average PWS and impact the known PWS occupationally were associated with ratings
of stuttering survey items. Many significant negative on the semantic differential scale item for unintelligent. No
correlations were shared among the perceptions of how significant correlations were noted between responses of
stuttering impacted the known person educationally, stuttering not having an effect on the known person and
occupationally, and socially. The more participants semantic differential items for the average PWS.
believed the known PWS was impacted in these areas,
the more likely they perceived them as unsociable, Correlation comparisons. For stuttering affecting the
insecure, dull, withdrawn, hesitant, fearful, self-conscious, known person socially, significant differences were found in
and tense. All three questions produced a number of correlations with traits of being social (Z = -3.35, p = .0008),
significant negative correlations with semantic differential secure (Z = -2.27, p = .023), outgoing (Z = -2.95, p = .003),
scale items, with social impact revealing 11, occupational daring (Z = -4.4, p < .001), bold (Z = -3.94, p < .001), fearless
revealing 11, and educational revealing 12. Significant (Z = -2.73, p = .006), self-assured (Z = -3.36, p < .001),
positive correlations were observed between responses and relaxed (Z = -2.15, p = .031). For affecting the person
in regard to stuttering not having an effect and traits educationally, significant differences were found related
of being social, secure, outgoing, daring, bold, fearless, to being secure (Z = -2.35 p = .018), intelligent (Z = -2.01, p
and self-assured. Overall, the higher participants rated = .044), outgoing (Z = -1.97, p = .048), daring (Z = -2.01, p =
that stuttering had an impact on the person socially, .044), and self-assured (Z = -2.28, p = .022). In regard to
educationally, or occupationally, the more likely the occupational affect, significant differences were found for
respondents favoured the negative traits. being social (Z = -3.55, p < .001), secure (Z = -3.02, p = .002),
daring (Z = -2.92, p = .003), bold (Z = -2.50, p = .012), fearless
Average PWS. Numerous significant negative (Z = -2.79, p = .005), and self-assured (Z = -3.09, p = .002).
correlations were observed for this category for semantic Finally, for the question of stuttering not affecting the known
differential scale items for the average PWS. In other person, significant differences were found in correlations for
words, the more participants perceived that stuttering the traits of being social (Z = 2.99, p = .002), secure (Z = 2.30,
had an impact on the known PWS, the more negative p = .021), and daring (Z = 2.97, p = .003). In summary, these
their attitudes were toward an average PWS. Ratings for associations between how stuttering impacts a person’s life
participant responses in regard to the social impact of were found to be significantly stronger for the known PWS
stuttering for the known person were related to responses compared to an average PWS, revealing that these ratings
to the traits of untrustworthy, dull, unreliable, and affected a known PWS, yet did not translate to associations
unfriendly. There were significant negative correlations of an average PWS.
Table 6. Correlations for Semantic Differential Scale Items and Impact of Stuttering for Known and Average PWS
Semantic Differential I feel that I feel that stuttering I feel that stuttering I feel that
Scale Item stuttering has has affected has affected stuttering has
affected this this person this person not affected this
person socially. educationally. occupationally. person in any way.
Known AVG Known AVG Known AVG Known AVG
Sociable-unsociable -.368* .002 -.306* -.096 -.325* .074 .357* .027
Trustworthy-untrustworthy -.183 -.270* -.275* -.280* -.240 -.212 .126 .189
Passive-aggressive -.226 -.108 -.010 -.102 -.096 .016 .199 .116
Secure-insecure -.330* -.080 -.355* -.098 -.337* -.001 .374* .126
Introverted-extroverted -.191 -.048 -.062 -.082 -.093 -.087 .112 .124
Intelligent-dull -.265* -.288* -.424* -.216 -.275* -.205 .208 .209
Withdrawn-outgoing -.400* -.082 -.354* -.141 -.269* -.087 .338* .128
Hesitant-daring -.456* .017 -.334* -.114 -.366* -.045 .401* .080
Intelligent-unintelligent -.225 -.247 -.417* -.306* -.361* -.287* .215 .232
Composed-anxious -.111 -.096 -.048 -.103 -.107 -.084 .088 .089
Sincere-insincere -.105 -.133 -.226 -.143 -.243 -.138 .012 .116
Likeable-unlikable -.003 -.194 -.126 -.092 -.170 -.180 -.036 .077
Shy-bold -.457* -.037 -.245 -.070 -.288* -.007 .322* .124
Calm-nervous -.283* -.103 -.281* -.118 -.250 .009 .230 .087
Pleasant-unpleasant -.114 -.138 -.170 -.038 -.139 -.034 .038 -.059
Reliable-unreliable -.043 -.258* -.222 -.196 -.116 -.177 -.003 .118
Employable-unemployable -.154 -.190 -.338* -.179 -.279* -.235 .073 .112
Fearless-fearful -.371* -.073 -.303* -.146 -.304* .009 .257* .122
Friendly-unfriendly -.116 -.266* -.122 -.143 -.135 -.204 .003 .212
Open-guarded -.113 .091 -.223 -.033 -.114 .002 .131 .025
Competent-incompetent -.100 -.072 -.185 -.162 -.223 -.129 .033 .047
Excited-frustrated -.267* -.054 -.138 -.081 -.133 -.054 .122 .125
Sensitive-insensitive -.057 .050 -.183 .050 -.169 -.005 .007 -.213
Self conscious-self assured -.428* -.068 -.302* -.048 -.357* -.016 .361* .157
Relaxed-tense -.313* -.075 -.308* -.140 -.327* -.161 .189 .173
N = 152, *p < .002

Discussion Perceptions of how the known PWS coped with

The present study explored the correlation between stuttering were also a significant factor related to positive
traits for the known PWS. It is important to discuss findings
perceptions of a known PWS and attitudes toward
related to coping as it relates to stuttering severity and
stuttering for the known and an average PWS. These
avoidance behaviours. It is possible that participants
perceptions of a known PWS were in regard to the quality
demonstrated wide variability related to how they defined
of relationship with the known person, how the person
and perceived effective coping with stuttering. Participants
managed their stuttering, and the impact stuttering
may have perceived the known person more positively
had on their life. Results from this study provide further
because they were demonstrating a mild stuttering
clarification regarding how familiarity with a PWS can have severity, which could be related to the known person
the potential to improve attitudes toward stuttering. demonstrating avoidance behaviours, thus providing the
The first interesting finding from this study was the perception of a more fluent speaker. Participants may
have been using the amount of stuttering as a way to
importance of experiences and contact with a PWS. Positive
judge whether the person was effectively communicating
attitudes toward the known PWS were related to how
or managing their stuttering. This discussion point also
important participants viewed the relationship, how well
relates to prior research that has found as stuttering
they knew them, and whether they had a good relationship
frequency increases, listeners demonstrate more negative
with this person. More favourable perceptions of the
evaluations of a person’s speech (Panico, Healey, Brouwer,
relationship with a known PWS were associated with high
& Susca, 2005). Avoidances related to stuttering moments
ratings of an average PWS as being trustworthy and reliable. is a real possibility and could have been perceived as
These findings are consistent with other studies that found effective coping with stuttering. Nevertheless, the more
that familiarity had a positive effect on attitudes toward participants believed the known person positively coped
stuttering (Klassen, 2001, 2002; Schlagheck et al., 2009). with their stuttering, the more positive their attitudes were
A closer look at the methodology of one of the Klassen toward the known PWS.
(2001) studies helps to understand this similarity in the
findings. The participants in that study were individuals who The idea that simply decreasing stuttering moments
were identified as having a close relationship with a PWS. might translate to increased perceptions of positive
The closeness, or quality, of this relationship may help to coping and managing stuttering brings up the topic of how
explain why familiarity had a positive effect on attitudes. Our people who stutter may perceive role models who stutter.
findings also support that closeness is an important aspect Hughes, Gabel, Goberman, and Hughes (2011) discussed
of familiarity. Simply knowing a PWS may not improve role models for people who stutter as part of their
attitudes toward stuttering; however, the association qualitative study of adults who stutter. The participants
between familiarity and attitudes toward stuttering appears in this study reported that when they were younger, they
wanted role models to assist them in managing their
to be stronger if the known person is important to the
stuttering. The use of role models who are dealing with
respondent. The number and type of questions asked
stuttering in a positive way could have implications not
related to familiarity may also explain the similarity in other
only for public attitudes, but also to help individuals cope
studies that found similar results. For example, our study
effectively with stuttering. Reitzes (2006) also noted the
asked a number of questions regarding perceptions toward
importance of providing mentors who stutter to school-
a known PWS to capture the complexity of familiarity. In
age children who stutter in his description of how an older
another study that found familiarity to have a positive effect child helped to mentor a younger child who stuttered in
on attitudes, Schlagheck et al. analyzed responses of 154 a school setting. Furthermore, Reitzes provided a review
individuals who did not stutter using open- and closed- of the connection between mentorship and coping
ended questions to describe the person they knew who with stuttering. Our findings related to coping could
stuttered. The use of open-ended questions may have also be applied to other perceptual studies related to
allowed Schlagheck et al.’s participants the opportunity speech therapy. For instance, Gabel (2006) found that
to expand on their perceptions of the person they knew. individuals perceived a PWS more positively if the person
The factors of closeness with a known PWS, and asking was involved in speech therapy and they demonstrated
more questions about the nature of familiarity, may help a more mild stuttering severity. The participants in
to explain the discrepancy with other studies that found Gabel’s study may have believed that speech therapy
familiarity to have no effect on attitudes (Boyle et al., 2009; was improving the person’s ability to cope and manage
Doody et al., 1993; Gabel et al., 2004; Hughes et al., 2010). their stuttering. If people who do not stutter believe that
speech therapy improves how a PWS copes with their knowledge regarding participant responses, thus adding
stuttering, this begs the question, “Do listeners believe that to the richness of the topic. Finally, the correlation analysis
a mild stuttering severity is related to effective coping with conducted is unable to determine whether familiarity
stuttering?” More research is needed to better understand with a known PWS causes attitudes toward stuttering
perceptions of how individuals cope with stuttering. to improve; however, it does provide insights into the
relationship that exists.
Perceptions of the impact of stuttering on the known
PWS were also an important factor. Perceiving the Another limitation is in respect to the decision to
known PWS as not being impacted by their stuttering use the word “average” in the survey protocol. When
was correlated with positive attitudes toward the known participants were reflecting on an average PWS, they may
and average PWS. Similar to perceptions of coping with have mentally visualized someone who was anywhere
stuttering, exposing the public to individuals who have along the spectrum of stuttering severity. This same
decreased the negative impact of stuttering on their life mental representation might have been applied to an
could improve public awareness and attitudes toward average PWS. Therefore, using the word “average” may
stuttering. This is where people in role model positions have skewed the results in that participants may have
(e.g., professional athletes, actors, and other celebrities) responded to questions with this mental representation
can play an important part in helping the general public, related to stuttering severity. In retrospect, asking
along with people who stutter, improve their perceptions participants to provide some descriptions of how they
toward stuttering. perceived “average” might have helped control this term
more. Future studies might provide a description of the
Correlation comparisons between the known and
stuttering severity rating to help participants mentally
average PWS indicated stronger associations with certain
survey and semantic differential scale items for the known represent a consistent hypothetical PWS.
compared to the average PWS. In general, knowing a PWS In addition, another limitation is that there may have
well, perceiving they are positively coping with stuttering, been confusion regarding whether participants really
and believing their stuttering does not negatively impact knew someone who stutters. The level of familiarity
their life was related to positive attitudes toward this with the known PWS, along with participants’ knowledge
particular person. Yet, these same perceptions did not about stuttering, could have influenced their responses.
translate to people who stutter in general. One possible
Furthermore, it could be suggested that participants may
explanation of this finding may be related to participants
not really have known a PWS; rather, they may have known
viewing the known person based upon that person’s
someone who was highly disfluent or demonstrated some
unique, individual characteristics, as well their personal
other communication disorder. Again, having participants
experience with the known PWS, and not basing their
describe the person they know who stutters and some of
perceptions on one characteristic of the person. For
their behaviours might clarify any confusion and address
example, the personal experiences with the known PWS
this potential limitation.
may have involved participants learning that they are a
supportive friend, fun to be around, and a good person. Despite these limitations, the current findings have
These types of experiences may have contributed to the implications for people who stutter. For example,
stronger correlations with the known compared to an encouraging a person who stutters to have quality
average PWS. interactions with others, where they get to know other
people in a meaningful way and view the relationship as
Limitations good and important, could possibly help to improve the
There are several important limitations to this study. attitudes of people who do not stutter toward stuttering.
First, the research design utilized a convenience sample, Furthermore, we can speculate that in the context of this
which impacts how the results can be generalized to a meaningful relationship, others may become more familiar
larger population. Also, this study used a quantitative with how stuttering impacts them and their coping style
design to explore familiarity and perceptions of a with stuttering. With these quality relationships, people
known PWS. Thus, participants were not provided with who stutter may then be able share, and others then learn,
the opportunity to elaborate on responses due to all that stuttering is a piece of who they are and may not
questions being in a closed-ended format. Qualitative or have a negative impact in areas of their life such as their
mixed methods designs could potentially provide in-depth occupation, educational experiences, and social life.

Future research Dorsey, M., & Guenther, R. K. (2000). Attitudes of professors and students toward
college students who stutter. Journal of Fluency Disorders, 25, 77–83. doi:
It is recommended that future studies explore 10.1016/S0094-730X(99)00026-1
familiarity with stuttering using mixed methods Gabel, R., Tellis, G., & Althouse, M. T. (2004). Perceptions of people who stutter:
designs and qualitative approaches. The use of these Effects of familiarity. In A. Packman, A. Meltzer, & H. F. M. Peters (Eds.), 4th
world congress on fluency disorders: Proceedings (pp. 460–465). Nijmegen,
methodologies may allow future participants to
Netherlands: Nijmegen University Press.
elaborate on their responses. It is also suggested that
other researchers examine the extent to which other Gabel, R. M. (2006). Effects of stuttering severity and therapy involvement on attitudes
towards people who stutter. Journal of Fluency Disorders, 31(3), 216–227. doi:
populations, such as employers and individuals in the 10.1016/j.jfludis.2006.05.003
helping professions, report familiarity levels with people
Hughes, C. D., Gabel, R. M., Goberman, A. M., & Hughes, S. (2011). Family experiences
who stutter to determine if this is a contributing factor to of people who stutter. Canadian Journal of Speech-Language Pathology and
attitudes toward stuttering in general. Finally, the extent to Audiology, 35(1), 45–55. Retrieved from http://cjslpa.ca/files/2011_CJSLPA_
Vol_35/No_01_1-102/hughes_gabel_goberman_hughes_CJSLPA_2011.pdf
which stuttering severity is factored into the question of
familiarity has yet to be determined. The additional testing Hughes, C., Gabel, R., & Palasik, S. (2011). Talking about stuttering with a known person
of these variables could provide further information to who stutters: Impact on perceptions toward stuttering. Perspectives on Fluency
and Fluency Disorders, 21, 50–58. doi: 10.1044/ffd21.2.50
explain the complexity of knowing a PWS and its impact on
attitudes toward stuttering. Hughes, S., Gabel, R., Irani, F., & Schlagheck, A. (2010). University students’ perceptions
of the life effects of stuttering. Journal of Communication Disorders, 43, 45–60.
doi: 10.1016/j.jcomdis.2009.09.002
Conclusions
Klassen, T. R. (2001). Perceptions of people who stutter: Re-assessing the negative
In summary, our findings help to shed light on the stereotype. Perceptual and Motor Skills, 92(2), 551–559. doi: 10.2466/
pms.2001.92.2.551
complexities of familiarity and its relationship with
attitudes toward stuttering. We examined other intricacies Klassen, T. R. (2002). Social distance and the negative stereotype of people who
stutter. Journal of Speech-Language Pathology and Audiology, 26(2), 90–99.
of familiarity, which involved perceptions of the quality of
Retrieved from http://cjslpa.ca/files/2002_JSLPA_Vol_26/No_02_77-120/
the relationship, impact of stuttering, and coping ability Klassen_JSLPA_2002.pdf
of a known PWS, and the relationship of these factors
Panico, J., Healey, E. C., Brouwer, K., Susca, M. (2005). Listener perceptions of stuttering
to attitudes. Our results support the idea that familiarity across two presentation modes: A quantitative and qualitative approach.
with a known PWS is associated with improved attitudes Journal of Fluency Disorders, 30, 65–85. doi: 10.1016/j.jfludis.2005.01.003
toward this particular person. Although more significant Reitzes, P. (2006). Providing mentors, role models, and peer support for children who
associations were found between familiarity and attitudes stutter. The Journal of Stuttering Therapy, Advocacy & Research, 1, 16–28.
for the known PWS, familiarity was also found to be related
Schlagheck, A., Gabel, R., & Hughes, S. (2009). A mixed methods study of stereotypes
to more favourable attitudes toward an average PWS on of people who stutter. Contemporary Issues in Communication Science and
certain traits. Disorders, 36, 108–117. Retrieved from http://www.asha.org/uploadedFiles/asha/
publications/cicsd/2009FMixedMethodsStudy.pdf
Silverman, F. H., & Bongey, T. A. (1997). Nurses’ attitudes toward physicians who stutter.
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Acknowledgements
The authors would like to thank the participants for
taking the time to participate in this study.
Authors’ Note
The authors do not have any conflicts of interest
to disclose related to this study. Please address any
correspondence related to this article to Charles D.
Hughes at the Department of Communication Sciences
and Disorders, 200 Health and Human Services Building,
Bowling Green State University, Bowling Green, Ohio, 43403.
Email: [email protected].

PERFORMANCE OF YOUNG, MIDDLE-AGED, OLDER ADULTS Canadian Journal of Speech-Language Pathology and Audiology (CJSLPA)
Performance of Young, Middle-Aged, and Older Adults on

Tests of Executive Function
La performance des jeunes adultes, des adultes d’âge moyen

et des aînés à des tests évaluant les fonctions exécutives
KEY WORDS Angela N. Burda

executive function Emily Andersen
cognition
Marissa Berryman
Maddisen Heun
aging
Claire King
Tina Kise
Abstract
Information on differently aged adults’ performance on tests of executive function administered
by speech-language pathologists is lacking. This potentially limits clinicians’ abilities to accurately
evaluate and treat persons with cognitive impairments. The objective of this study was to
determine potential differences among young, middle-aged, and older adults on 2 tests of
Angela N. Burda executive function: the Behavioural Assessment of Dysexecutive Syndrome and the Functional
Emily Andersen Assessment of Verbal Reasoning and Executive Strategies. In total, 105 healthy adult participants
Marissa Berryman completed both tests in this pilot study. Participants were equally divided into the following 3
Maddisen Heun age groups: Young, Middle-aged, and Older, with ages ranging from 20–88 years old. Older adults
Claire King
demonstrated statistically significantly lower scores compared to young and middle-aged adults
Tina Kise
University of Northern Iowa,
on both tests. No significant performance differences were found between young and middle-
Cedar Falls, Iowa, aged adults. Further research is necessary to determine a definitive pattern of performance on
USA these tests in adults across the lifespan.
253 Performance of Young, Middle-Aged, and Older Adults on Tests of Executive Function Volume 41, No. 3, 2017
Revue canadienne d’orthophonie et d’audiologie (RCOA) PERFORMANCE OF YOUNG, MIDDLE-AGED, OLDER ADULTS
Abrégé
L’information concernant la performance des adultes de différentes tranches d’âge à des tests
évaluant les fonctions exécutives et administrés par les orthophonistes est manquante. Cette
situation peut limiter la capacité des cliniciens à évaluer avec précision et à intervenir auprès de
personnes ayant un trouble cognitif. L’objectif de cette étude était de déterminer les différences
potentielles entre les performances des jeunes adultes, des adultes d’âge moyen et des aînés à deux
tests évaluant les fonctions exécutives : le Behavioural Assessment of Dysexecutive Syndrome et
le Functional Assessment of Verbal Reasoning and Executive Strategies. Au total, 105 adultes en
santé ont complété les deux tests de cette étude pilote. Les participants ont été divisés en trois
groupes égaux en fonction de leur âge : jeunes adultes, adultes d’âge moyen et aînés. L’âge des
participants variait entre 20 et 88 ans. Les aînés ont obtenu des résultats significativement plus
faibles aux deux tests comparativement aux jeunes adultes et aux adultes d’âge moyen. Aucune
différence significative n’a été trouvée entre les performances des jeunes adultes et celle des adultes
d’âge moyen. Des recherches supplémentaires sont nécessaires afin de déterminer les profils de
performance des adultes à ces tests, et ce, aux différents âges de la vie.

Executive function is a term that encompasses of Dysexecutive Syndrome (BADS; Wilson, Alderman,
numerous abilities involving higher level cognitive Burgess, Emslie, & Evans, 1996) and the Functional
processes, including: initiating, forming goals, applying Assessment of Verbal Reasoning and Executive Strategies
knowledge and judgment in problem-solving situations, (FAVRES; MacDonald, 2005). Middle-aged adults had
sequencing, carrying out plans to completion, inhibiting higher scores than young adults on the Rule Shift task of
inappropriate behaviours, and organizing pertinent the BADS. No other differences occurred on the remaining
information (Crawford & Channon, 2002; Pickens, subtests or any subtests on the FAVRES. Older adults were
Ostwald, Murphy-Pace, & Bergstrom, 2010). In essence, not included in that study.
intact executive functioning facilitates dynamic
adaptations to novel and varied situations. Impaired Tests to evaluate executive function performance
executive function can adversely impact the completion Tests of executive function require individuals
of daily activities, social communication, and social to perform tasks that evaluate various skills (Purdy,
cognition. Persons with executive dysfunction can lack 2015). Faria, Alves, and Charchat-Fichman (2015)
structure and coherence in discourse and leave out recently reported some of the most frequently used
pertinent information during conversation (Douglas, neuropsychological tests to evaluate executive functions
2010). Individuals can also have difficulty interpreting in older adults were the Trail Making Test (TMT) Form B;
the behaviour of others and have reduced theory of the Verbal Fluency Test (VFT) – F, A, S and the Animals
mind (Sohlberg & Turkstra, 2011; Van Overwalle, Baetens, category; the Clock Drawing Test (CDT); and the Stroop
Mariën, & Vandekrerckhove, 2014). Such challenges can Test (Lezak, Howieson, Bigler, & Tranel, 2012). These
make interactions and conversations with others difficult tests have similarities to the BADS and FAVRES, the two
(Douglas, 2010; Sohlberg & Turkstra, 2011). tests used in this study. The TMT Form B and portions
of the BADS require individuals to use working memory
Executive function performance in differently and repeatedly switch attention between different
aged adults sequences. The VFT tasks require individuals to search
Some researchers have reported executive function their memory for specific information; semantic memory
performance decreases with age and declines earlier than is also assessed. The FAVRES evaluates semantic memory
previously believed (Allain et al., 2005; Garden, Phillips, & during generation tasks that are comparable to verbal
MacPherson, 2001). Others have reported little executive fluency tasks. The CDT is a visuospatial pen and paper
function decline until old age, and that cognitive declines task that requires planning within an allotted space, similar
in those under 60 years of age are not typically clinically to the Key Search on the BADS. The Stroop Test and Test
important (Singh-Manoux et al., 2012). However, individuals 1 of the BADS both evaluate inhibitory control. Although
with Alzheimer’s disease have shown slight cognitive the FAVRES may not have as many tasks that directly
changes 10–20 years prior to diagnosis (Rajan, Wilson, match those of the tests reported in Faria et al. (2015), its
Weuve, Barnes, & Evans, 2015; Tondelli et al., 2012). If older subtests better reflect everyday activities (e.g., planning
adults develop executive dysfunction, their functional one’s work day or writing a letter of complaint; MacDonald
status may be affected (Pickens et al., 2010) as deficits in & Johnson, 2005). Similar to Allain et al. (2005), the
pragmatics, discourse, memory, attention, and strategic majority of studies that utilized the tests of executive
thinking typically occur (Geffner, 2007). The ability to function discussed in Faria et al. (2015) found that older
make decisions autonomously may be called into question adults tended to have lower scores versus younger
when individuals display characteristics of executive adults. Many studies also included more than one test
dysfunction (Pickens et al., 2010), possibly impacting the since different tests evaluate different executive function
capacity to live independently or the ability to provide abilities (Faria et al., 2015).
informed consent for a medical procedure or care.
Of the tests used in this study, the BADS includes
Young and middle-aged adults have performed well on six tests (i.e., subtests) that determine the severity
tasks measuring executive function, including those that of dysexecutive impairments by evaluating high-level
mimic the real world and require open-ended planning tasks such as “planning, organising, initiating, monitoring
(Allain et al., 2005; Garden et al., 2001). More recently, and adapting behaviour” (Chamberlain, 2003, p. 33).
Burda et al. (2014) examined performance differences Individuals provide verbal and written responses and
between healthy younger and middle-aged adults on two complete a hands-on activity. One test asks temporal
tests of executive function: the Behavioural Assessment judgment questions (e.g., How long do most dogs live
for?). Another test provides persons with a zoo map and on the performance of older adults on these specific tests
open-ended instructions to visit several exhibits following is lacking. Yet, medically based S-LPs need to know how
a set of rules. After completing this task, patients are given well healthy adults across the lifespan perform on these
the same zoo map with more specific instructions on the tests in order to determine if their patients’ performance
sequence of exhibits to visit. The normative sample was is indicative of cognitive-communicative deficits or if their
composed of 216 healthy adults grouped into age brackets performance is age-appropriate. Such information could
(i.e., 16–31, 32–47, 48–63, 64 and older) and 78 persons further aid treatment and prognosis by providing a clearer
aged 19–78 years with various neurological disorders. picture of how much cognitive change can be attributed
Although participants in the norming group under the age to normal aging. The current study extended the study by
of 64 performed significantly better than those aged 64 or Burda et al. (2014) by including older adults. The objective
older, no comparisons between young and middle-aged of this pilot study addressed the following research
adults were included (Wilson et al., 1996). question: Are there statistically significant differences
between young, middle-aged, and older adults on the
The FAVRES assesses four high-level cognitive- BADS and the FAVRES?
communication skills that can occur in daily life: planning
an event, scheduling a workday, making a decision, and Methods
building a case (MacDonald & Johnson, 2005, p. 896).
Planning, organizing, sequencing, controlling inhibitions, Participants
and “prioritizing tasks with time constraints” are assessed Following approval of the protocol by the University of
(MacDonald & Johnson, 2005, p. 897). Tasks (i.e., subtests) Northern Iowa’s Institutional Review Board (Protocol #: 09-
generally contain restrictions (e.g., meetings must occur 0270), participants were recruited for this cross-sectional
at specific times when scheduling a workday). Generation quasi-experimental study from small, mid-sized, and large
and prediction tasks are also completed. For example, urban and rural communities in the Midwest by posting
after planning a children’s event in Task 1, patients generate flyers in public areas (e.g., libraries). A power analysis for an
activities one could do with an adult and then predict two effect size of .08 with an alpha of .05 indicated that a total
good and two bad things that could happen at the chosen sample size of 105 was needed. Participants were equally
event. As opposed to laboratory measures, ecologically divided into the following age groups: Young (aged 20–39
valid tasks can give a better idea of daily functioning years), Middle-Aged (aged 40–59 years), and Older (aged
(Moriyama et al., 2002; Sussman, Rychtarik, Mueser, Glynn, 60 and older). Participant inclusion criteria included: no
& Pruesu, 1986), possibly helping to predict individuals’ history of any neurological damage or events, possessing
behaviours in daily life (Silver, 2000). The FAVRES was at least a high school level of education, native English-
normed on 101 healthy adults ages 17–89 years and 52 speaking, and passing a pure tone hearing screening with
adults with an acquired brain injury; no information was tones presented at 20 dB HL at the frequencies of 500,
included on age-related performance (MacDonald, 2005). 1000, 2000, and 4000 Hz for the young and middle-
aged adults. Older participants were included if they had
Objective of the study no greater than a mild hearing loss in their better ear,
Speech-language pathologists (S-LPs) work with several defined as no greater than 40 dB hearing loss at any of the
populations who exhibit executive dysfunction (e.g., previously documented frequencies (Burda, Casey, Foster,
persons with brain injuries, multiple sclerosis, or dementia; Pilkington, & Reppe, 2006). Participants were required to
Geffner, 2007; Royall, Palmer, Chiodo, & Polk, 2004). score a minimum of 28 or higher on the Mini-Mental State
Clinical assessments are generally based on traditional Examination (MMSE; Folstein, Folstein, & Fanjiang, 2001).
tasks rather than functional tasks representative of real Basic ethical considerations adopted by the University
life, allowing for gross misestimates of performance of Northern Iowa were taken to ensure the protection of
(Crawford & Channon, 2002). The relatively sparse participants in this study.
normative data on tests of executive function that S-LPs
may use complicates the matter. The literature lacks Stimuli and procedures
specific information on potential performance differences Tests were administered according to the test manual
between differently aged adults on the BADS and FAVRES protocols. In order to control for possible testing order
(MacDonald, 2005; Wilson et al., 1996). While Burda et al. effects, every other participant (n = 53) was administered
(2014) reported little performance difference on the BADS the BADS (Wilson et al., 1996) first; the remaining 52
and FAVRES between young and middle-aged adults, data participants were administered the FAVRES (MacDonald,

2005) first. This process was followed for each age group. variable. Since higher levels of education have led to
Testing was completed in a single session, typically lasting higher scores on tasks measuring executive function
120 minutes. Breaks were provided as needed. (Ardila, Ostrosky-Solis, Rosselli, & Gomez, 2000), an
additional series of two-factor ANOVAs were conducted
Data analysis to determine potential significant differences between
participant groups’ education levels and MMSE scores. Age
Participant responses were scored according to the
was the independent variable; Education Level and Score
procedures found in the test manuals. Raw scores on the
were the dependent variables, respectively. Statistical
BADS were converted to profile scores. Profile scores
analyses were performed using SPSS 22.0.
ranged from 0–4. Some subtests (e.g., the Modified Six
Elements Test) had timed components, which factored
Reliability
into calculating the profile score. Performance of normal
controls indicated planning time and time to complete Subtest raw scores were used to calculate inter- and
a task were essential elements of executive function. intra-rater reliability on approximately 20% of a randomly
Summing the profile scores for each of the six tests led to chosen sample (i.e., 15 participants). For inter-rater
an overall profile score. If patients completed the entire reliability, the investigators’ scores were correlated with
test, they earned a Total Profile Score ranging from 0–24. scores of a trained speech-language pathology graduate
student. For intra-rater reliability, the investigators
Participants earned the following raw scores for each scored the selected protocols twice. The second scoring
FAVRES Task (i.e., subtest): Time, Accuracy, and Rationale. took place two weeks after the initial scoring. Pearson
They also earned raw scores on Reasoning Subskills. r correlations were calculated. Inter-rater reliability for
Individuals earned the highest points possible for the most the FAVRES was r = .92; intra-rater reliability was r = .94.
appropriate response. If participants provided a reasonable Inter-rater reliability for the BADS was r = .90; intra-rater
related response, they earned some, but not all, of the reliability was r = .94.
points. Raw scores were then converted to standard scores
in the same areas (e.g., Time, Accuracy). Raw scores were Results
also used to calculate the Total Score for the test. The mean
Participants
standard score was 100 with a standard deviation of 15.
Participants were 105 adults (49 men, 56 women) with
To address the study’s objective, a series of two- 35 participants in each age group. Participants had high
factor Analyses of Variance (ANOVAs) with Bonferroni mean MMSE scores. The majority had completed or were
correction for multiple comparisons were used. Age was completing some type of post-high school education (See
the independent variable and Score was the dependent Table 1).
Table 1. Demographics
Young Adults Middle-Aged Adults Older Adults

(n = 35) (n = 35) (n = 35)
Demographic Information M SD M SD M SD
Age in Years 23.71 5.25 50.31 5.27 69.83 8.21
MMSE Score* 29.00 1.41 29.46 .78 28.34 1.59
Years of College 6.66 2.84 3.06 2.22 5.03 3.16
Note. MMSE = Mini-Mental State Examination. *The highest possible score on the MMSE is 30.
Descriptive statistics Inferential statistics

Overall mean scores on the BADS and the FAVRES Several statistically significant differences occurred
were obtained (see Tables 2 and 3). In both tests, older in both tests. On the BADS, the results showed an effect
adults generally had the lowest mean scores compared of group for the Rule Shift Card test, F (2, 104) = 5.46, p ≤
to the other two groups. There were some exceptions. .006; the Zoo Map test, F (2, 104) = 4.65, p ≤ .01; the BADS
On the BADS, middle-aged adults had the highest mean Total Profile Score, F (2, 104) = 6.34, p ≤ .003; and the
scores for the Action Program while young adults had the BADS Standard Score, F (2, 104) = 6.22, p ≤ .003.
lowest mean scores. On the FAVRES, older adults had the On the FAVRES, an effect for group occurred for
lowest mean standard scores for Accuracy and Rationale Accuracy scores on the following subtests: Task 1 (Planning
measures. For measures of Time, young adults had the an Event), F (2, 104) = 4.41, p ≤ .014; Task 2 (Scheduling),
lowest mean standard scores for Task 1 (Planning an F (2, 104) = 8.91, p ≤ .0001; Task 4 (Building a Case), F (2,
Event), while middle-aged adults had the lowest mean 104) = 4.69, p ≤ .01; and Accuracy Total, F (2, 104) = 7.64,
scores for Task 2 (Scheduling). p ≤ .001. Significant differences also occurred for Rationale
Table 2. Mean and Standard Deviations of BADS Profile Scores for Young, Middle-Aged, and Older Adults

(n = 35) (n = 35) (n = 35)
BADS Total Score
M SD M SD M SD
Subtests Possible
Rule-Shift
4 3.40 .65 3.80 .47 3.23 1.00
Cards
Action
4 3.46 1.22 3.89 .53 3.60 .81
Program
Key Search 4 3.26 .95 2.86 1.17 2.77 1.00
Temporal
4 1.20 .63 1.31 .68 1.17 .57
Judgment
Zoo Map 4 2.89 .99 2.51 1.09 2.09 1.20
Modified Six
4 3.66 .76 3.74 .89 3.40 .81
Elements
Total Points
24 17.89 1.95 17.97 2.26 16.26 2.56
Score
Standard
100 98.97 9.34 99.37 10.69 91.29 12.19
Score
Note. BADS = Behavioural Assessment of Dysexecutive Syndrome.

Table 3. Means and Standard Deviations of FAVRES Standard Scores for Young, Middle-Aged, and Older Adults
(n = 35) (n = 35) (n = 35)
FAVRES Tasks Total SS

M SD M SD M SD
Accuracy SS Possible
Task 1 108 100.94 16.02 96.89 18.43 87.91 20.58
Task 2 106 90.46 21.26 95.11 17.09 73.31 32.79
Task 3 107 93.57 22.42 71.89 30.39 90.23 29.64
Task 4 106 82.00 30.77 85.80 19.48 57.31 39.73
Total Test 111 88.40 21.22 97.23 21.34 65.91 35.36
Rationale SS
Task 1 106 101.77 14.94 95.37 19.50 87.31 31.84
Task 2 109 99.31 14.94 89.74 28.09 88.74 18.50
Task 3 103 92.60 22.03 82.20 28.26 72.31 39.94
Task 4 107 80.11 31.89 88.37 17.98 67.17 33.55
Total Test 111 89.20 20.85 109.60 9.54 68.09 27.17
Time SS
Task 1 132 105.91 16.09 93.83 25.28 105.97 12.20
Task 2 144 101.23 18.99 100.11 13.78 94.06 25.00
Task 3 130 104.51 9.82 105.77 10.60 94.49 21.43
Task 4 135 109.00 11.77 104.06 11.71 105.54 11.78
Total Test 126 107.89 14.82 86.03 31.96 101.03 17.91
Reasoning SS
142 91.09 13.42 86.94 32.10 82.71 13.96
Note. FAVRES = Functional Assessment of Verbal Reasoning and Executive Strategies; SS = Standard Score.
scores for the following: Task 1, F (2, 104) = 3.39, p ≤ .04; study adds information that was previously unavailable in
Task 2, F (2, 104) = 3.17, p ≤ .05; Task 3 (Making a Decision), both tests. Overall, age appeared to affect performance
F (2, 104) = 4.41, p ≤ .02; and Rationale Total, F (2, 104) = on both the BADS and the FAVRES. As hypothesized, older
10.04, p ≤ .0001. Finally, statistically significant differences adults had statistically significantly lower scores compared
occurred for Task 3 Time scores, F (2, 104) = 3.56, p ≤ .03. to young and middle-aged adults on several subtests. Not
surprisingly, no significant differences occurred between
Post hoc testing. Tukey’s post hoc testing on the BADS young and middle-aged adults. Burda et al. (2014)
indicated middle-aged adults had statistically significantly found young and middle-aged adults had no significant
higher scores on the Rule Shift Card test compared to performance differences on the FAVRES and all but one
older adults (Tukey’s Value = 0.57, p ≤ .005); young adults subtest on the BADS. Middle-aged adults had significantly
scored significantly higher on the Zoo Map task than did higher scores on the Rule Card Shift Test versus young
older adults (Tukey’s Value = 0.80, p ≤ .008). For the BADS adults. Garden et al. (2001) also found no evidence of
Total Profile score, both young and middle-aged adults middle-aged adults having difficulty with changing tasks or
had significantly higher scores on the BADS Total Profile following rules on a task similar to the six elements subtest
Score versus older adults (Tukey’s Value = 1.62, p ≤ .009 of the BADS.
and Tukey’s Value = 1.71, p ≤ .006, respectively). Young and
middle-aged adults also had statistically higher scores on In the current study, older adults had the majority of the
the BADS Standard Score compared to the older adults lowest mean scores on both the BADS and the FAVRES,
(Tukey’s Value = 7.68, p ≤ .01 and Tukey’s Value = 8.09, likely one of the most ecologically valid executive function
p ≤ .006, respectively). tests available to S-LPs. An interesting trend is that there
were no significant performance differences on Task 3
Results from Tukey’s post hoc testing on the FAVRES (Making a Decision) among age groups, although younger
revealed that for Accuracy scores, young adults had adults took more time completing the task compared to
statistically significantly higher scores on Task 1 than older the other groups. It is uncertain why this particular subtest
adults (Tukey’s Value = 13.02, p ≤ .011). Young and middle- did not garner similar outcomes (i.e., older adults having
aged adults scored higher on Task 2 than older adults significantly lower scores vs. the other groups). Results
(Tukey’s Value = 18.71, p ≤ .006 and Tukey’s Value = 23.57, p of this study concur with the assertions by Allain et al.
≤ .000, respectively). Young adults also scored significantly (2005) and Garden et al. (2001) that executive function
higher on Task 4 compared to older adults (Tukey’s Value performance decreases with age. The results also mirror
= 24.68, p ≤ .008). Young and middle-aged adults had findings by Allain et al. (2005) in that older adults had
significantly higher Accuracy Total scores than older adults poorer performance on the BADS Zoo Map test compared
(Tukey’s Value = 22.48, p ≤ .002 and Tukey’s Value = 19.88, to young adults. Such results may not be surprising
p ≤ .006, respectively). For Rationale scores, Tukey’s post because, compared to other cognitive tests, tests of
hoc testing indicated that young adults had statistically executive function can be more sensitive to the effects of
significantly higher scores than older adults on Tasks 1, 2, aging due to their complexity (Morris, Worsley, & Matthews,
and 3 (Tukey’s Value = 14.46, p ≤ .033; Tukey’s Value = 10.57, 2000; Murray, 2012). However, all older participants self-
p ≤ .038; and Tukey’s Value = 20.29, p ≤ .019, respectively). reported no history of neurological events (e.g., transient
Young and middle-aged adults had significantly higher ischemic attack), and all were living on their own at the
Rationale Total scores compared to older adults (Tukey’s time of testing. Consequently, findings from this study must
Value = 21.11, p ≤ .000 and Tukey’s Value = 20.28, p ≤ .001, be interpreted cautiously. While this study adds to the
respectively). Finally, young adults had higher Task 3 Time literature, a broad statement denoting that lower scores on
scores than older adults (Tukey’s Value = 10.02, p ≤ .024). the BADS and FAVRES are typical of healthy older adults
cannot be made until more research indicates this is indeed
Education levels and MMSE scores. No statistically the case. In addition, care should be taken when interpreting
significant differences occurred among age groups for scores from the BADS and FAVRES in clinical settings. Older
education levels or MMSE scores, F(2, 104) = 1.33, p ≥ .27 adult patients may have performed more poorly on these
and F(2, 104) = 0.17, p ≥ .92 respectively. tests pre-morbidly than younger or middle-aged patients.
Thus, further inquiry may be necessary to ascertain if older
Discussion patients have executive dysfunction and if so, to what
This pilot study is one of few that have investigated extent. Interviews with patients and/or loved ones could aid
young, middle-aged, and older healthy adults’ in determining pre-morbid level of functioning and evidence
performance on the BADS and the FAVRES. The current of potential cognitive declines. Careful comparison of test

scores with these responses and observations will ideally Burda, A. N, Casey, A. M., Foster, T. R., Pilkington, A. K., & Reppe, E. A. (2006).
Effects of accent and age on transcription of medically related utterances:
allow S-LPs to develop treatment plans that best meet their A pilot study. Communication Disorders Quarterly, 27, 110–116. doi:
patients’ needs. 10.1177/2F15257401060270020101
Chamberlain, E. (2003). Behavioral Assessment of the Dysexecutive Syndrome

Limitations and future research (BADS). [Test Review]. Journal of Occupational Psychology, Employment and
Disability, 5, 33–37.
Limitations exist with this investigation. While Singh-
Manoux et al. (2012) reported that cognitive declines in Crawford, S., & Channon, S. (2002). Dissociation between performance on
abstract tests of executive function and problem solving in real-life-
individuals under 60 years of age are usually not clinically type situations in normal aging. Aging & Mental Health, 6, 12–21. doi:
important, such assertions require longitudinal study. 10.1080/13607860120101130
Thus, no predictions can be made based on results of Douglas, J. M. (2010). Relation of executive functioning to pragmatic outcome
the current study. However, participants could become following severe traumatic brain injury. Journal of Speech Language and
familiar with tests in a longitudinal study, potentially biasing Hearing Research, 17, 365–382. doi: 10.1044/1029-4388
results (Singh-Manoux et al., 2012). Lack of randomization Ellis, C. (2009). Does race/ethnicity really matter in adult neurogenics? American
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skewed to the lower end of age ranges, particularly the older
adults (Mage = 69.83). Few participants represented minority Faria, C. D. A., Alves, H. V. D., & Charchat-Fichman, H. (2015). The most frequently
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physical activity, diet, and mental and social engagement. Geffner, D. (2007, November). Managing executive function disorders. Presentation
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high saturated fat intake, high dietary cholesterol, and a
Lezak, M. D., Howieson, D. B., Bigler, E. D., & Tranel, D. (2012). Neuropsychological
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MacDonald, S. (2005). Function Assessment of Verbal Reasoning and Executive
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Brunner, & Marmot, 2005). Further research is needed to MacDonald, S., & Johnson, C. J. (2005). Assessment of subtle cognitive-
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determine how differently aged individuals with acquired of the Functional Assessment of Verbal Reasoning and Executive Strategies
neurogenic communication disorders perform on the (FAVRES). Brain Injury, 19, 895–902.
BADS and FAVRES compared to healthy age-matched Moriyama, Y., Mimura, M., Kato, M., Yoshino, A., Hara, T., Kashima, H., … Watanabe, A.
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Acknowledgements
Funding was provided by the University of Northern Iowa’s
College of Humanities, Arts, and Sciences Small Grant.
Authors’ Note
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of the paper.
Correspondence concerning this article should

be addressed to Angela N. Burda, Department of
Communication Sciences and Disorders, University of
Northern Iowa, 230 Communication Arts Center, Cedar Falls
(IA), 50614-0356, U.S.A. Email: [email protected].

HEARING LOSS AND STIGMA Canadian Journal of Speech-Language Pathology and Audiology (CJSLPA)
Canadian-French Validation of Two Questionnaires That

Measure the Stigma Associated With Hearing Impairment:
KEY WORDS Initial Development
stigma questionnaire
hearing loss Développement initial et validation franco-canadienne de
hearing aids deux questionnaires mesurant les stigmates associés à une
instrument translation perte auditive
transcultural
validation
psychometric testing
Claude Vincent Claude Vincent

Université Laval,
Québec, QC Jean-Pierre Gagné
CANADA Tony Leroux
Centre interdisciplinaire de
recherche en réadaptation et
Audrey Clothier
intégration sociale, Marianne Larivière
Québec, QC Frédéric S. Dumont
CANADA
Martine Gendron
Jean-Pierre Gagné
Université de Montréal,
Montréal, QC
CANADA
Tony Leroux
Montréal, QC
CANADA
Centre de recherche
interdisciplinaire en réadaptation
du Montréal métropolitain,
Montréal, QC
CANADA
Audrey Clothier
Centre interdisciplinaire de
recherche en réadaptation et Abstract
intégration sociale,
Québec, QC Questionnaires evaluating stigma and its consequences are available in English for several
CANADA stigmatizing traits. In many Western societies, including French-speaking countries, hearing loss
is a stigmatizing trait. Hence, there is a need for French-language standardized questionnaires for
Marianne Larivière
Université de Montréal, measuring stigma associated with hearing loss. The goal of this study was to adapt, translate, and
Montréal, QC validate 2 questionnaires that assess different aspects of stigmatization and its consequences
CANADA among adults with hearing impairment. The Stigma Consciousness Questionnaire (SCQ) for Women
Frédéric S. Dumont and the Stigma Scale for Mental Illness were specifically adapted for older adults with hearing
Centre interdisciplinaire de impairment. The strategy consisted of the translation and back-translation of the questionnaires by
recherche en réadaptation et 2 translators, revision by a committee of experts, and administration to 5 bilingual older participants.
intégration sociale, These 2 novel questionnaires were then administered to 32 Canadian-French participants, 65 years
Québec, QC of age or older. For the Canadian-French adaptations of the SCQ for Hearing Loss (SCQ-CF) and the
CANADA
Hearing Loss Stigma Questionnaire (HLS-CF), the results yielded good internal consistency
Martine Gendron (α = .79 and .84, respectively) and slightly lower repeatability, with about 10% (1/10 and 3/28) of the
Centre de recherche items having no significant test-retest correlations. Factor analysis performed on the SCQ-CF data
interdisciplinaire en réadaptation
du Montréal métropolitain,
indicated 3 factors rather than the single factor reported for the original questionnaire. This study
Montréal, QC resulted in 2 English and French questionnaires for assessing stigma associated with hearing loss
CANADA that will be used for further validations.
263 Canadian-French Validation of Two Questionnaires That Measure the Stigma Associated With Hearing Impairment: Initial Development Volume 41, No. 3, 2017
Revue canadienne d’orthophonie et d’audiologie (RCOA) HEARING LOSS AND STIGMA
Abrégé
Plusieurs questionnaires évaluant les stigmates, ainsi que les conséquences y étant associées, sont
disponibles en anglais pour divers traits stigmatisants. Dans de nombreux pays occidentaux, dont
les pays francophones, la perte auditive est un trait stigmatisant. Des questionnaires normalisés en
français sont donc nécessaires pour mesurer les stigmates associés à la perte auditive. L’objectif
de cette étude était d’adapter, de traduire et de valider deux questionnaires évaluant différents
aspects de la stigmatisation, ainsi que les conséquences y étant associées, auprès d’adultes
ayant une perte auditive. Deux questionnaires, soit le Stigma Consciousness Questionnaire
(SCQ) for Women et le Stigma Scale for Mental Illness, ont été adaptés spécifiquement pour les
aînés ayant une perte auditive. Ces questionnaires ont été traduits en français, puis retraduits en
anglais (processus de traduction inversée), par deux traducteurs. Ils ont ensuite été révisés par
un comité d’experts et administrés à cinq participants ainés bilingues. Enfin, les deux nouveaux
questionnaires ont été administrés à 32 participants franco-canadiens âgés de 65 ans et plus. Les
résultats montrent que les adaptations franco-canadiennes des questionnaires SCQ for Hearing
Loss (SCQ-CF) et Hearing Loss Stigma Questionnaire (HLS-CF) ont une bonne cohérence interne
(α = 0,79 et 0,84, respectivement) et une stabilité légèrement inférieure à celle des versions
originales : environ 10 % (1/10 et 3/28) des items n’ont pas de corrélation significative lors du test-
retest. L’analyse factorielle effectuée sur les données du SCQ-CF a identifié trois facteurs, alors
que la version originale du questionnaire en avait identifié un seul. Cette étude a permis d’obtenir
deux questionnaires évaluant les stigmates associés à la perte auditive (disponibles en anglais et en
français) et qui feront l’objet de validations supplémentaires.

People with hearing impairment may be perceived This article presents the initial development of
as less capable, cognitively diminished, and poor social transcultural validation of two questionnaires assessing
communication partners (Heine & Browning, 2002; different aspects of stigma and its consequences among
Jennings, Southall, & Gagné, 2013; Kochkin, 2007; Parrette older adults with hearing loss. This article also serves as
& Scherer, 2004; Southall, Gagné, & Jennings, 2010). In a model for the rigorous process that may be used to
terms of self-perception, hearing difficulties can lead translate and adapt existing measurement tools in another
hearing-impaired individuals to consider themselves old, language. Moreover, the psychometric properties of the
weak, and less capable, leading them to shun rehabilitation original English versions and the adapted Canadian-French
services (Gagné, Southall, & Jennings, 2009). This may versions of the questionnaires are compared in this article.
cause them to believe that others judge them negatively.
The social and self-stigma associated with hearing loss Description of the Stigma Consciousness Questionnaire
constitutes one of the most important barriers to hearing (SCQ)
aid use (Fraser, Kenyon, Lagacé, Wittich, & Southall, 2015; The SCQ is a 10-item self-report questionnaire that
Gagné et al., 2009; Kochkin, 2007; Southall et al., 2010). measures the extent to which respondents expect to be
Hearing impairment has an important impact on quality stereotyped because of their disability, social role, or sexual
of life. Not only does it bring its share of functional and orientation. It is also intended to measure how this affects
communication difficulties (Mulrow et al., 1990); it is the way respondents experience their stereotyped status
also associated with stigma that can create important (Pinel, 1999). This questionnaire was initially developed
social and emotional hardships. The stigma associated to measure stigma associated with being a woman
with hearing loss often incorporates ageist stereotypes (development N = 722 and final form tested on N = 302;
(Coleman, 2006; Espmark & Scherman, 2003; Fraser et Pinel, 1999). In subsequent studies, Pinel (1999) tested the
al., 2015; Southall et al., 2010; Tannenbaum et al., 2015). It generalizability of the stigma-consciousness construct by
is common for older adults with hearing loss to quickly give adapting and validating the scale for gay men (n = 23) and
up on their hearing aids or simply refuse to use them due lesbians (n = 27), Caucasians (n = 198), Asians (n = 63),
to fear of stigmatization. Some of them eventually stop Hispanics (n = 53), and Afro-Americans (n = 21).
participating in social activities altogether because they do
The initial version of the SCQ focused on two domains:
not want to be perceived as being “deaf” or to be seen with
(1) the phenomenological experiences of women when
hearing aids (Kochkin, 2007). Accordingly, interventions
interacting with men (e.g., “I never worry that my behaviors
that involve working on the negative perceptions of hearing
will be viewed as typically female”) and (2) beliefs on how
loss with this population have been proposed in order
men view women (e.g., “Most men have a lot more sexist
to encourage people with hearing impairment to seek
thoughts than they actually express”). The scale questioned
rehabilitation services (Hetu, 1996).
women about their perceptions of how they are judged by
When implementing a new intervention program designed men and of how differently men interact with them.
for people with hearing loss who self-stigmatize, it may be When answering the SCQ for Women, respondents are
useful to appraise the client’s perception of the stigmatizing asked to read each of the 10 statements and indicate to
trait before, during, and after the program. Unfortunately, what extent they agree with each statement by rating them
only English-language measures are available for individuals on a 7-point scale ranging from 0 (completely disagree)
of other stigmatized groups such as women, gay men and to 6 (completely agree). The scale includes a midpoint
lesbians, ethnic communities (Lewis, Derlega, Griffin, & of 3, denoting “neither agree nor disagree”. Seven of the
Krowinski, 2003; Pinel, 1999), and people diagnosed with 10 items are reverse scored. A high total score indicates
mental illness (King et al., 2007). In audiology, there is a need that a respondent’s level of stigma consciousness is high.
to measure stigma associated with hearing loss, and to do so In other words, the respondent is strongly concerned
it must be done in the mother tongue of the client. Quebec’s with how others view him or her and is more aware of
population (7,651,000) accounts for 23.9% of the Canadian the signs of sexism. The evaluation of the instrument’s
population, and Quebec’s francophones account for at internal consistency as well as the discriminant and
least 90% of all of Canada’s French-speaking population convergent validities were evaluated by comparing the SCQ
(Marmen & Corbeil, 2004). The importance of measuring to other instruments assessing concepts such as self-
stigma includes the need for researchers and professionals consciousness, modern sexism, and gender attitudes. The
in all bilingual regions to have access to valid and reliable instrument’s construct validity and evaluation of test-retest
instruments in both French and English. reliability were also performed (Pinel, 1999).
Description of the Stigma Scale for Mental Illness (HLS-CF). In French, this questionnaire is entitled
The Stigma Scale for Mental Illness is a 28-item Stigmatisation associée à la déficience auditive.
instrument that asks respondents about their experiences Two other translations of each questionnaire were
of discrimination and their feelings concerning prejudice. It then performed independently, one by a member of the
is divided into three subscales: discrimination, disclosure, research team and the other by a professional translator
and positive aspects (King et al., 2007). The first subscale with no particular background in the health domain. French
is composed of 13 items that address the discriminatory was the native language of both individuals who translated
attitudes of others and their consequences (e.g., lost the questionnaires. Then, using solely the French versions,
opportunities) as perceived by the respondent. The a back-translation into English was done independently by
second subscale is composed of 10 items that address two experienced Anglophone audiologists blinded to the
the respondent’s embarrassment concerning mental original English questionnaires.
illness and his or her way of managing disclosure in order
to avoid discrimination. The third subscale is composed Following that step, a committee of experts (N = 4)
of five items that question the respondent’s perspective consisting of the research team and the professional
on the possibility that having a mental illness has made translator met in order to review the preliminary French
him or her a better person (e.g., more understanding and versions of each questionnaire and to generate only one
accepting of others). French experimental version. The back-translated English
versions were compared to their respective original
When this stigma scale is administered, respondents (English) versions to see how much the original and
are asked to read the 28 statements and check off the translated versions were alike. The more closely the back-
answer that best corresponds to each of the statements. translated versions resembled the original English versions,
Respondents are asked not to ponder too long on each the more they were deemed accurate. When discrepancies
question because the questionnaire aims to obtain their in wording were observed, the committee examined both
first impression. Response options vary from “strongly translated versions carefully and decided which wording
agree” to “strongly disagree” on a 5-point Likert-type scale. was the most accurate. The same process was used to
A higher score on the stigma scale for mental illness is translate the titles, the instruments’ introductory text, the
indicative of a greater amount of stigma. Evaluation of the instructions, and the response options in order to obtain
instrument’s test-retest reliability and internal consistency satisfactory experimental versions formatted similarly to
was performed (King et al., 2007). the original instruments.
Methods
Experimental versions
Instrument translation Ethical approval was obtained from the Research Ethics
For both questionnaires assessing hearing loss stigma, Board of the Centre de recherche interdisciplinaire en
the translation protocol used was inspired by the initial réadaptation du Montréal métropolitain (CRIR-731-0412).
steps of the methodology proposed by Vallerand (1989). As Before taking part in the study, each participant read
outlined in Figure 1, the first step of the procedure involved and signed an informed consent form. The experimental
preparing preliminary versions of the original questionnaires. versions of the questionnaires were administered to ensure
The research team began by confirming that each original that there was no ambiguity and to assess the validity of
instrument was correctly adapted to the phenomenon the content. Both the translated and original versions were
of stigmatization generated by a hearing disability. Both administered to five bilingual persons using a two-step
questionnaires were modified since they originally targeted procedure. The questionnaires (see Appendices A–D)
groups other than persons with hearing impairment. were administered in a pre-established order (SCQ French
Consequently, the SCQ was adapted for this clientele and version, SCQ English version, then HLS English version and
identified as the Canadian-French Stigma Consciousness HLS French version). In the methodology proposed by
Questionnaire for Hearing Loss (SCQ-CF). In French, the Vallerand (1989), five participants are recommended.
scale is referred to as the Échelle de la conscience de la
stigmatisation personnelle (associée à la perte d’audition). The first part was carried out with a bilingual 79-year-old
retired woman without hearing loss. Her native language
Similarly, the Stigma Scale for Mental Illness was adapted was Canadian French and she learned English while working
to target persons with hearing loss and was identified as the as a secretary at an anglophone accounting firm. With
Canadian-French Hearing Loss Stigma (HLS) questionnaire the help of a research team member, this participant

Figure 1. Adaptation and translation protocol for both stigma questionnaires
completed both versions of each questionnaire. For each an item was unclear, the following rule was applied: If the
questionnaire, she was asked to point out any ambiguities ambiguous item only occurred in the French version, the
between the French and the English versions of the unclear item was rephrased as needed. If, on the other hand,
same test items, as well as the introductory text and test the same item was considered unclear in both languages,
instructions of the translated versions. She was also asked it was left unchanged. Once this step was completed,
to identify any differences in meaning that she noticed the research team and the professional translator met to
between both versions of the questionnaires. Following validate the revisions made to the translated versions of the
the administration of the questionnaire, the research two instruments.
team member compared the answers and collected the
participant’s comments. Whenever a mismatch occurred The second part of the administration of the
in the answers provided for the same test item in the two experimental versions involved the participation of three
languages, the research team member discussed the females and one male. The four participants were between
nature of the ambiguity with the participant. Whenever 66 and 82 years of age and all of them had hearing loss
ranging from mild to severe. This was an important aspect of acceptable to minimize the carryover effects due to memory
the experimental versions because it was the first time that and to limit the possibility of a change in participant status
the questionnaires were administered to participants who (Marx, Menezes, Horovitz, Jones, & Warren, 2003). Finally,
had the same profile as the intended population (i.e., older for each translated questionnaire, an alpha-maximized
adults with hearing loss). One participant was a retired office factor analysis (oblimin rotation, delta = 0) was conducted
manager, and another was a retired financial advisor. The to assess the underlying latent variables. This psychometric
third person was a designer and the fourth was a translator. property verifies whether the items of a scale cluster into the
The participants were asked to complete the French and appropriate subscales, as supported by the theory.
English versions of both questionnaires and point out
areas of ambiguity. The purpose of this step was to further With our expected sample size we knew that the factor
improve the translated experimental versions. analysis for the HLS would not be conclusive (N = 32 for 28
items), but we reported the data to show the results that
Evaluation of the psychometric properties of the would be obtained with this questionnaire using this sample
translated versions size. Otherwise, it was postulated that the psychometric
properties of the translated questionnaires could be at least
According to Vallerand’s methodology (1989), the as good as those of the original test versions.
research team needed to complete the transcultural
validation by reproducing and reporting the same tests as the
Participants
original (English) questionnaire. This had been done for the
SCQ-CF and the HLS-CF versions for total scores, internal A convenient sample of 32 persons was proposed based
consistency, test-retest stability and factor analysis. The on the feasibility of a stigma group intervention program.
mean total score and standard deviation are presented for By “convenient” we mean that we recruited persons who
both versions as well as for the sub-scores when available. initially wanted to participate in a research project focusing
Calculations were made with G*Power software, version on preventing stigma related to hearing loss and wearing
3.1.7, using sample sizes, means and standard variations to hearing aids. The intervention program consisted of two
evaluate significant differences with the original article. groups of participants (14 > n < 16) that met together to
practice adaptive strategies and conduct debriefings with
Statistics were calculated using SPSS 23 software. If peers. We took this opportunity to ask participants if they
missing data were encountered, we used the mean answer would be willing to validate the questionnaires for the study
from two other participants having the most similar answer in French and they all agreed. Older adults were recruited
to the participant with the missing value (based on hot-deck with the help of audiologists from the Centre intégré
imputation). The underlying principle was that researchers universitaire de santé et de services sociaux (CIUSSS) du
were to replace a missing value with the actual score from a Centre-sud de l’île de Montréal - Institut Raymond-Dewar
similar case in the current data set (Roth, 1994). To replace (a rehabilitation centre specializing in services for persons
each missing data point in the present study, the two with hearing impairment). The audiologists informed their
participants with the most similar response patterns were patients that a research project on hearing difficulties was
identified from the 31 other participants, and the mean of taking place. Patients who wanted to participate in the
their answers was used to fill in the missing answer. Internal study were invited to contact a member of the research
consistency was assessed to examine the degree to which team. Participant inclusion criteria were: (1) to be willing
the items that made up each scale were homogenous. The to participate and (2) to recognize having some hearing
coefficient of reliability computed was Cronbach’s alpha (α), difficulties or issues associated with hearing loss. Hearing
which can range between 0 and 1. In a good questionnaire, aid ownership as well as a clinical diagnosis of hearing loss
items must be balanced between homogeneity and diversity; were not required to participate. Finally, because of their
this is why some authors suggest using a range between 0.7 unique profile, cochlear implant users were excluded from
and 0.9 (Boyle, 1991; Hyde, 2000; Norman & Streiner, 1999). the study. Recruited patients signed a consent form.
Temporal stability was assessed by administering each
translated questionnaire on two separate occasions in order Results
to ascertain the correlation between the two sets of scores. The individuals selected for the study were adults who
The second test session took place approximately four weeks were 65 years of age or older (N = 32). The majority of
after initial testing. In psychometrics literature, an interval them (n = 24) were hearing aid owners. Table 1 provides a
of 2 days to 6 weeks is acceptable (Cohen, Kamarck, & summary description of the participants involved in the
Mermelstein, 1983; Lee, 2012). A two-week interval is generally validation of the questionnaires.

Table 1. Characteristics of Participants Involved in Canadian-French Validation of the Stigma Consciousness

Questionnaire (SCQ) and the Hearing Loss Stigma (HLS) Questionnaire
Sample Demographics
Degree of Hearing Psychometric properties
size
hearing loss aid users Mean age (range) Male:Female ratio investigated
(N = 32)
Mild 73.0
7 28% 2:5
(15-40 dB) (68-80)
Internal consistency
Moderate 75.5
19 84% 5:14 Factor analysis
(41-70 dB) (66-90)
Temporal stability
Severe 78.2
6 100% 1:5
(71+ dB) (70-86)
Final Canadian-French version and comparison of

psychometric properties of the SCQ Psychometric properties of the SCQ-CF as well as the
The translated versions of the questionnaire appear in psychometric properties of the respective original English
Table 2. Every test item from the original English questionnaire questionnaire are displayed in Table 3. The latter are placed
is presented, along with the accompanying tests items from immediately under the results of the translated version to
the translated Canadian-French version of the questionnaire. facilitate comparison.
Table 2. Item Translation of the Stigma Consciousness Questionnaire1 (SCQ) for Hearing Loss
Item English version Canadian-French (CF) translation

Stereotypes about hearing loss have not Les stéréotypes concernant la perte d’audition ne m’affectent
1
affected me personally. pas personnellement.
Je ne suis jamais inquiet que mes comportements puissent
I never worry that my behaviors will be viewed as
2 être perçus comme étant typiques d’une personne ayant une
stereotypical of a person who has a hearing loss.
perte d’audition.
When interacting with people who have normal Lorsque je dialogue avec des gens ayant une audition normale,
3 hearing, I feel like they interpret all my behaviors je sens qu’ils interprètent tous mes comportements en fonction
in terms of the fact that I have a hearing loss. du fait que j’ai une perte d’audition.
Most people with normal hearing do not judge people La plupart des gens ayant une audition normale ne jugent pas les gens
4
with hearing loss on the basis of their ability to hear. ayant une perte d’audition en fonction de leur capacité à entendre.
Le fait que je suis une personne malentendante n’a aucune
My being hearing impaired does not influence
5 influence sur la façon dont les gens ayant une audition normale
how people with normal hearing act with me.
agissent avec moi.
I almost never think about the fact that I have
Je ne pense presque jamais au fait que j’ai une perte d’audition
6 a hearing loss when I interact with people who
lorsque je dialogue avec quelqu’un qui a une audition normale.
have normal hearing.
My being hearing impaired does not influence Le fait que je suis une personne malentendante n’a aucune
7
how people act with me. influence sur la façon dont les gens agissent avec moi.
Most people with normal hearing have a lot more La plupart des gens ayant une audition normale ont beaucoup
8 prejudicial thoughts about people with hearing plus de préjugés à l’endroit des personnes ayant une perte
loss than they actually express. d’audition qu’ils ne le disent en réalité.
I often think that people with normal hearing Je crois souvent que les personnes ayant une audition normale
9* are unfairly accused of having prejudicial sont injustement accusées d’avoir des préjugés envers les
thoughts about people with hearing loss.* personnes qui ont une perte d’audition.*
La plupart des gens qui ont une audition normale ont de la

Most people with normal hearing have a problem
10 difficulté à considérer les personnes qui ont une perte
viewing people with hearing loss as equals.
d’audition comme étant des égaux.
Note. 1Translated as Échelle de la conscience de la stigmatisation personnelle (associée à la perte d’audition). “SCQ-CF for
Hearing Loss” is a better option to keep the original questionnaire in mind. *The temporal reproducibility of this item (9) was
not observed. Do not take this into account during longitudinal follow-up.
Table 3. Comparison Between the Psychometric Properties of the Original Stigma Consciousness Questionnaire
(SCQ) for Women1
French English
N = 32 2012
Total score (SD) 37.1 (9.7)* 23.6 (6.8)
Factor analysis 3 factors 1 factor
Eigenvalues 3.9, 1.5 and 1.3 -
Total variance explained 67% (39% + 15% + 13%) 23%
Common variance explained 55% (35% + 11% + 9%) 91%
KMO .704 -
Bartlett’s test < .001 -
Determinant 0.010 -
N = 32 3021
Internal Consistency (α) .79 .72
No. item increases α if deleted (new α) 2 (0.80) 0
N = 32 57
Temporal Stability (ICC): r .62 .76
Number of non-significant items (#) 1 (#9) 0
Time interval (weeks) 4 5
Notes. 1From Pinel, 1999, study 1; 2From Pinel, 1999, study 5; *Statistically different from the English version (α probability of error < .05). Total score
was made by an addition of the items after the inversion of the score of the appropriate items (1, 2, 4, 5, 6, 7 and 9); SD = Standard deviation;
KMO = Kaiser-Meyer-Olkin, degree of collinearity between variables; ICC = Intraclass correlation coefficient.
When comparing the Canadian-French and English In comparison, the original article identified only one
versions, it can be observed that the latent variables of the factor (principal-axis factor analysis), which accounts for
SCQ-CF are different from the original English version. The 23% of the total variance. Of the three factors identified in
alpha-maximized factor analysis revealed three factors after the present study, the first one contains items 4 to 7. These
an oblimin rotation (eigenvalues: 3.9, 1.5 and 1.3). These three items are related to interaction with others, especially
factors account for 67% of the total variance (39% + 15% + people with normal hearing. The second factor contains
13%). The determinant was 0.010, indicating an absence of items 1, 2, and 9. These statements are associated with
multicollinearity. The Kaiser-Meyer-Olkin (KMO) measure, the feeling respondents have about the stereotypes they
indicating the degree of collinearity between variables, was project onto others. The third factor contains items 3, 8, and
satisfying (.704) and Bartlett’s test was significant (< .001), 10. These variables are related to respondents’ perceived
demonstrating the absence of an identity matrix. truthfulness of normal hearing people.

The Canadian-French version of the SCQ for hearing alpha value for the positive aspect subscale (.33). A lower
loss has a Cronbach α value of .79. The removal of two internal consistency was also observed in the original
items slightly increased the α value to .80. No other article for this subscale.
change in the α value was observed when other test
items were removed (lowest: .74). Cronbach’s α was also The time elapsed between testing sessions was 4
evaluated for the three identified factors (Factor 1: .88, weeks for our study, compared to a mean of 2 weeks
Factor 2: .62, and Factor 3: .56). For the second factor, the in the original article. The original article reported that
removal of item 2 reduced the α value to .31, indicating the coefficient of correlations ranged from .40 to .71 for
that it was the main constituent of this factor. The same individual items. The same range of individual correlations
is true for the third factor, where the removal of item 8 was observed for 25 of the 28 items (.42-.74). For the other
induced a marked decrease in α to .38. In comparison, three test items, the correlation was not significant (items
the original article reported a lower α value of .72 (no item 5, 6, and 15; r = .05-.28).
increase the α when an item is removed). Discussion
The Canadian-French SCQ for hearing loss had a test- The goal of this study was to adapt, translate, and
retest correlation of .62 for the global score, compared to validate two questionnaires that assess different aspects
.76 in the original article. The time elapsed between testing of stigma and its consequences among older adults with
sessions was 4 weeks for our study, compared to a mean hearing loss. We hypothesized that the psychometric
of 5 weeks in the original article. The correlations were properties would be as good as in the original article, even
significant for nine of the 10 test items, and the correlation if their sample sizes were made of other clienteles with a
score ranged from .38 to .66. We did not find any correlation potentially lower chance of exposure to loud noise. We
for item 9 (p = .20; r = .15). obtained very good comparisons for internal consistency
and temporal stability of the HLS-CF, even if the factor
Final Canadian-French version and comparison of analysis was not conclusive as anticipated. The SCQ-CF
psychometric properties of the HLS
showed better internal consistency than the original article
Every test item of the original English HLS questionnaire but a lower temporal stability and different results for the
is presented in Table 4, along with the accompanying test factor analysis. With these results, we did not reach an
items of the translated Canadian-French version of overall validation for the novel questionnaires, but these
the questionnaire. initial developments constitute a respectable preliminary
validation. These aspects will be analyzed in detail in
Psychometric properties of the Canadian-French
this section.
version of the HLS as well as the psychometric properties of
the original English questionnaire are displayed in Table 5. Canadian-French Stigma Consciousness Questionnaire
For this questionnaire, there were 12 missing data (SCQ) for Hearing Loss
points in total, out of all 32 participants answering 28 Even though the participant/item ratio is low (3.2/1), we
questions each, representing only 1.3% of all answers. performed an alpha-max factor analysis that indicated
The imputation method has been previously described a satisfactory determinant, KMO and Bartlett’s test.
in the Methods section. The factor analysis could not This factor analysis maximizes Cronbach’s α for each
be used due to the small number of participants (N = factor. The oblimin rotation allows the factors not to
32 for 28 items), as indicated by the low KMO (.415). In be orthogonal, and in the case where there is truly no
the original article, the investigators recruited an extra correlation between factors, the results are the same as
100 participants in order to be able to perform this those for a varimax. A correlation matrix between factors
analysis. The internal consistency of the HLS-CF shows after the oblimin rotation shows correlation between
an equivalent coefficient compared to the original factors 1 and 2 (-.31) and between factors 1 and 3 (.27), but
English version of the questionnaire (.91 versus .87, no correlation between factors 2 and 3 (-.04). Tabachnick
respectively). The removal of items did not increase the and Fidell (2007, p. 646) indicate that a correlation under
alpha value significantly. The internal consistency was also .32 is considered orthogonal because the factors have
calculated for the three sub-scores. The discrimination less than 10% common variance. That we identified three
and disclosure subscales showed high and comparable factors rather than only one may be due to the fact that
alpha values (.91 versus .87, respectively) compared to the the questionnaire was adapted to a new population that
original article (.87 and .85). We observed a much lower perceives stereotypes differently. We are not the only
Table 4. Item Translation of the Hearing Loss Stigma1 (HLS) Questionnaire
Item English version Canadian-French (CF) translation
I have been discriminated against in education J’ai subi la discrimination durant mes études en raison de mes
1
because of my hearing problems. problèmes d’audition.
Sometimes I feel that I am being talked down to J’ai parfois l’impression qu’on me rabaisse en raison de mes
2
Having had hearing problems has made me a Mes problèmes d’audition ont fait de moi une personne plus
3
more understanding person. compréhensive.
4 I do not feel bad about having hearing problems. Je ne m’en fais pas à propos de mes problèmes d’audition.
I worry about telling people I received help Je crains de dire aux gens que j’ai reçu de l’aide pour mes
5*
concerning my hearing problems.* problèmes d’audition.*
Some people with hearing problems are Certaines personnes ayant des problèmes d’audition ont des
6*
cognitively challenged.* difficultés cognitives.*
People have been understanding of my Les gens se montrent compréhensifs à l’égard de mes
7
hearing loss. problèmes d’audition.
I have been discriminated against by friends and Je subis la discrimination de la part de mes amis et parents en
8
relatives because of my hearing problems. raison de mes problèmes d’audition.
I have been discriminated against by employers Je subis la discrimination de la part d’employeurs en raison de
9
because of my hearing problems. mes problèmes d’audition.
My hearing problems have made me more Mes problèmes d’audition ont fait de moi une personne qui
10
accepting of other people. accepte mieux les autres.
Very often I feel alone because of my Il m’arrive très souvent de me sentir seul(e) en raison de mes
11
hearing problems. problèmes d’audition.
I am scared of how other people will react if Je crains la façon dont les autres personnes réagiront si elles
12
they find out about my hearing problems. découvrent mes problèmes d’audition.
I would have had a better chance in life if I did not J’aurais eu plus de chance dans la vie si je n’avais pas eu de
13
have hearing problems. problèmes d’audition.
I do not mind people in my neighborhood knowing Cela ne me dérange pas que les gens de mon voisinage soient
14
I have hearing problems. au courant de mes problèmes d’audition.

I would say I have hearing problems if I was Je dévoilerais mes problèmes d’audition si je postulais
15*
applying for a job.* un emploi.*
I worry about telling people that I have consulted Je crains de dire aux gens que j’ai consultés des spécialistes
16
hearing experts about my hearing problems. pour mes problèmes d’audition.
People’s reactions to my hearing problems make Les réactions des gens à mes problèmes d’audition m’amènent
17
me keep myself to myself. à ne pas me livrer.
I am angry with the way people have reacted to La façon dont les gens réagissent à mes problèmes d’audition
18
my hearing problems. me met en colère.
I have not had any trouble from people Les gens ne m’ont jamais causé d’ennuis en raison de mes
19
I have been discriminated against by health Je subis la discrimination de la part de professionnels de la

20
professionals because of my hearing problems. santé en raison de mes problèmes d’audition.
People have avoided me because of my Des gens m’ont évité(e) en raison de mes problèmes
21
hearing problems. d’audition.
People have insulted me because of my Des gens m’ont insulté(e) en raison de mes problèmes
22
hearing problems. d’audition.
Having hearing problems has made me a Mes problèmes d’audition ont fait de moi une personne
23
stronger person. plus forte.
I do not feel embarrassed because of my

24 Je ne suis pas gêné(e) de mes problèmes d’audition.
hearing problems.
25 I avoid telling people about my hearing problems. J’évite de dévoiler mes problèmes d’audition aux gens.
Having hearing problems makes me feel that Mes problèmes d’audition m’amènent à penser que la vie
26
life is unfair. est injuste.
I feel the need to hide my hearing problems Je sens le besoin de cacher mes problèmes d’audition
27
from my friends. à mes amis.
I find it hard telling people I have J’ai de la difficulté à dévoiler mes problèmes d’audition
28
hearing problems. aux gens.
Note. 1Translated as Stigmatisation associée à la déficience auditive. HLS-CF is a better option to keep the original questionnaire in mind. *The
temporal reproducibility of these items (5, 6 and 15) was not observed. Do not take this into account during longitudinal follow-up.
Table 5. Comparison Between the Psychometric Properties of the Original Stigma Scale for Mental Illness1
French English
N = 32 185-192
Mean scores2 (SD)
Total 33.7 (16.3) * 62.6 (15.4)
Discrimination 15.8 (10.6) * 29.1 (9.5)
Disclosure 10.0 (6.6) * 24.7 (8.0)
Positive aspect 7.9 (2.6) 8.8 (2.8)
N = 32 163
Factor analysis Not Valid 3 factors
Eigenvalues NA 7.7, 2.8 and 2.1
Total variance explained NA 72% (44% + 16% +12%)
KMO .415 -
Bartlett’s test < .001 -
N = 32 93
Internal Consistency (α)
All items .91 .88
Discrimination .91 .87
Disclosure .87 .85
Positive aspect .33 .64
N = 32 60
Temporal Stability 3 (ICC) : r .42-.73 .40-.71
Number of non-significant items (#) 3 (5, 6 and 15) 0
Time interval (weeks) 4 2
Notes. 1From King et al., 2007; 2Each question scored 0-4 in the direction of greater stigma. Total score and subscores were made by a an addition
of the items; 3Presented item by item in the original article; *Statistically different from the English version (α probability of error < .05);
SD = Standard deviation; KMO = Kaiser-Meyer-Olkin, degree of collinearity between variables; ICC = Intraclass correlation coefficient.

authors to have observed these three factors for a different considering the different populations studied. The factor
version of the SCQ. An academic work by Huie shows analysis was also not considered due to the low KMO and
the same three factors, composed of the same items, lack of participants.
after a factor analysis performed on 149 participants who
completed the Stigma Consciousness Questionnaire for An excellent and comparable Cronbach α value was
obtained for the adapted instrument compared to the one
Race (Huie, 2010). This cannot be a coincidence, and might
reported for the original questionnaire (.91 versus .88). The
explain the fact that the relationship between the normal-
internal consistency is also similar for the discrimination
hearing population and the hearing-impaired population (or
and disclosure subscales. Cronbach’s α for the positive
population with and without mental illness, in the case of
aspect is very low even when we consider that in the original
Huie’s work) differs compared to the relationship between
version it was by far the subscale with the lowest Cronbach
women and men. We also need to consider that factors
α value. The removal of item 6 greatly increased the alpha
2 and 3 are mainly driven by items 2 and 8 respectively,
value (to .55), indicating that it no longer fits in this subscale.
and in Pinel (1999), the factor loading for items 2 and 8
The meaning of this item has been adapted between
was among the weakest associated with the unique factor
questionnaires, and it is normal to observe this difference
(.33 and .40). For this questionnaire, we obtained a lower
(going from “Some people with mental health problems
test-retest score compared to the original article for the
are dangerous” to “Some people with hearing problems are
global score (.62 versus .76) and we observed that nine of
cognitively challenged”).
the 10 items had significant test-retest correlations, ranging
from .38 to .66. It is thus unlikely that the removal of the We observed a comparable range of correlation
non-significant item (item 9) would increase the global coefficients for the 25 items showing significant correlation.
test-retest score to the level of the original article. However, Only three items (5, 6, and 15) had no correlation in the
by looking more closely at this item, we realized that seven test-retest (see Footnote 1). A closer examination of the
participants switched their answers to this question during data revealed that the problem did not come from the
the test-retest (i.e., from agree to disagree or vice versa). By fact that answers were random on the retest. Again, the
replacing only one of these drastic changes (e.g., completely problem comes from the fact that two participants had
agree to completely disagree), we obtained a significant chosen opposite ratings relative to their original answers.
correlation (p = .036; r = .373). We are not sure what could The replacement of only one of these answers makes the
have motivated these drastic changes of opinion for this correlations significant. These two participants had no
particular item. Further investigations could have be done to other surprising answers and the two problematic answers
verify whether participants understood this item, especially were not part of the imputed data. We could also verify
when item 9 was also one of the two items that increased the interpretation of these three items to determine if the
Cronbach’s α very slightly (from .79 to .80) when it was participants’ understanding of the question differed.
removed.1 However, this increase is very small and since we
did not observe large variations in Cronbach’s α when items Limits of the study and future research
were removed, we believe this questionnaire is reliable for
An increase in sample size would help to confirm
measuring stigma consciousness. In 1999, Pinel reported
the underlying latent variables of the questionnaires. In
total scores for different populations and versions of this
addition, validation measures targeting stigma need to be
questionnaire. We report a total score that is significantly
conducted on two additional questionnaires that we have
higher than the one reported for women but is quite similar
prepared for use with Canadian-French-speaking adults: the
to the one calculated for men (n = 142, mean 33.5, SD 6.83; International Outcome Inventory - Alternative Interventions
α probability of error .29). (IOI-AI) (Laplante-Lévesque, Hickson, & Worrall, 2012) and
the Expected Consequences of Hearing aid Ownership
Canadian-French Hearing Loss Stigma (HLS)
(ECHO) (Cox & Alexander, 2000). Since this is a first step
questionnaire
in producing two questionnaires in French, it should be
The total score for our questionnaire is significantly lower seen as a preliminary validation, and in that sense, more
than the one reported for mental illness stigma. Scores research is needed to enhance the psychometric qualities
for the discrimination and disclosure subscales are also of those novel questionnaires. Additional validation work is
significantly lower, but the positive aspect subscale is not needed to clarify some of the issues that arose during this
different. We were not surprised to see these differences, first transcultural study (e.g., reproducibility of some items,
1
In both versions of this questionnaire, an asterisk (*) has been added with a footnote to invite the clinicians not to include poorly reproducible items
when computing subscores in longitudinal follow-ups.
missing data, item 9 on the SCQ, factorial analysis, and small & J. Spitzer (Eds.), Advanced practice in adult audiologic rehabilitation:
International perspective (pp. 63–92). San Diego, CA: Plural Publishing Inc.
sample size (N = 32)).
Heine, C., & Browning, C. J. (2002). Communication and psychosocial consequences
Conclusion of sensory loss in older adults: Overview and rehabilitation directions.
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two questionnaires that address the concept of stigma Hétu, R. (1996). The stigma attached to hearing impairment. Scandinavian Audiology
associated with hearing loss. Results indicate that they Supplementum, 43, 12–24.
both have psychometric properties comparable to the Huie, F. (2010). Stigma consciousness and academic achievement: The role of
versions used for the stigma against women and mental self-regulatory processes. Unpublished manuscript, Graduate School of
illness, with the exception of the latent variables, since Education, George Mason University, Fairfax, VA. Retrieved from mason.gmu.
edu/~fhuie/portfolio/AdvancedQuantFinalPaper.doc
they have been slightly modified for the hearing impaired.
Readers who would like to obtain the questionnaires Hyde, M. L. (2000). Reasonable psychometric standards for self-report outcome
measures in audiologic rehabilitation. Ear Hear, 21, 24S–36S.
produced in this study should contact one of the
first two authors of this manuscript. These two novel Jennings, M. B., Southall, K., & Gagné, J. P. (2013). Social identity management
strategies used by workers with acquired hearing loss. Work, 46(2), 169–180.
questionnaires addressing stigma (SCQ and HLS) provide doi: 10.3233/WOR-131760
useful information for clinicians when working with French-
King, M., Dinos, S., Shaw, J., Watson, R., Stevens, S., Passetti, F., & Serfaty, M. (2007).
and English-speaking adults. Clinical implementation The Stigma Scale: Development of a standardised measure of the stigma of
of these questionnaires should be incorporated into mental illness. British Journal of Psychiatry, 190, 248–254. doi: 10.1192/bjp.
bp.106.024638
practice. Since it is more important to address stigma in
clinics than to ignore it, we encourage clinicians to use Kochkin, S. (2007). MarkeTrak VII: Obstacles to adult non-user adoption of hearing
both questionnaires in French and in English but to be aids. Hearing Journal, 60(4), 24–51. doi: 10.1097/01.HJ.0000285745.08599.7f
careful with the interpretation of items having poor or weak Laplante-Lévesque, A., Hickson, L., & Worrall, L. (2012). Comparing response options
reproducibility. For all items where reproducibility is still a for the International Outcome Inventory for Hearing Aids (IOI-HA) and for
Alternative Interventions (IOI-AI) daily-use items. International Journal of
challenge (only four), an asterisk (*) has been added with a Audiology, 51(10), 788–791. doi: 10.3109/14992027.2012.695875
footnote to invite the clinicians not to include them when
Lee, E. H. (2012). Review of the psychometric evidence of the Perceived Stress Scale.
computing subscores. Also, French and English clinicians Asian Nursing Research, 6(4), 121–127. doi: 10.1016/j.anr.2012.08.004
are welcome to email to authors with any suggestions to
Lewis, R. J., Derlega, V. J., Griffin, J. L., & Krowinski, A. C. (2003). Stressors for gay
upgrade item formulation. These novel questionnaires
men and lesbians: Life stress, gay-related stress, stigma consciousness,
could also be used while larger validation studies are being and depressive symptoms. Journal of Social and Clinical Psychology, 22(6),
undertaken, especially with respect to factor analysis, 716–729. doi: 10.1521/jscp.22.6.716.22932
since this was the first time these questionnaires have Marmen, L., & Corbeil, J. P. (2004). New Canadian perspectives. Languages in
been used for older adults with hearing loss. Canada 2001 census (Statistics Canada Cat. No. CH3-2/8-2004). Retrieved
from http://publications.gc.ca/collections/Collection/CH3-2-8-2004E.pdf
Marx, R. G., Menezes, A., Horovitz. L., Jones. E. C., & Warren, R. F. (2003). A
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Acknowledgements
This study was made possible by funding from the
Partnership of the Réseau provincial de recherche en
adaptation-réadaptation (REPAR), the Centre intégré
universitaire de santé et des services sociaux (CIUSSS) du
Centre-sud de l’île de Montréal – Institut Raymond-Dewar,
and the CIUSSS de la Capitale Nationale – Institut de
réadaptation en déficience physique de Québec. Also, we
want to thank the Faculté de médecine of the Université
Laval, which offered a bursary to Audrey Clothier who
completed a summer research internship under one of
the researchers’ supervision. The authors wish to thank
audiologists Dale Bonnycastle and Ronald Choquette for
the back-translations, translator Lorraine Paquet, and the
five participants who contributed to the pre-test.
Authors’ Note
Correspondence concerning this article should be
addressed to Claude Vincent, Centre interdisciplinaire
de recherche en réadaptation et intégration sociale, 525
boulevard Hamel, Office H-1112, Québec (QC), G1M 2S8.
Canada. Email: [email protected].
Appendix A. Hearing Loss Stigma (HLS) Questionnaire (Adapted from King, 2007)
NAME: DATE:
DATE OF BIRTH: MALE FEMALE
Instructions:
You will find below a list of sentences. For each one of them, you need to check off the answer that best
suits you by circling the answer in the appropriate square.
Answer all the questions without exception. Don’t spend too much time thinking about the answer, as it is
your first impression that is important.
1. I have been discriminated against in education because of my hearing problems.
Neither agree
Strongly agree Agree Disagree Strongly disagree
nor disagree
2. Sometimes I feel that I am being talked down to because of my hearing problems.
Neither agree
nor disagree
3. Having had hearing problems has made me a more understanding person.
Neither agree
nor disagree
4. I do not feel bad about having hearing problems.
Neither agree
nor disagree
5. I worry about telling people I received help concerning my hearing problems. *
Neither agree
nor disagree
6. Some people with hearing problems are cognitively challenged. *
Neither agree
nor disagree
7. People have been understanding of my hearing loss.
Neither agree
nor disagree

8. I have been discriminated against by friends and relatives because of my hearing problems.
Neither agree
nor disagree
9. I have been discriminated against by employers because of my hearing problems.
Neither agree
nor disagree
10. My hearing problems have made me more accepting of other people.
Neither agree
nor disagree
11. Very often I feel alone because of my hearing problems.
Neither agree
nor disagree
12. I am scared of how other people will react if they find out about my hearing problems.
Neither agree
nor disagree
13. I would have had a better chance in life if I did not have hearing problems.
Neither agree
nor disagree
14. I do not mind people in my neighborhood knowing I have hearing problems.
Neither agree
nor disagree
15. I would say I have hearing problems if I was applying for a job.*
Neither agree
nor disagree
16. I worry about telling people that I have consulted hearing experts about my hearing problems.
Neither agree
nor disagree
17. People’s reactions to my hearing problems make me keep myself to myself.
Neither agree
nor disagree
18. I am angry with the way people have reacted to my hearing problems.
Neither agree
nor disagree
19. I have not had any trouble from people because of my hearing problems.
Neither agree
nor disagree
20. I have been discriminated against by health professionals because of my hearing problems.
Neither agree
nor disagree
21. People have avoided me because of my hearing problems.
Neither agree
nor disagree
22. People have insulted me because of my hearing problems.
Neither agree
nor disagree
23. Having hearing problems has made me a stronger person.
Neither agree
nor disagree
24. I do not feel embarrassed because of my hearing problems.
Neither agree
nor disagree
25. I avoid telling people about my hearing problems.
Neither agree
nor disagree

26. Having hearing problems makes me feel that life is unfair.
Neither agree
nor disagree
27. I feel the need to hide my hearing problems from my friends.
Neither agree
nor disagree
28. I find it hard telling people I have hearing problems.
Neither agree
nor disagree
* The temporal reproducibility of these items (# 5, 6 and 15) was not observed. Do not take this into account during longitudinal follow-up.
Appendix B. Stigmatisation associée à la déficience auditive or HLS-CF1

NOM : DATE :
DATE DE NAISSANCE : HOMME FEMME
Directives :
Voici une liste de phrases. Pour chacune, encerclez la réponse qui correspond le mieux à votre expérience.
Veuillez indiquer une réponse pour chacune des phrases sans passer trop de temps à analyser les choix de
réponse: c’est votre première impression qui importe.
1. J’ai subi la discrimination durant mes études en raison de mes problèmes d’audition.
Complètement Ni en accord Complètement

En accord En désaccord
en accord ni en désaccord en désaccord
2. J’ai parfois l’impression qu’on me rabaisse en raison de mes problèmes d’audition.

3. Mes problèmes d’audition ont fait de moi une personne plus compréhensive.

4. Je ne m’en fais pas à propos de mes problèmes d’audition.

5. Je crains de dire aux gens que j’ai reçu de l’aide pour mes problèmes d’audition. *

6. Certaines personnes ayant des problèmes d’audition ont des difficultés cognitives. *

7. Les gens se montrent compréhensifs à l’égard de mes problèmes d’audition.

1
Hearing Loss Stigma (HLS) Questionnaire in Canadian French

8. Je subis la discrimination de la part de mes amis et parents en raison de mes problèmes d’audition.

9. Je subis la discrimination de la part d’employeurs en raison de mes problèmes d’audition.

10. Mes problèmes d’audition ont fait de moi une personne qui accepte mieux les autres.

11. Il m’arrive très souvent de me sentir seul(e) en raison de mes problèmes d’audition.

12. Je crains la façon dont les autres personnes réagiront si elles découvrent mes problèmes d’audition.

13. J’aurais eu plus de chance dans la vie si je n’avais pas eu de problèmes d’audition.

14. Cela ne me dérange pas que les gens de mon voisinage soient au courant de mes problèmes d’audition.

15. Je dévoilerais mes problèmes d’audition si je postulais un emploi. *

16. Je crains de dire aux gens que j’ai consultés des spécialistes pour mes problèmes d’audition.

17. Les réactions des gens à mes problèmes d’audition m’amènent à ne pas me livrer.

18. La façon dont les gens réagissent à mes problèmes d’audition me met en colère.

19. Les gens ne m’ont jamais causé d’ennuis en raison de mes problèmes d’audition.

20. Je subis la discrimination de la part de professionnels de la santé en raison de mes problèmes d’audition.

21. Des gens m’ont évité(e) en raison de mes problèmes d’audition.

22. Des gens m’ont insulté(e) en raison de mes problèmes d’audition.

23. Mes problèmes d’audition ont fait de moi une personne plus forte.

24. Je ne suis pas gêné(e) de mes problèmes d’audition.

25. J’évite de dévoiler mes problèmes d’audition aux gens.


26. Mes problèmes d’audition m’amènent à penser que la vie est injuste.

27. Je sens le besoin de cacher mes problèmes d’audition à mes amis.

28. J’ai de la difficulté à dévoiler mes problèmes d’audition aux gens.

* La reproductibilité temporelle de ces items (#5, 6 et 15) n’a pas été observée. Ne pas prendre en compte cet élément lors
d’un suivi longitudinal.
Appendix C. Stigma Consciousness Questionnaire (SCQ) for Hearing Loss

(Adapted from Pinel, 1999)
NAME: DATE:
DATE OF BIRTH: MALE FEMALE
Instructions
Please circle the letter that indicates the extent to which you agree with
each statement listed below.
A. Completely agree
B. Agree
C. More or less agree
D. Neither agree nor disagree
E. More or less disagree
F. Disagree
G. Completely disagree
1. Stereotypes about hearing loss have not affected me personally. A B C D E F G
2. I never worry that my behaviors will be viewed as stereotypical of a person who

A B C D E F G
has a hearing loss.
3. When interacting with people who have normal hearing, I feel like they interpret all my
A B C D E F G
behaviors in terms of the fact that I have a hearing loss.
4. Most people with normal hearing do not judge people with hearing loss on the basis
A B C D E F G
of their ability to hear.
5. My being hearing impaired does not influence how people with normal hearing act with me. A B C D E F G
6. I almost never think about the fact that I have a hearing loss when I interact with people
A B C D E F G
who have normal hearing.
7. My being hearing impaired does not influence how people act with me. A B C D E F G
8. Most people with normal hearing have a lot more prejudicial thoughts about people
A B C D E F G
with hearing loss than they actually express.
9. I often think that people with normal hearing are unfairly accused of having prejudicial
A B C D E F G
thoughts about people with hearing loss. *
10. Most people with normal hearing have a problem viewing people with hearing loss as equals. A B C D E F G
* The temporal reproducibility of this item (# 9) was not observed. Do not take this into account during longitudinal follow-up.

Appendix D. Échelle de la conscience de la stigmatisation personnelle

(associée à la perte d’audition) or SCQ-CF1 for Hearing Loss
NOM : DATE :
DATE DE NAISSANCE : Homme Femme
Directives
Pour chacun des énoncés ci-dessous indiquez votre niveau d’accord ou de désaccord
A. Complètement en accord
B. En accord
C. Plus ou moins en accord
D. Ni en accord ni en désaccord
E. Plus ou moins en désaccord
F. En désaccord
G. Complètement en désaccord
1. Les stéréotypes concernant la perte d’audition ne m’affectent pas personnellement. A B C D E F G
2. Je ne suis jamais inquiet que mes comportements puissent être perçus comme étant
A B C D E F G
typiques d’une personne ayant une perte d’audition.
3. Lorsque je dialogue avec des gens ayant une audition normale, je sens qu’ils interprètent
A B C D E F G
tous mes comportements en fonction du fait que j’ai une perte d’audition.
4. La plupart des gens ayant une audition normale ne jugent pas les gens ayant une perte
A B C D E F G
d’audition en fonction de leur capacité à entendre.
5. Le fait que je suis une personne malentendante n’a aucune influence sur la façon dont les
A B C D E F G
gens ayant une audition normale agissent avec moi.
6. Je ne pense presque jamais au fait que j’ai une perte d’audition lorsque je dialogue avec
A B C D E F G
quelqu’un qui a une audition normale.
7. Le fait que je suis une personne malentendante n’a aucune influence sur la façon dont les
A B C D E F G
gens agissent avec moi.
8. La plupart des gens ayant une audition normale ont beaucoup plus de préjugés à l’endroit
A B C D E F G
des personnes ayant une perte d’audition qu’ils ne le disent en réalité.
9. Je crois souvent que les personnes ayant une audition normale sont injustement accusées
A B C D E F G
d’avoir des préjugés envers les personnes qui ont une perte d’audition. *
10. La plupart des gens qui ont une audition normale ont de la difficulté à considérer les
A B C D E F G
personnes qui ont une perte d’audition comme étant des égaux.
* La reproductibilité temporelle de cet item (#9) n’a pas été observée. Ne pas prendre en compte cet élément lors d’un suivi
longitudinal.
1
Stigma Consciousness Questionnaire (SCQ) for Hearing Loss in Canadian French
EVALUATION OF AUDIOLOGY SIMULATION TRAINING Canadian Journal of Speech-Language Pathology and Audiology (CJSLPA)
Students’ Evaluation of Audiology Simulation Training
L’évaluation des étudiants d’une formation en

audiologie utilisant des mises en situation
KEY WORDS Ahmad A. Alanazi

audiology Nannette Nicholson
case scenarios
debriefing
education
evaluation
manikins
simulation
standardized patients
standardized parents
Abstract
The use of simulation in the field of audiology as a strategy and tool for teaching and learning
in clinical education programs is increasing. Eliciting feedback from students is important to
design, improve, and implement successful simulation learning experiences. Yet, few simulation
studies have reported outcomes of student feedback following simulation training. The purpose
of this study was to explore students’ perceptions of the simulation training components
following 3 simulated hearing screening and parent counselling scenarios. Seventeen Doctor
of Audiology (Au.D.) students participated in a simulation training, which included the use of
a manikin, standardized parents, 3 case scenarios, debriefing sessions, and assessment. This
cross-sectional mixed-methods study used a 12-item survey to elicit feedback from the students’
perspective about simulation training components. This survey consisted of 10 statements with a
Likert scale rating response methodology (1 = strongly disagree, 7 = strongly agree) and 2 open-
ended questions to elicit written comments. Participants completed the feedback perception
Ahmad A. Alanazi,
King Saud bin Abdulaziz tool after the final case scenario. Overall, students agreed or strongly agreed (M = 6.74, SD =
University for Health Sciences, 0.32) that the simulation event enhanced their learning experience and opportunities for quality
Riyadh, Saudi Arabia improvement were identified. Results showed student appreciation and recognition of the
simulation training as adding value and enhancing their learning experience. Attention to details,
Nannette Nicholson, organization, adequate time, participants’ feedback, and evaluation when planning and preparing
University of Arkansas
for Medical Sciences,
simulation training is one way to achieve higher participant satisfaction levels. Additional research
Little Rock, Arkansas, on student perception of simulation training components will provide evidence to inform future
USA simulation training.
289 Students’ Evaluation of Audiology Simulation Training Volume 41, No. 3, 2017
Revue canadienne d’orthophonie et d’audiologie (RCOA) EVALUATION OF AUDIOLOGY SIMULATION TRAINING
Abrégé
Il y a une augmentation de l’utilisation de mises en situation comme stratégie et outil de formation
et d’apprentissage dans les programmes d’enseignement clinique du domaine de l’audiologie. Une
rétroaction de la part des étudiants est importante pour la conception, l’amélioration et la réussite
de l’implantation d’expériences d’apprentissage utilisant des mises en situation. À ce jour, peu
d’études ont recueilli la rétroaction d’étudiants ayant participé à des mises en situation. L’objectif
de cette étude était d’explorer la perception des étudiants à l’égard de diverses composantes
de mises en situation cliniques, et ce, après qu’ils aient participé à trois scénarios simulant des
dépistages auditifs et du counseling à des parents. Dix-sept étudiants au doctorat en audiologie
ont participé à une formation utilisant des mises en situation et comprenant l’usage d’un
mannequin, de « patients simulés », de trois scénarios de cas, de périodes de discussion guidée
entre le participant et l’animateur (debriefing sessions) et d’évaluations. Cette étude transversale
à méthodes mixtes a utilisé un sondage composé de 12 items pour recueillir la rétroaction des
étudiants concernant les différentes composantes d’une formation utilisant des mises en
situation. Ce sondage comprenait 10 énoncés utilisant une échelle de Likert (1 = fortement en
désaccord, 7 = fortement en accord) et deux questions ouvertes pour susciter des commentaires
écrits. Les participants ont complété le sondage à la fin du troisième scénario. De façon générale,
les étudiants ont indiqué qu’ils étaient en accord ou fortement en accord (M = 6.74, ET = 0.32) avec
le fait que les mises en situation avaient optimisé leur expérience d’apprentissage et ils ont identifié
des améliorations potentielles de qualité. Les résultats ont montré que les étudiants appréciaient
et reconnaissaient la valeur ajoutée d’une formation utilisant des mises en situation sur leurs
apprentissages. L’attention portée aux détails, à l’organisation, à la durée, à la rétroaction des
participants et à l’évaluation lors de la planification et de la préparation d’une formation utilisant
des mises en situation sont plusieurs façons d’obtenir un taux de satisfaction plus élevé de la part
des participants. Des recherches supplémentaires recueillant la perception des étudiants à l’égard
des composantes d’une formation utilisant des mises en situation fournira des évidences afin de
façonner les futures formations utilisant cette méthode d’apprentissage.

Simulation is one of the most valuable innovations in simulation accuracy of imitating reality determines the
clinical education, and is defined as “an act of imitating the level (i.e., low, mid, or high) of manikin fidelity (Issenberg &
behavior of a physical or abstract system, such as an event, Scalese, 2008; Wu & Shea, 2009). Low-fidelity manikins are
situation or process that does or could exist” (Baek, 2009, p. frequently used in medicine because of their lower cost
27). Simulation has become an accepted strategy in clinical and the potential for repetitive use (Grober et al., 2004). A
education and training for healthcare professionals for two common misconception reported in the literature is that a
reasons: (a) increased attention to and emphasis on patient high-fidelity simulation is better than a low-fidelity one. High-
safety, and (b) evidence-based efficiency of simulation fidelity simulation is useful for skills involving interactions
as a learning experience. Simulation training improves between students’ cognitive and hands-on skills, as well
technical skills (Cook, 2014; Karakus, Duran, Yavuz, Altintop, as interaction with other healthcare personnel in the
& Caliskan, 2014; Ohtake, Marchilene, Schillo, & Rosen, same simulation training (Gaba, 2006). Maran and Glavin
2013) and non-technical skills, such as critical thinking and (2003) suggest that manikins, regardless of their fidelity, are
decision-making (Lapkin & Levette-Jones, 2011; Wotton, almost all potentially useful, but because of a lack of clear
Davis, Button, & Kelton, 2010). Simulation supports student educational goals, many manikins are insufficiently used.
practice with no fear of harming patients, thus reducing
error and anxiety (Dearmon et al., 2013; Yule, Flin, Paterson- Manikins can be either controlled by an operator (e.g., a
Brown, & Maran, 2006). The use of simulation as a learning facilitator), or are automated (i.e., autonomous), changing
environment is an innovative method for training audiology status according to the intervention (Epps et al., 2014). The
students; however, the use of simulation in audiology is use of manikins as a teaching and assessment tool has
still in its earliest stages (Alanazi et al., 2016). Simulation recently been reported in the field of audiology (Alanazi et
training can be divided into two categories: (a) simulation al., 2016; Kaf, Masterson, Dion, Berg, & Abdelhakiem, 2013).
environment and (b) learning experience. These categories However, few manikins are available to train audiology
consist of several important components, such as manikins, students. For example, Baby Isao, manufactured by
safe environments, case scenarios, standardized patients Intelligent Hearing Systems (2016), is a high-fidelity manikin
(SPs), facilitators, debriefing, and students’ satisfaction. that can be used to teach infant hearing screening and
diagnostic techniques (i.e., otoacoustic emissions [OAEs]
Simulation environment and auditory brainstem responses [ABRs]). OAEs are
sounds emitted by the cochlea, either spontaneously or
The simulation environment is a physical place evoked by an auditory stimulus. ABRs are neuroelectrical
where simulation training is conducted and where the signals (or auditory evoked potentials) generated by the
facilitator creates a friendly learning atmosphere (i.e., a auditory nerve and brainstem in response to an auditory
safe environment), focuses on the learning objectives, stimulus. The simulator used in the current study consisted
and manages time (Fanning & Gaba, 2007; Meakim et al., of the Baby Isao doll, the simulator box, a laptop computer,
2013; Rall, Manser, & Howard, 2000). The simulation facility and software.
requires space, staff (e.g., facilitators and technicians),
technology (e.g., video-playback systems and cameras), Learning experience
roles, objectives, time allocation, manikins with different
fidelities (i.e., low, mid, or high fidelities), observing and Standardized patients (SPs). SPs are trained actors
debriefing rooms, adequate funding, access to SPs, who mimic or present particular scenarios. Prior to the
etc. Orientation to the simulation environment before use of SPs, training and evaluating healthcare students
simulation training is also a critical part of creating the safe was performed by observing students’ clinical skills with
environment. All of these requirements help in providing real patients (Stillman et al., 1986). This method was
successful educational experiences. not efficient due to the differences between patients in
terms of symptoms and other situational factors such
Although “simulation is a technique, not technology” as appointment time, attendance, and difficulties with
(Gaba, 2007, p. 126), simulation training often depends on accommodation of all students to observe one case. Thus,
manikins. The use of manikins can enhance the students’ other training and evaluation methods were developed to
learning experience because of their advanced capabilities assess healthcare students’ skills, one of which is the use
and outputs, such as physiological changes (Epps, White, of SPs (Howley, 2013). The use of SPs has become one
& Tofil, 2014). Manikins have been successfully used in of the most common forms of physical examination and
both learning and assessment of clinical skills to achieve communication skills assessments in medical education
many learning objectives (Blackstock & Jull, 2007). The (Epstein & Hundert, 2002). In audiology, there is shortage of
published studies that use SPs as an educational method process, including: (a) reactions, (b) description, (c)
(Alanazi et al., 2016). analysis, and (d) summary. This approach focuses on
identifying positive aspects of the training (what went well)
Case scenario. The case scenario structure and as well as negative aspects (what could have gone better),
content depend on the purpose of using SPs (i.e., the while eliciting suggestions regarding aspects they would
goal of the SP encounter). If the learning expectations change if given another opportunity. The goal is to use
of the simulation training are set at high learning levels context-specific factors, including choice of approach,
(e.g., students implement all the core competencies of time availability, students’ rationale for action, and learning/
interprofessional collaborative practice: (a) values and performance gap between objectives and knowledge, skills,
ethics, (b) roles and responsibilities, (c) interprofessional or behaviours, thereby facilitating and maximizing clinical
communication, and (d) teams and teamwork), then decision-making (Eppich & Cheng, 2015).
a detailed case scenario is needed to meet all of the
objectives (Howley, 2013; Interprofessional Education Debriefing is still considered the underdeveloped part
Collaborative Expert Panel, 2011). Although efforts of simulation training (Neill & Wotton, 2011). Participation in
to develop a guide for preparing SP case scenarios in debriefing is expected to increase the participants’ ability to
healthcare simulation have been proposed (Baile et al., transfer knowledge to real situations (Halm, Lee, & Franke,
2000; Cahill, 2015; Kim et al., 2006; Seropian, 2003), there 2011). For example, Ryoo and Ha (2015) explored the effect
remains a shortage of developed SP cases and related between the use and non-use of debriefing on clinical
materials in the literature (Howley, 2013). For example, performance competency among 49 second-year nursing
Seropian (2003) suggests that case scenarios include students. They found that the debriefing group (n = 24)
several elements: (a) objectives, (b) personnel and scored significantly higher than the non-debriefing group
equipment, (c) computer setup and operator instructions, (n = 25) in communication skills and in another 15 skills in
(d) paperwork and supporting documentation, (e) context, the psychomotor domain. Similarly, Shinnick, Woo, Horwich,
(f) knowledge and teaching information, (g) references and Steadman (2011) examined the difference in knowledge
related to the objectives, and (h) notes for further of heart failure among 162 students who were assigned into
improvement of the scenarios. Kim et al. (2006) report debriefed and non-debriefed groups. Debriefed students
that case scenarios should be: (a) relevant, (b) realistic, (c) showed an increase in knowledge of heart failure. Morgan
engaging, (d) challenging, and (e) instructional. Generally, et al. (2009) divided 71 anesthesiologists into two groups
SPs could be involved in the simulation training in three (debriefed and non-debriefed) and found that the non-
ways: (a) the pre-encounter stage, where information debriefed group scored lower on technical skills.
about the SP is given to the student before the actual
encounter; (b) the encounter stage, where the student Facilitator. The role of the facilitator can be filled
meets the SP; and (c) the post-encounter stage, where by a trained simulation facilitator, faculty member, or
feedback is given to the student by the SP (Dinsmore, student, depending on the level of facilitation needed:
Bohnert, & Preminger, 2013). high, intermediate, or low (Fanning & Gaba, 2007). The
debriefing process and role of the facilitator are integrally
Debriefing. Debriefing is a process following the related. While the literature suggests using debriefing as an
simulation exercise consisting of a guided discussion integrated component of healthcare simulation training,
between facilitators and participants in an effort to enhance few studies report outcomes of the debriefing process
understanding of what went well and what could have or debriefing practices, particularly in audiology (Alanazi,
gone better during the simulation exercise. Debriefing Nicholson, & Thomas, 2017). Fanning and Gaba (2007)
helps participants connect what they have learned in the stated, “There are surprisingly few papers in the peer-
simulation training with previous knowledge to enhance reviewed literature to illustrate how to debrief, how to teach
their learning (Fanning & Gaba, 2007). There is no standard or learn to debrief, what methods of debriefing exist, and
structure of the debriefing process; nevertheless, several how effective they are at achieving learning objectives and
models have been proposed to help educators organize goals” (p. 115). Recognizing this gap in information, Lusk
the structure, such as the Guidelines, Recommendations, and Fater (2013) explored the debriefing process and role
Events, Analysis, and Transfer (GREAT) model and the of the facilitator and debriefing process across disciplines
Promoting Excellence and Reflective Learning in Simulation such as aviation, psychology, education, medicine, and
(PEARLS) framework (Dufrene & Young, 2013; Eppich nursing, and identified common themes and practices. A
& Cheng, 2015; Owen & Follows, 2006). The PEARLS common practice is the use of Tanner’s model of clinical
framework specifies four distinct phases of the debriefing judgment to facilitate critical thinking and clinical decision-

making skills. This model incorporates four phases, of these assessment tools and/or the contribution of
including: (a) noticing, (b) interpreting, (c) responding, the results to quality improvement efforts in planning
and (d) reflecting. This continuous cycle of moving in and subsequent simulation training are limited.
out of phases (reflection-in-action and reflection-on-
action) provides students with opportunities to practice Alanazi et al. (2017) conducted a systematic review of
generalization and application of clinical judgment (Lusk publications in health professions to identify and evaluate
& Fater, 2013). Thus, the debriefing process within the the best available evidence (level and quality) of the use of
simulation training session serves as a platform to coach simulation training to improve clinical skills, knowledge, and
and assist students as they learn to apply and generalize self-confidence among healthcare students. The authors
skills. The PEARLS framework of facilitation can be reported that only seven of 30 reviewed studies reported
used in conjunction with Tanner’s model of clinical students’ satisfaction. When all the simulation-training
judgment to optimize student learning outcomes and skill components are put together appropriately, a high level
development. of satisfaction among participants is expected. Student
participants’ satisfaction is important in clinical education
Why students’ perception of the simulation training because it may correlate with performance and may help
is important students develop skills and acquire knowledge (Bremner,
Training students in the simulation facilities needs Aduddell, Bennett, & VanGeest, 2006; Pike, 1991). Thus, the
to be meaningful for students. The use of evaluation purpose of this study was to explore students’ perceptions
tools of students’ perceptions is a method to increase and satisfaction with the hearing screening and parent
meaning, deepen the learning experience, gather more counselling simulation training.
information about student preferences, and plan for quality
Methods
improvement of the simulation training. Implementation
of evidence-based educational practices requires an This study was conducted at the University of Arkansas
approach in which current, high-quality, rigorous research for Medical Sciences (UAMS) Simulation Center and
evidence is integrated with educator expertise and student received the UAMS Institutional Review Board approval
preferences (Coalition for Evidence-Based Policy, 2003). (#204279). The simulation training consisted of pre-event
Therefore, the evaluation of the simulation training by exposure to knowledge, three case scenarios with specific
students is critical in building and designing successful objectives relevant to newborn hearing screening and parent
simulation training (or simulation programs). counselling, and the combined use of Baby Isao with SPs in
the role of standardized parents, who are in the position of
The evaluation of the simulated training differs from making informed decisions that will impact their child’s future
the assessment of students’ performance and learning (e.g., parents choose spoken or signed language as a method
outcomes, which use assessment tools such as the of communication for their child). The content and format of
Audiologic Counseling Evaluation (Adamson, Kardong- the simulation case scenarios used in this study are shown
Edgren, & Willhaus, 2013; English, Naeve-Velguth, Rall, in Table 1 and have been previously described in detail by
Uyehara-Isono, & Pittman, 2007). Many evaluation
Alanazi and colleagues (2016).
tools have been developed that focus on student self-
reports of their perception and/or satisfaction with the
Participants
simulation training (Alanazi et al., 2016; Alinier et al., 2008;
Levett-Jones et al., 2011). While verbal debriefing is the Seventeen female Doctor of Audiology (Au.D.) students
more common procedure to facilitate learning following (M age = 24.59 years, SD = 1.50, range = 22–29 years; Au.D.
simulation training, Lestander, Lehto, and Engström cohort = second- and third-year students) participated
(2016) suggest that the post-simulation evaluation serve as volunteers in this study. The role of students in the
as another opportunity for student reflection. Petranek simulation training was either as active or passive (observer)
(2000) suggests a written reflection as an efficient participants. Six students (two students in active roles, one
learning strategy, while Baikie and Wilhelm (2005) propose from each year in the program, per scenario) conducted
that written words facilitate expression of experiences the hearing screening and counselled the parents, whereas
that are too sensitive to describe face-to-face. The use of the remaining students (passive role) watched the case
open-ended questions is recommended to generate new scenarios unfold on a large screen monitor through the
information that may have otherwise been overlooked closed-circuit video system. All students participated in the
(Knudsen et al., 2012). However, reports on the use briefing and debriefing sessions.
Table 1. Standardized Parents and Case Scenarios
Standardized Parent Case Scenario
The baby failed the screening. The mother accepted the results and
One ethnically diverse standardized parent refused the follow-up diagnostic evaluation due to religious and
cultural beliefs.
The baby passed the hearing screening. A certified sign language

Two standardized parents (culturally deaf in
interpreter was recruited. The parents were unhappy because their
real life and in the scenario)
baby passed the screening.
The baby failed the screening. The father was angry and blamed the
Two standardized parents mother, who was a musician, because she exposed the child to loud
music in utero.
Simulation training any part of the simulation training that did not meet your
Two types of simulation were used in this study: (a) expectations”.
one manikin, Baby Isao, and (b) five trained standardized
parents, and one sign-language interpreter representing Procedures
three different case scenarios (Table 1). Each scenario Student participants completed a pre-training
consisted of a 10-minute briefing session, a 20-minute curriculum about newborn hearing screening training on the
simulation experience (i.e., hearing screening and National Center for Hearing Assessment and Management
counselling parents), and a 30-minute debriefing session (2015) website and had observed 10 hours of neonatal
guided by an experienced facilitator. hearing screening as part of their clinical rotations at
Arkansas Children’s Hospital prior to the simulation. In
Materials addition, students were given the opportunity to practice
A 12-item perception survey (Appendix A: Students’ conducting hearing screening with Baby Isao on their own
Perception of Simulation Training Components [SPSTC] before the simulation event. Details about the upcoming
survey) consisting of 10 statements and two open-ended simulation training were not provided prior to the event.
questions was developed by the UAMS Simulation Center On the day of the simulation event, two student volunteers
personnel to include the critical components of simulation were randomly selected by the facilitator prior to each case
training as discussed in the literature. This survey was to perform the hearing screening and break bad news (e.g.,
modified by the authors to collect students’ perceptions a baby has a hearing loss) and counsel the standardized
and feedback about this training through three aspects: (a) parents about the next steps in the process. The remaining
the simulation environment, (b) the learning experience, student watched the simulated scenarios via a widescreen
and (c) the highlights of the simulation training. Students video monitor in a separate room. The debriefing sessions
were asked to rate their level of agreement with the were structured using the PEARLS framework and were
simulation training categories based on a Likert scale, where guided by a trained simulation facilitator familiar with the
1 = strongly disagree (very dissatisfied) and 7 = strongly learning objectives. Tanner’s model of clinical judgment
agree (very satisfied). Participants were instructed to was used to facilitate critical thinking and clinical decision-
use “not applicable” if a statement did not pertain to the making skills (Lusk & Fater, 2013). Audiology faculty
simulation training performed. Statements rated as “not members participated in the briefing and debriefing
applicable” were not assigned a numeric value and were sessions, and the standardized parents participated in the
eliminated from the average ratings. Each participant was debriefing session in which they performed. The three case
given an opportunity to provide short answers to inquiries scenarios were completed sequentially in one day. The total
about the third category (i.e., the highlights of the simulation simulation training was completed in about three hours. After
training). The two open-ended inquiries designed to elicit the final case scenario, the SPSTC survey was distributed
additional information were: (a) “Describe any part of the and students were asked to complete the evaluation of the
simulation training that was exceptional” and (b) “Describe simulation training prior to leaving the centre.

Results student ratings for items 1 (suitability), 2 (well-equipped),

Quantitative and qualitative results of the responses to and 3 (safety). Of the total students, two passive students
the SPSTC survey are presented for three aspects of training: (#1 and #5) strongly disagreed with the following statement:
(a) simulation environment, (b) learning experience, and (c) “The orientation to the simulation was suitable” (item 1).
highlights of the learning experience. Descriptive statistics One student (#13) rated the statement “The simulation
are presented for items 1–10 and a thematic analysis is center was well equipped” (item 2) as not applicable. This
presented for items 11 and 12. Items 1–10 were rated using student’s response was eliminated from the analysis.
a Likert scale, where 1 = strongly disagree and 7 = strongly
agree. Responses rated as not applicable were eliminated Learning experience
from the analysis. Overall, these results suggest that the The overall mean of responses for this category (items
majority of students agreed or strongly agreed that the 4–10) was 6.93 (range = 1–7, SD = 0.11). Student perceptions
simulation training event enhanced their learning experience of the following items were elicited: item 4 = case scenario,
(M = 6.74, SD = 0.32, range = 6–7). An additional analysis 5 = debriefing, 6 = reflection, 7 = facilitator, 8 = standardized
was conducted to explore specific feedback responses parents, 9 = feedback, and 10 = application. The statement
about the simulation environment (items 1–3), the learning “The learning experience will help me in my clinical practice”
experience (items 4–10), and highlights of the learning (item 10) was the only item rated with “strongly agree” by all
experience from the students’ perspective (items 11–12). students. Five passive student participants (#8, #10, #12,
#13, and #16) rated “The debriefing sessions helped me
Simulation environment reflect on my practice” statement (item 6) as not applicable.
The overall mean for items 1–3 was 6.51 (range = 1–7,
SD = 0.77), based on a Likert scale where 1 = strongly Highlights of the simulation training

disagree and 7 = strongly agree. Figure 1 shows the mean Although the amount of qualitative data (i.e., responses

Simulation Environment
7
6
5 Item 1
Rating
4 Item 2
Item 3
3
2
1
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Students
Figure 1. Simulation environment ratings for items 1–3 on the perception survey are
Figure 1. Simulation environment ratings for items 1–3 on the perception survey are shown by participant (N = 17). Simulation
shownratings
training by participant
were 1 = strongly(N = 17).
disagree to 7 Simulation
= strongly agree. training ratings
Note. Student #13 ratedwere
item 21as=
notstrongly
applicable, disagree
so there
to only
are 7 =two strongly
responses. Item 1 =Note:
agree. Student
“The orientation #13 rated
to simulation item 2 item
was suitable”; as not applicable,
2 = “The so there
simulation center are
was well
equipped”; item 3 = “The simulation environment felt safe for participation”.
only two responses. Item 1 = “The orientation to simulation was suitable”; item 2 =
“The simulation center was well equipped”; item 3 = “The simulation environment
295 felt safe
Students’ forof Audiology
Evaluation participation”.
Simulation Training Volume 41, No. 3, 2017
to open-ended statements: items 11 and 12) was not huge, without affecting real patients.” Of the total students, 17%
these responses were imported into NVivo qualitative identified the use of the standardized parents, 12% the
data analysis software (QSR International Pty Ltd., 2015). case scenarios, and 12% the debriefing component as the
The frequency of thematic concepts was identified. highlights of the simulation training. For instance, student
The deductive qualitative content analysis (i.e., themes #11 stated, “The actors were exceptional.” Student #2
[simulation components] in this approach are already reported, “The case scenarios were so realistic.” Moreover,
known from the survey) was used to explore these student #8 described the case scenarios as “Such realistic
responses generated from the open-ended statements scenarios- ones that we do not see often and could
(Burnard, Gill, Stewart, Treasure, & Chadwick, 2008). An use some hands on with!” Student #6 commented on
open coding procedure was performed by reading each debriefing with, “The debriefing helped a lot. I learned so
response to these statements and making notes next much to take into my daily practice.” Six percent of the
to key words of the responses. The five most frequently students suggested that more structured briefing during
presented themes are shown in Figure 2. The brackets the orientation session would be helpful to be familiarized
within quotations are used to clarify meaning and provide a with the simulation environment. One student noted that
brief explanation. briefing did not meet her expectations: “We [students] need
to know more before setting, what is expected of us [to do in
More than half of student participants (53%) reported the simulation environment]?”
that all of the training components were exceptional,
without referring to an individual component. For example, Discussion
student #3 said, “Everything was wonderful. I really did To evaluate the simulation training from the students’
not realize how valuable of an experience this would be.” perspectives, a post-event evaluation survey was used
Student #7 said, “I loved this experience. It would be great to to elicit feedback about three major components of
have the opportunity to have a rotation here for all of us in the simulation training: (a) simulation environment, (b)
the future. If not this, more events like this would be great!” learning experience, and (c) highlights of the simulation
The remaining students reported individual components training. Results and findings from the current study
as the highlights of the simulation training. Six percent of suggest that the simulation training enhanced students’
the students indicated safety of the environment as the perception of the learning experience. These results are
most exceptional component of the simulation training. For consistent with previous studies that reported students’
example, student #1 described the exceptional component satisfaction (Alanazi et al., 2016; Dearmon et al., 2013;
of the simulation training as “Practice with counseling Ohtake et al., 2013).
Highlights of the Simulation Training
100
80
Percentage
60
40
20
0
Safe Standardized Case Debriefing All
Environment Parents Scenarios Components
Thematic Analysis
Figure 2. Simulation training components that were exceptional according to the

students’
Figure 2. Simulation descriptions
training componentsand thatthe number
were of participants
exceptional who
according to thereferred
students’todescriptions
each of theand the number of
participants whothemes
referred 17).ofNote:
(Nto=each “All Components”
the themes indicates
(N = 17). Note. “All the responses
Components” demonstrating
indicates the responsesthat
demonstrating
that everything was exceptional
everything wasabout the simulation
exceptional environment
about the simulation andenvironment
learning experience.
and learning experience.

Simulation environment audiology student’s first time participating in simulation

Orientation. The vast majority of simulation activities training at the Simulation Center, it may be that the student
take place in simulation centres, teaching hospitals, misunderstood the statement and thought it referred
and medical schools (Passiment, Sacks, & Huang, 2011). to audiology equipment as opposed to the Simulation
Orientation to the simulation environment before a Center equipment or facility. One quality improvement
simulation activity is necessary, because it allows students modification may be to restate this item as “The simulation
to become familiar with simulators, roles, objectives, and center facility was well-equipped”. This rewording may help
time allocation (Meakim et al., 2013). Lack of introduction clarify the intent of this item.
may contribute to a feeling of anxiety and may leave Safety. The simulation training is a learning environment
students feeling underprepared and unable to apply the and should be physically comfortable (i.e., feeling safe
knowledge and practice the skills. In the current study, and relaxed expressing oneself and emphasizing trust).
two students strongly disagreed with the statement, “The Meakim et al. (2013) defined the safe training environment
orientation to the simulation was suitable” (item 1). Although as “the emotional climate that facilitators create by the
all students had completed the newborn hearing screening interaction between facilitators and participants. In this
training module before the actual simulation training, no positive emotional climate, participants feel at ease taking
additional details about the upcoming event were given risks, making mistakes, or extending themselves beyond
to students. Instructions were limited in that students their comfort zone” (p. S9). Without such an environment,
knew they would be participating in an event at the UAMS the simulation training may be restricted to achieve its goals.
Simulation Center with no further details about the event. All students in the current study rated the statement “The
Giving learners detailed information in advance about simulation environment felt safe for participation” (item 3)
the patient’s condition and what was going to happen in with “agree” or “strongly agree”, indicating that they felt that
the encounter stage would (a) reduce the benefits of the it was a safe setting to practice and learn through action and
simulation training because learners would lose the ability interaction with the standardized parents.
to understand the learning objectives by themselves, and
(b) remove the element of surprise (Alinier, 2011). However, Learning experience
it is recommended that facilitators provide general learning
objectives from which learners cannot predict exactly Standardized patients. SPs are not intended to
what will happen in the scenarios. Students’ feedback replace experience with real patients, but they are used
presents faculty and facilitators with an opportunity for to teach and evaluate clinical skills and knowledge in a
quality improvement in execution of the case scenarios in safe environment (Barrows, 1993; Stroud, Smith, Edlund,
subsequent simulation training. In addition, lessons learned & Erkel, 1999). Because of the numerous advantages of
point toward the need to offer better general descriptions the use of SPs, many health professions have used SPs
of the tasks that the students are expected to complete as a standard teaching approach; therefore, audiology
during future training sessions. programs are encouraged to use SPs as standard practice
for their students. In the present study, the standardized
Equipment. Sixteen student participants in our parents, who were professional actors with prior paid
study agreed or strongly agreed with the statement “The experience, were included to train students on how to
simulation center was well equipped” (item 2). One reason deliver bad news and counsel parents. Therefore, the
for the high rating of this component may be the fact that standardized parents were reliable in imitating the case
the current study was conducted in the UAMS Simulation scenarios and provided participants with helpful advice.
Center. The Simulation Center contains seven simulation Patient feedback is important in terms of pointing out
theatres fully equipped with high-fidelity manikins, overhead strengths and weaknesses of students’ skills, and SPs offer
viewing cameras, panoramic wall-mounted units, and five this feedback from the patients’ perspective (Howley &
debriefing classrooms. The use of Baby Isao, involving Martindale, 2004). This feedback is typically not available
various patient states and background noise conditions with real patients. Therefore, the standardized parents
for demonstration and simulation purposes to teach in our study participated in the debriefing session in
hearing screening, was unique. One student rated this item which they performed. One of the standardized parents
(item 2) as not applicable. The authors explored why this commented on active student participants, “There were a
student might not have understood the relevance of this lot of points where you all definitely did things that put us
item, inappropriately marking it as not applicable. Since at ease. Your tones of voice were very calming. And you all
audiology is an equipment-intensive field, and this was the made really good eye contact.” All student participants in
our study rated statements relevant to the standardized skill (and professional competencies generally) in specific
parents’ performance (items 8 and 9) with “agree” or content areas (Council for Academic Accreditation,
“strongly agree”. American Speech-Language-Hearing Association, 2016).
Although ASHA may not consider debriefing hours as
It is generally recognized that the use of SPs limits direct patient contact hours, this activity is equivalent to
the number of active student participants that can be a “case conference” or review of a case following a clinical
efficiently accommodated at a time (Bearnson & Wiker, encounter, and can be recorded as hours for the “other”
2005). In this study, the role of six students was active (i.e., category. Decisions about how to count the time invested
they performed the hearing screening and encountered in debriefing activities following simulation are left to the
the standardized parents), while the role of the remaining interpretation and discretion of each accredited program.
students was passive (i.e., observation of the encounters
with the standardized parents). Active students may have In our study, the facilitator used the PEARLS model
recognized more areas for improvement through active that helped to understand how and where students (a)
participation in the simulation sessions as opposed to expressed their feelings and thoughts, (b) described the
passive participation. However, regardless of the role in the learning experience, (c) followed a guided reflection, and (d)
simulation training, all student participants strongly agreed reviewed all the objectives through the facilitator guidance.
that the learning experience was beneficial and would The analysis phase of this model included a plus-delta
help them in their clinical practice (item 10). Comments analysis (+/Δ), in which the participants, observers, and
provided in response to the open-ended questions the standardized parents reflected on the performance,
indicated that some students believed that assignment to including positive aspects (the +) as well as aspects they
the active role would be a beneficial learning experience would change in the future (the Δ). Student participants
for all students. Quality improvement efforts will focus on in our study either agreed or strongly agreed with the
implementation of this suggestion in future training. statement “The debriefing sessions were well prepared”
(item 5). Debriefing was rated by student participants as an
Case scenarios. The case scenarios must reflect reality exceptional component of their simulation training (item
as much as possible. In the current study, all three stages 5). Although simulation training research always refers to
of the use of the standardized parents in the simulation debriefing, attention to the systematic analysis of debriefing
training (i.e., the pre-encounter, encounter, and post- data is rare (Neill & Wotton, 2011; Wotton et al., 2010).
encounter stages) were implemented. Moreover, three
scenarios were designed to represent diverse cultural and Furthermore, the reflection component has been used
socioeconomic backgrounds and incorporate a variety of effectively as part of a pedagogical approach in audiology
emotional responses: an angry parent, parents from deaf and communication sciences and disorders, and benefited
culture experiencing grief, and a parent from a minority students (Chabon & Lee-Wilkerson, 2006; Goldberg,
population displaying acceptance of hearing loss for cultural Richburg, & Wood, 2006; Munoz & Jeris, 2005; Ng, Bartlett,
and religious beliefs. These scenarios required clinical & Lucy, 2012). The majority of student participants in our
judgment “in action” to quickly make a decision about the study rated the statement “The debriefing sessions helped
best way to respond to the situation. Following completion me reflect on my practice” (item 6) with “agree” or “strongly
of the case, students were given an opportunity to use agree”. However, five students rated the same item as not
reflection “on action” about their choices and to discuss applicable. Authors examined the student’s roles as active
what went well, what did not go well, and what could have or passive participants and found that the students rating
gone better. All students agreed or strongly agreed that the item as not applicable were passive participants.
the case scenarios seemed realistic (item 4). The detailed
preparation, practice, and implementation of scripts Facilitator. An experienced debriefing facilitator may
contributed to the high satisfaction levels. apply different techniques to guide the conversation
and provide beneficial feedback. Moreover, the facilitator
Debriefing. The structure of debriefing sessions is may create a friendly learning atmosphere, focus on the
very important and can be achieved by using any of the learning objectives, and manage time (Fanning & Gaba,
debriefing models. Accrediting organizations such as the 2007; Lederman, 1992; Rall et al., 2000). The perception
Council for Academic Accreditation (CAA), an organization of the simulation training is connected to the facilitator’s
under the American Speech-Language-Hearing Association skills (Fanning & Gaba, 2007). In high debriefing, the
(ASHA), require Au.D. programs to provide evidence that facilitator assists only if needed and the participants debrief
their students are able to demonstrate knowledge and themselves; in contrast, participants depend totally on the

facilitator in low debriefing. Intermediate debriefing requires with the use of a written reflection structured according
less facilitator involvement than low debriefing. Our study to Tanner’s model to assess clinical decision-making
required a high facilitation level because of the challenging development and judgment in simulation, a qualitative
scenarios incorporated in our simulation event. Student study has the potential to generate new knowledge that may
participants in our study either agreed or strongly agreed have been unnoticed with the time-constrained, open-
with the statement “The facilitator was supportive” (item 7). ended feedback approach used in this study.
Simulation training highlights Limitations and future research

Repetitive practice is recognized as one of the best One limitation of this study is the small sample size. The
methods to facilitate learning (Bradley, 2006; Morey et convenience sample was composed of students enrolled
al., 2003). Therefore, assessment of student satisfaction in one Au.D. program. No attempt was made to control for
in simulation is important in terms of guiding quality participant ethnicity, gender, or age. The evaluation process
improvement efforts for future training. Satisfaction was limited to the students’ perspectives on the simulation
does not equal increased knowledge and skill; however, training components and did not measure professional
correlation of students’ perceptions and performance competencies in any specific area. Additional comparative
suggests that simulation may build self-confidence, which information could have been gained by including
in turn helps students develop skills and acquire knowledge faculty, facilitators, and the standardized parents in the
(Bremner et al., 2006). Alanazi and colleagues (2016) assessment. Finally, the topic of this simulation training was
assessed Au.D. students’ satisfaction after simulation broad enough that it could have easily been expanded in
training on hearing screening and parental counselling via an academic health centre as an interprofessional training
a 23-item satisfaction survey. The authors reported that all opportunity to include speech-language pathology, nursing,
participants rated their satisfaction level as “satisfied” or and other health profession students.
“very satisfied” after the educational simulation activity.
Conclusion
Open-ended statements were used in this survey Assessment of the simulation training components in
as a mixed-method strategy to elicit qualitative student this study indicates that students viewed the use of the
perception data about the exceptional features of this standardized parents, case scenarios, and debriefing using
simulation training that may have been overlooked. This the PEARLS framework as a novel and effective approach in
method provides immediate feedback and elicits relatively audiology education. Debriefing allows audiology students
short immediate responses due primarily to the time to reflect on their performance and feelings including
constraints. However, this method fails to elicit the rich, positive aspects as well as aspects they would change
thoughtful responses that are acquired without time in the future. In addition, evaluation was instrumental in
constraints. Written reflections serve to facilitate critical identifying quality improvement opportunities for future
thinking by providing students with the opportunity to simulation training, thus contributing to satisfaction with this
connect previous experience with future actions based training. The evaluation of participants’ perceptions about
on lessons learned in the present (Petranek, 2000). simulation training is one way to achieve higher satisfaction
Use of Tanner’s model in a structured written reflection (or agreement) levels when the same simulation training
assignment could further enhance student learning by is repeated. Additional research on students’ perceptions
providing students with the opportunity to record their of simulation training components will provide evidence to
observations, interpret actions and decisions, analyze inform future simulation training efforts, as well as facilitate
responses, and reflect upon outcomes and alternative the development and refinement of the perception survey
scenarios (Lusk & Fater, 2013). used in this study.
Addition of a written reflection assignment will be References

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Appendix A
Students’ Perception of Simulation Training Components (SPSTC) Survey
Event: Student’s Number Date:

Please indicate your level of agreement (satisfaction) with each statement
Strongly Disagree Mostly Somewhat Mostly Strongly Agree Not
The Simulation Training Disagree Agree
(Very Dissatisfied) Disagree Agree Agree (Very Satisfied) Applicable
1 2 3 4 5 6 7 N/A
Simulation 1. The orientation to simulation
Environment was suitable
2. The simulation center was
well equipped
3. The simulation environment
felt safe for participation
Learning 4. The case scenarios were
Experience realistic
5. The debriefing sessions
were well prepared
6. The debriefing sessions
helped me reflect on my
practice
7. The facilitator was
supportive
8. Standardized parents acted
as real parents
9. Standardized parents
provided useful feedback
10. The learning experience will
help me in my clinical practice
Please respond to the following statements
Simulation 11. Describe any part of
Training the simulation training
Highlights that was exceptional
12. Describe any part of the
simulation training that did
not meet your expectations

DIAGNOSIS OF AOS Canadian Journal of Speech-Language Pathology and Audiology (CJSLPA)
Diagnosing Apraxia of Speech on the Basis of

Eight Distinctive Signs
Diagnostiquer l’apraxie de la parole en se basant sur

huit signes distinctifs
KEY WORDS Roel Jonkers*

apraxia of speech Judith Feiken*
diagnosis
Ilse Stuive
specific signs
*The first two authors contributed equally to the manuscript.
Abstract
This paper reports the results of a study on the use of a fixed number of specific signs to
differentially diagnose Apraxia of Speech (AoS) from aphasia or dysarthria. This was done with
Roel Jonkers a diagnostic instrument for AoS that was developed in the Netherlands in 2012, the Diagnostic
University of Groningen,
Instrument for Apraxia of Speech (DIAS; Feiken & Jonkers, 2012). There were 8 signs identified
Groningen,
THE NETHERLANDS as specific to AoS, namely: inconsistency of errors, number of errors with consonants versus
vowels, difference between sequencing and alternating diadochokinesis, groping, initiation
Judith Feiken and problems, syllable segmentation, cluster segmentation, and articulatory complexity. The DIAS was
Ilse Stuive administered to 30 individuals with AoS, 10 individuals with aphasia, 10 individuals with dysarthria,
Center for Rehabilitation, and 35 control individuals. Results showed that a differential diagnosis could be made in 88% of the
University Medical Center,
cases using a minimum of 3 out of 8 specific signs of AoS as criteria. With the exception of 2 patients
Groningen,
THE NETHERLANDS with aphasia, no other group exhibited the presence of 3 or more signs of AoS. It was concluded
University of Groningen,
that the presence of 3 signs is sufficient to differentially diagnose AoS from aphasia and dysarthria,
Groningen, despite the fact that there is a large amount of variability in the presence of signs of AoS itself in the
THE NETHERLANDS different individuals.
303 Diagnosing Apraxia of Speech on the Basis of Eight Distinctive Signs Volume 41, No. 3, 2017
Revue canadienne d’orthophonie et d’audiologie (RCOA) DIAGNOSIS OF AOS
Abrégé
Cet article présente les résultats d’une étude investiguant l’utilisation d’un nombre spécifique de
signes pour distinguer l’apraxie de la parole de l’aphasie ou de la dysarthrie dans un processus
de diagnostic différentiel. Pour ce faire, un test d’évaluation de l’apraxie de la parole ayant été
développé aux Pays-Bas en 2012, soit le Diagnostic Instrument for Apraxia of Speech (DIAS; Feiken
et Jonkers, 2012), a été utilisé. Huit signes ont été identifiés comme étant spécifiques à l’apraxie
de la parole : inconstance des erreurs, nombre d’erreurs sur les consonnes versus les voyelles,
différence entre les séries diadococinésiques en séquence et en alternance, tâtonnement,
problèmes d’initiation, segmentation des syllabes, segmentation des groupes consonantiques et
complexité articulatoire. Le DIAS a été administré à 30 participants ayant une apraxie de la parole,
10 participants ayant une aphasie, 10 participants ayant une dysarthrie et 35 participants formant
un groupe contrôle. Les résultats ont montré qu’un diagnostic différentiel de l’apraxie de la parole
peut être effectué dans 88% des cas en utilisant un minimum de trois critères sur huit. Aucun
participant inclus dans les autres groupes expérimentaux n’a été identifié avec un minimum de trois
signes spécifiques à l’apraxie de la parole, à l’exception de deux participants ayant une aphasie. La
présence de trois signes spécifiques a ainsi été jugée suffisant pour distinguer l’apraxie de la parole
de l’aphasie ou de la dysarthrie, et ce, malgré le fait qu’il existe une grande variabilité dans les signes
observés au sein des individus ayant une apraxie de la parole.

The importance of standardizing the assessment of based on theories regarding the characteristics and nature
Apraxia of Speech (AoS) has been repeatedly emphasized of AoS.
in scientific literature (Knollman-Porter, 2008; Wambaugh,
2006; West, Hesketh, Vail, & Bowen, 2008; World Health A literature review revealed 33 distinctive signs of AoS,
Organization, 2005). AoS is generally defined as an which were categorized by the authors into primary and
impairment in programming the positioning of speech secondary signs. The primary signs were categorized into
organs and the sequencing of articulations (Darley, three subgroups: initiation errors, incorrectly articulated
1968; Ziegler, 2008). There is, however, no consensus phonemes, and sequencing errors. Initiation errors
on how to diagnostically differentiate AoS from related include pausing before an utterance, visible or audible
communication disorders such as aphasia and dysarthria struggle to position the articulators (groping), and restarts
(Ziegler, Aichert, & Staiger, 2012). Also, there is still a debate (Duffy, 2005; Strand et al., 2014). Incorrectly articulated
in scientific circles regarding which particular signs lead phonemes lead to signs like distortions or substitutions.
to the diagnosis of AoS (Lowit, Miller, & Kuschmann, 2014; In distortions, the target phoneme is still recognizable. If
McNeil, Pratt, & Fossett, 2004; Ziegler, 2008). it is no longer possible to recognize the target phoneme
a substitution occurs, where the change of one or more
To diagnose AoS, in the Netherlands, speech-language features leads to the production of another phoneme
pathologists (S-LPs) usually administer general language (den Ouden, 2002). Sequencing errors are exchange
tests or a dysarthria test (Feiken, Hofstede, & Jonkers, errors at the level of sound or syllable (Haynes, Pindzola, &
2008; Jonkers, Terband, & Maassen, 2014), or base their Emerick, 1992; Square, Roy, & Martin, 1997; Ziegler, 2008).
diagnosis on clinical judgments. Internationally, there are The number of initiation errors and distortions seems to
a few standardized and normed instruments available, be affected by articulatory complexity as well (Staiger &
like the Apraxia Battery for Adults (ABA-2; Dabul, 2000) Ziegler, 2008). This is reflected at the phoneme level in a
and the Motor Speech Examination (MSE; Ogar et al., larger number of errors with consonants as compared to
2006; Wertz, LaPointe, & Rosenbek, 1984) for English, as vowels (Wertz et al., 1984), and at the word level in a larger
well as the Hierarchische Wortlisten (Liepold, Ziegler, & number of errors with syllables containing consonant
Brendel, 2002) for German. There are also criteria lists clusters as compared to simple syllables (Staiger & Ziegler,
available to identify AoS, such as the Mayo Clinic Apraxia 2008).
of Speech Battery (Darley, Aronson, & Brown, 1975; Duffy,
2005; Wertz et al., 1984); the checklist of McNeil, Robin, The secondary signs are signs that can be assumed to be
and Schmidt (2009); and the Academy of Neurologic reactions to the underlying disorder. Speakers with AoS may
Communication Disorders and Sciences (ANCDS) list pause more often (Aichert & Ziegler, 2004; Duffy, 2005)
(Knollman-Porter, 2008; Wambaugh, 2006). However, between the consonants of a cluster (cluster segmentation;
according to Knollman-Porter (2008) and West et al. McNeil, 2002) or the syllables of a word (syllable
(2008), there are no instruments or lists that provide segmentation; Staiger & Ziegler, 2008), and lengthen vowels
reliable identification of AoS. (Van der Merwe, 2009). In so doing, individuals with AoS
create more time for articulatory motor programming, to
A recently developed tool, published by Strand, Duffy, lower the number of articulation errors.
Clark, and Josephs (2014), could be valuable in diagnosing
(progressive) AoS. Strand et al. presented a rating scale The categorized primary and secondary signs were
for the diagnosis and description of AoS and tested this in compared to the signs seen in other neurologic speech
a group of participants with (progressive) AoS or aphasia, disorders, like aphasia and dysarthria. Overlapping signs
reporting high reliability scores as well as good validity of were omitted. Examples of these signs are a word-length
the tool. In the same vein, the current study investigates effect or the presence of substitutions, which are signs
whether the identification of specific signs is useful for the that can be found in both AoS and aphasia (Romani &
differential diagnosis of AoS. These signs were measured Galluzzi, 2005; Ziegler, 2005). A sign that is found in both
with a recently developed Dutch diagnostic test, the individuals with AoS and dysarthria is slow speech, but also
Diagnostic Instrument for Apraxia of Speech (DIAS; Feiken problems with diadochokinesis in general (Duffy, 2005;
& Jonkers, 2012). In contrast to the scale tool of Strand Ziegler, 2002). However, as alternating diadochokinesis
et al. (2014), the DIAS could be valuable in differentially (/pa-ta-ka/) is specifically more difficult for individuals with
diagnosing stroke-induced AoS from dysarthria and AoS than sequencing diadochokinesis (/pa-pa-pa/; Ziegler,
aphasia. The diagnosis is based on the presence of eight 2002), this characteristic can be considered as a specific
signs indicative of AoS, which were carefully selected sign of AoS.
The resulting eight signs were considered to be one participant with aphasia the specific etiology was
critical signs useful for the differential diagnosis of unknown. Aphasia was diagnosed with the standard
AoS. The scored signs are: 1) inconsistency in the Dutch diagnostic test, the Aachen Aphasia Test (Graetz,
pronunciation of repeated phonemes, 2) more errors De Bleser, & Willmes, 1992). Only participants having
with consonants than with vowels, 3) more difficulty aphasia with phonological deficits, reflected in low scores
in alternating diadochokinetic rate (/pa-ta-ka/) than for repetition and phonological errors in spontaneous
sequencing diadochokenitic rate (/pa-pa-pa/), 4) visual speech, were included. Dysarthria was diagnosed with the
or audible groping, 5) initiation problems (restarts), 6) Dutch Radboud Dysartrie Onderzoek [Radboud Dysarthria
syllable segmentation, 7) segmentation of consonant Investigation] (RDO; Knuijt & de Swart, 2007). The 20
combinations, and 8) effect of articulatory complexity. participants without AoS were selected on the basis of
These signs are assessed using the DIAS, which is their entry in the rehabilitation centre where this study
described in the Methods section. was performed. The first 10 participants with aphasia
and dysarthria—irrespective of the type of aphasia or
In this study, it will first be investigated whether the
dysarthria—that fit the inclusion criteria were tested.
eight signs of AoS can be scored reliably. The diagnosis
Therefore, this group was less balanced with respect to sex
of AoS will be based on the presence of a number of
than the group with AoS. A group of 35 control speakers
these signs. For the differential diagnosis of AoS with
that matched the participants with AoS in age, sex, and
aphasia and dysarthria not all signs need to be present,
education was also tested to determine the cut-off points
as the same underlying deficit may lead to different
for the different signs. This group consisted of 14 male and
primary and secondary signs. How many signs need to
21 female participants, mean age 52.3 years (range 23–64).
be present in order to come to a differential diagnosis will
A chi-square test revealed no difference between the AoS
be investigated. The outcomes of a study with 50 brain-
group and the control group with respect to sex (χ(1) =
damaged speakers and 35 non-brain-damaged control
0.754, p > .05). However, the AoS group turned out to be
speakers will be presented.
significantly older than the control group (t(63) = 2.489, p <
Methods .05). Nevertheless, the mean age of both groups was below
60, and in the AoS group only four of the 35 participants
Participants were older than 70. Therefore, age is not assumed to be of
Participants were selected as possibly having AoS by influence on the outcomes.
the treating S-LP based on the most recent criteria, i.e.,
the ANCDS list (Wambaugh, 2006). Another S-LP then All participants gave their informed consent.
independently confirmed this judgment. This S-LP was Testing was done with permission of the Medical Ethics
blinded to the diagnosis of the first S-LP. Both S-LPs were Committee of the University Hospital Groningen (UMCG).
independent in the sense that they were not co-authors of All participants were native speakers of Dutch. Participants
the article. This study only considered those cases where had a normal intellect (IQ > 70) and vision, and their
both S-LPs agreed on the clinical diagnosis of AoS. hearing and neurocognitive abilities did not interfere with
an acceptable assessment. All patient group data are
Thirty participants (15 male, 15 female; mean age presented in Table 1.
58.4 years, range 34–78) clinically diagnosed with AoS
were assessed with the DIAS. To study the potential of All individuals with AoS also suffered from aphasia.
differentially diagnosing between patients with AoS, In order to determine if the results of this study could
aphasia, and dysarthria on the basis of clinical signs, 20 be explained by a difference in the severity of aphasia
participants without AoS but with aphasia (n = 10; eight between the group with AoS and aphasia, their scores on
male, two female; mean age 62.7 years, range 45–77) the Token Test of the AAT were compared. Originally, the
or dysarthria (n = 10; nine male, one female; mean Token Test was developed to be a test for the reception
age 55.8 years, range 18–77) were also tested with the of language, but currently the Token Test is used as a
DIAS. All participants with AoS suffered from a single selective instrument to detect the presence of aphasia
stroke. The same holds for eight of the participants with and as an indicator of its severity (El Hachioui et al., 2013;
dysarthria and eight of the participants with aphasia. One Orgass & Poeck, 1966). The maximum score on this test
individual with aphasia and one with dysarthria suffered is 50, which reflects a negative score. Individuals without
from a traumatic brain injury. One other individual with aphasia had a mean score of 2.4 (SD = 2.5) on this test
dysarthria suffered from a subarachnoid bleed, and for (Graetz et al., 1992).

Table 1. Participants by Speech Category
Age in years TPO in months

Group Sex
(Mean and SD) (Mean and SD)
Apraxia of speech (n = 30) 58.4 (11.6) 15 m, 15 f 32.0 (25.4)
Aphasia (n = 10) 62.7 (9.8) 8 m, 2 f 29.7 (53.9)
Dysarthria (n = 10) 55.8 (16.3) 9 m, 1 f 10.5 (4.4)
Control speakers (n = 35) 52.3 (11.3) 14 m, 21 f -
Note. m = male, f = female, TPO = time post onset
Materials
In the test for the articulation of phonemes,
All individuals were tested with the DIAS (Feiken &
participants are instructed to repeat vowels and
Jonkers, 2012). The DIAS contains four tests, of which
consonants three times consecutively. This test evaluates
three were used in this study.1 The test for orofacial
the conscious production of individual consonants. In AoS,
apraxia will not be discussed here, as it is only part of
inconsistent distortions and substitutions of phonemes
the instrument to diagnose orofacial apraxia. Three
often occur (Sign 1; Darley et al., 1975; den Ouden, 2002;
tests were administered to assess the presence of the
Varley & Whiteside, 2001;Wertz et al., 1984). Inconsistent
eight aforementioned signs: articulation of phonemes,
errors in this study are assumed to be different
diadochokinesis, and articulation of words. All items
pronunciations during the repetition of three phonemes.
can be found in Appendix A. In Table 2, an overview is
Wambaugh (2006) states that errors of speakers with
given of the three tasks that were used for differential
AoS are consistent. However, this is a different kind of
diagnosis, mentioning the different signs that were
consistency, as it refers to the consistency of error types
studied. Not all signs were investigated in every
across different tests.
subtest, but the three subtests were indicated for
specific signs. Below, the tests are described including With respect to the number of errors made with
descriptions of the specific signs per test. consonants or vowels (Sign 2), more errors with
Table 2. Subtests of the DIAS
Differential Control score

Test Cut-off score
diagnostic criteria mean (SD)
- Inconsistency of errors (1)
Articulation of phonemes 0.09 (0.51) 2
- Number of errors with
(15 consonants; 15 vowels) 0.09 (0.74) 2
consonants vs. vowels (2)
Diadochokinesis - Difference between

0.94 (0.11) 0.74
(6 series of sequencing sequencing and alternating
and alternating syllables diadochokinesis (3)
0 2*
or words) - Groping (4)
- Initiation problems (5) 0.003 (0.02) 1 out of 11 blocks

Articulation of words - Syllable segmentation (6) 0 >0
(6 blocks of 11 words) - Cluster segmentation (7) 0 >0
- Articulatory complexity (8) 0.10 (0.39) 0.88
Note. *Groping was not seen in the control group, thus every occurrence could be considered deviant. However, as clinicians questioned this
symptom during the pilot phase on certain occasions, the cut-off was set to 2.
1
It is not intended to provide an elaborate description of the subtests and the theoretical background of the DIAS. Feiken and Jonkers (2012) and Jonkers
et al. (2014) provide more information on construct and item validity, specificity, and sensitivity of the test.
consonants than with vowels are expected (Duffy, 2005; alternate version of the item, which could be explained by
Wertz et al., 1984). a word frequency effect. The internal consistency of this
test is .97 (Cronbach’s alpha).
The test for the articulation of phonemes consists
of 30 items: 15 consonants (C) and 15 vowels (V). This With the test for the articulation of words, the
composition allows one to assess whether there is a presence of the final four signs of AoS is studied, among
difference in the number of errors between consonants which are initiation problems (Sign 5). Problems with the
and vowels. Consonants differed in place or manner of initiation of speech are often seen in individuals with AoS
articulation. Vowels were chosen on the basis of their (Haynes et al., 1992; LaPointe, 1990). They can appear in
position in the vowel triangle (Kooij & van Oostendorp, different forms. LaPointe (1990) describes false starts
2003). Place of articulation of the consonants was and repetition of sounds or syllables as instances of
varied to circumvent perseveration. After, for example, initiation problems. As mentioned in the introduction, as a
the consonant /m/, an alveolar sound like /d/ followed. reaction to articulation problems speakers with AoS may
The internal consistency of this test is .96 (Cronbach’s also pause more often, leading to cluster segmentation
alpha). To account for a possible effect of consistency, (McNeil, 2002; Sign 6) or syllable segmentation (Staiger
participants were asked to repeat every phoneme three & Ziegler, 2008; Sign 7). Finally, individuals with AoS make
times in a row. more repetition errors with consonant clusters (Staiger &
Ziegler, 2008) and with longer words (Ziegler, 2005), and
The second test in the DIAS that plays a role in
this is reflected in the articulatory complexity sign (Sign 8).
differential diagnosis is a diadochokinesis task. Oral
diadochokinesis is seen as a sensitive measure for The test for the articulation of words (word repetition)
neuromotoric speech capacities (Ziegler, 2002), as it contains 66 items with increasing length and articulatory
demands maximum performance of a participant. Deger complexity. The test consists of 11 blocks of six words,
and Ziegler (2002), Ogar et al. (2006), and Wertz et al. where every block differed in complexity, with respect
(1984) note that individuals with AoS will have more to the number of syllables, number of phonemes and
difficulties in alternating different syllables (alternating articulatory complexity (CV structures, CC clusters within
diadochokinesis) than repeating the same syllables a syllable, CCC clusters within a syllable, and CC clusters at
(sequential diadochokinesis), which is defined as Sign 3.2 the syllable boundary). Every block of six items focused on
Initiation problems, substitutions, omissions, slow speech a specific structure. The words in the test do not differ with
rate, segmentation of syllables or clusters, and repeated respect to word frequency. The internal consistency of
attempts to produce an item are possible consequences this test is .99 (Cronbach’s alpha). Kuschmann, Miller, and
of difficulties with alternating diadochokinesis. In Lowit (2014) provide requirements for intelligibility tests
accordance with Duffy (2005), the diadochokinesis test used in speakers with AoS, considering, among others,
was also specifically used to observe the symptom of adequacy, completeness, levels of difficulty, number of
groping (Sign 4). items, and frequency of items. The list of items in this test
fits with the requirements mentioned here.
The diadochokinesis test contains 12 items: six
sequencing and six alternating items. This subtest is set up
Procedure
according to the level of complexity, starting with simple
CV structures, like the sequencing item /pa-pa-pa/ versus All tests were administered in one session in a fixed
the alternating item /pa-ta-ka/, and ending with CCVCC order. All assessments were videotaped and scored
structures, like /stank-stank-stank/ versus /stank-blank- later. The administration of the subtests was multimodal,
drank/. In some of the alternating items the consonant meaning that the items were presented both visually and
in initial or final position changes, whereas in others the auditorily to circumvent influences of visual or auditory
consonants within a cluster change. Most of the words problems. Participant and tester sat face-to-face in a quiet
used in these structures were meaningful words. The room. To prevent lip reading, the participant was asked
words were controlled for frequency of occurrence using not to look at the tester during the assessment. In cases
the CELEX frequency list for Dutch (Baayen, Piepenbrock, where this was not possible, the mouth of the tester was
& Gulikers, 1995). The sequential items always had the covered. Testing (including the test for orofacial apraxia)
lowest frequency, to prevent any poor performance on the lasted about 45 minutes. After instruction, all subtests
2
There is some confusion in the literature about what should be seen as sequential diadochokinesis and what should be seen as alternating
diadochokinesis. Duffy (2005), for example, uses the terms with the inverse meaning. However, there is agreement on the fact that the repetition of
different syllables, like /pa-ta-ka/, is more difficult for individuals with AoS than the repetition of the same syllable (/pa-pa-pa/).

started with two examples. In the case of an inadequate reliability. In Table 3, the ICC values and Kappa scores for all
response to (one of the) examples, the participants were reliability measures are presented. The lowest inter-rater
corrected. During assessment no help or feedback was agreement was seen for cluster segmentation, although
provided, except for one repetition of the target if the this agreement is still acceptable. There was a strong
participant requested it. There was no time pressure to agreement for more errors with consonants than with
answer, except for in the diadochokinesis test. In this test vowels. All other intra-class correlations showed very high
participants were first asked to repeat every sequence of agreement. The Kappa values for groping indicated good
three syllables once, and if this was possible, they were to excellent agreement. With respect to the ICC values for
asked to repeat every sequence as often and correctly as the intra-rater reliability, all correlations were significant
possible within 8 seconds. The tester told the participant at the level of .001 and indicated a very high agreement.
when to start and stop. Not all correlations were significant for the test-retest
reliability. A non-significant and poor agreement was found
Scoring for articulatory complexity. Ratings for the other signs
For each test, the presence of the specific signs was were again significant, and agreement varied from good
evaluated. Cut-off points for the presence of signs were (groping) or strong (cluster segmentation) to very high (all
determined based on scores of the control speakers. other signs).
A symptom was considered to be present if a score
differed more than two standard deviations from the Number of signs
mean score of the control speakers (adjusted upwards if In order to find out what the necessary number of
necessary). These cut-off points are presented in Table signs would be for the diagnosis of AoS, the number of
2. In Appendix B, how the specific signs were scored per signs in the three groups was calculated and afterwards it
test is described. Scoring and interpreting of the errors was decided what the ideal number needed for a reliable
could be done in 45 minutes. diagnosis would be. In comparing the presence of signs in
participants with AoS with those noted in individuals with
The number of signs was counted for every participant
dysarthria and aphasia, it was found that the presence of
and it was evaluated whether it was possible to distinguish
at least three signs was needed to diagnose AoS in most
individuals with AoS from individuals with dysarthria or
of the individuals with AoS. In 26 of the 30 individuals with
aphasia based on the number of signs present. Severity is
AoS, three or more signs were determined. Three of the
not considered in the current study. This means that the
four individuals with fewer signs were individuals with very
presence of a sign is important but the frequency with
severe speech problems. In these individuals only the
which a sign is noted is not.
first two subtests could be administered, and therefore
most of the signs could not be determined. Only in one
Reliability
case a participant was able to do all the subtests and still
Intra-rater reliability was obtained by comparing the had fewer than three signs. Three individuals with AoS,
scoring of sign presence on the basis of video recordings however, showed only three signs, which means that when
of the DIAS of 30 participants twice, with an intermediate using four signs as diagnostic criteria, a smaller number of
period of six months, by the same experienced clinical individuals with AoS would be diagnosed properly.
linguist. Inter-rater reliability was based on the scores of
three experienced S-LPs not involved in the intra-rater In the group of individuals with dysarthria (n = 10), none
reliability, who scored the video recordings of the DIAS of the individuals had three or more signs of AoS. In the
administration independently. Test-retest reliability was aphasia group (n = 10), two individuals had three signs of
obtained by testing 10 participants with the DIAS twice, AoS, while the other eight individuals showed fewer signs.
with an intermediate period between two and six weeks. Seven individuals not assumed to have AoS showed two
Again, video recordings were scored. signs, which would lead to a larger number of misdiagnoses
if these were to be used as diagnostic criteria. This means
Results that the presence of three signs was the best way to divide
Reliability the groups into individuals with and without AoS.
Intra-rater and inter-rater reliability correlations (intra- In Table 4, an overview is provided with the number
class correlations (ICC) or Kappa scores) for scoring of individuals in the AoS group that displayed a specific
the eight signs were significant and showed overall good sign. Every sign was found in almost half of the speakers
Table 3. Reliability Measures for the Different Signs
Inter-rater Intra-rater Test-retest

reliability reliability reliability
Inconsistent realization of phonemes .84 (p < .01) .98 (p < .001) .93 (p < .001)
More errors with consonants than with vowels .76 (p < .01) .95 (p < .001) .81 (p < .05)
More problems with alternating than

.92 (p < .001) .98 (p < .001) .98 (p < .001)
with sequencing syllables
Initiation problems .81 (p < .001) .95 (p < .001) .92 (p < .001)
Syllable segmentation .81 (p < .001) .98 (p < .001) .99 (p < .001)
Cluster segmentation .62 (p < .001) .90 (p < .001) .73 (p < .05)
Articulatory complexity .80 (p < .001) .95 (p < .001) .32 (p > .05)
Groping Kappa
Rater 1-2 .73 (p < .05) .86 (p < .001) .74 (p < .05)
Rater 1-3 .73 (p < .05)
Rater 2-3 1.00 (p < .001)
Note. All comparisons: intra-class reliability, except for the groping sign, for which Kappa-scores were used.
Table 4. Number of Individuals With AoS Showing Specific Symptoms of AoS
Individuals with AoS

Signs
Symptoms (n = 30)
Inconsistency of errors 17/30
Number of errors with consonants vs. vowels 13/30
Difference between sequencing and alternating diadochokinesis 18/30
Groping 23/30
Initiation problems 28/30
Syllable segmentation 25/30
Cluster segmentation 14/30
Articulatory complexity 18/30

with AoS. The sign more errors with consonants than with to detect the presence of the influence of articulatory
vowels was found in the lowest number of speakers with complexity with a simpler measure.
AoS. Only 13 of the 30 speakers showed this sign. In almost
all speakers with AoS (28/30), initiation errors occurred. In the individuals with AoS, the signs were present, but
No specific pattern was seen with respect to the number with a large amount of variation. This is consistent with
of primary or secondary signs. the assumption that the same underlying disorder can
manifest itself in different primary or secondary signs.
Severity of aphasia However, the differential diagnosis could be determined
with the presence of three of eight signs. In 26 of 30
The mean Token Test score of the individuals with tested individuals with AoS, three or more signs were
AoS was 24.9 (SD = 13.5) and of the individuals with only present. Three of the four remaining individuals could not
aphasia 27.0 (SD = 16.6). An unpaired t-test did not show a be diagnosed properly as they were severely impaired
significant difference between these scores (t(38) = 0.4, patients who could not complete all the subtests.
p > .05). This indicates that differences between the These individuals were for example unable to do the
groups with respect to the presence of signs do not diadochokinesis test at all, or could only repeat one or two
relate to the severity of the aphasia. words of the repetition test. Therefore, in these individuals
not all signs could be counted. This leads to a restriction
Discussion
on a valid diagnosis on the basis of signs, namely that
The current study investigated whether it is possible individuals should be assessed with the entire diagnostic
to differentially diagnose AoS from dysarthria or aphasia test and that all signs can at least be scored properly. Only
on the basis of the presence of signs of AoS. With the one individual with a clinical diagnosis of AoS scored with
Dutch DIAS (Feiken & Jonkers, 2012), the presence of eight fewer than three signs. For this individual it is difficult to
specific signs of AoS was studied in a group of individuals decide whether he/she was incorrectly diagnosed with
with AoS, dysarthria, and aphasia, as well as a control AoS by the S-LP or incorrectly diagnosed as not having AoS
group. The individuals with AoS were selected on the basis using the DIAS.
of clinical judgment by an S-LP using the most recent
selection criteria for AoS, i.e., the ANCDS list (Wambaugh, The presence of three of more signs was not seen
2006) and this judgment was independently confirmed in any of the ten individuals with dysarthria; however,
by the judgment of a second blinded S-LP. The individuals three signs were present in two of the 10 individuals with
with dysarthria and aphasia were diagnosed with the RDO aphasia. This result can be interpreted in two different
(Knuijt & de Swart, 2007) and the Aachen Aphasia Test ways. One could conclude that it is not always possible to
(Graetz et al., 1992), respectively. make a differential diagnosis between aphasia and AoS
in some cases. Another possible interpretation is that
Haley, Jacks, De Riesthal, Abou-Khalil, and Roth (2012) diagnosing on the basis of the presence of symptoms is
showed that clinicians are reliably able to list and interpret preferable to clinical judgment, because of the possibility
the signs of AoS, but show poor agreement in differentially that these aphasic speakers also suffer from AoS. Control
diagnosing AoS. This is because clinicians observe and speakers and the individuals in the other patient groups
prioritize the signs differently, and consequently reach rarely showed these signs. The fact that more signs were
different conclusions. In this study, we showed that the present in the group of speakers with AoS than in the
eight signs can be scored reliably by experienced S-LPs. group of speakers with aphasia appeared to be unrelated
Both the inter- and intra-rater reliability showed significant with severity of aphasia, because Token Test scores for
and sufficiently high correlations. This also holds for both groups were comparable. However, there is some
the test-retest variability, except for the articulatory debate about the role of the Token Test as a measure for
complexity sign. Although this sign was found in 18 of the severity of aphasia. Although authors use the Token Test
30 speakers with AoS, it seems that the presence of this in such a way (e.g., El Hachioui et al., 2013), the developers
sign is not as clear to interpret as the other signs. This of the Token Test originally presented it as an instrument
might have to do with the fact that the calculation of this to diagnose language comprehension impairments only
sign is more complex than the other signs, although the (see also De Renzi & Faglioni, 1978). In that case, the only
inter- and intra-rater reliability were good. It could also justified conclusion is that the presence of three or more
be that the presence of this sign is subtler to detect than distinctive signs in participants with AoS in the current
the others, which means that in some cases raters might study seems unrelated to the presence of an aphasic
miss its presence. For future studies it is recommended comprehension disorder.
No specific signs seem to favour the diagnosis of AoS. signs of AoS into primary signs (like initiation errors and
All signs were found regularly in the different individuals, distortions) and secondary signs (like segmentation
with a minimum of 13 out of 30 speakers with AoS showing of consonant clusters or intersyllabic pauses) is taken
the sign of more errors with consonants than with vowels. into account, it is likely that individuals differ in how they
This reveals that it does not seem to be possible to further express AoS. Therefore, different specific signs could lead
restrict the number of symptoms to be present. It is also to the diagnosis of AoS. The present study showed that,
clear that not all signs are found in all individuals with AoS. nevertheless, only three signs need to be present to result
Only the symptom of initiation problems was seen in in a valid differential diagnosis between speakers with and
almost all speakers. without AoS.
As mentioned in the introduction, there is a lively debate This current study is limited by the fact that, although
on the diagnosis of AoS and on which type of tasks to use a significant number of individuals with AoS participated,
for diagnosis. There is a discussion in the literature as to the groups of individuals with dysarthria and aphasia
what importance non-speech tasks, such as repetition of were rather small. Accordingly, no specific distribution
phonemes and diadochokinesis, could contribute to the was made in the different types of individuals with
diagnosis of AoS. Ziegler (2003) doubts the role of such dysarthria (e.g., ataxic dysarthria or flaccid dysarthria) or
tasks due to their unrelatedness to natural speech. It is aphasia (e.g., conduction aphasia or Wernicke’s aphasia).
indeed impossible to diagnose AoS on the sole basis of In future studies, the authors intend to account for the
such tasks, but in line with Kuschmann et al. (2014), it is type of dysarthria or aphasia by testing a larger number
assumed that these non-speech tasks provide information of participants.
on the underlying impairment, whereas it is also necessary
to focus on real words, as is done in the repetition task, A second limitation is the fact that this study was
for a closer correlation with natural speech. Both types of conducted with Dutch participants using a Dutch
tasks, therefore, have merit in the assessment of AoS. The instrument. It is assumed, however, that the specific
importance of a diadochokinesis test is also reflected in symptoms that were considered with this instrument
the fact that 18 of the individuals with AoS showed greater might be considered in other languages as well. The fact
problems with alternating diadochokinesis as compared to that Strand et al. (2014) were able to use signs for the
sequential diadochokinesis. diagnosis of AoS shows that a diagnosis on the basis of the
presence of signs does not have to be test-specific.
The discussion on diagnosis partly has to do with the
lack of consensus on the exact underlying deficit(s) and Finally, the fixed order of the subtests could have
the differential diagnosis with respect to aphasia and influenced the outcomes. Participants might have
dysarthria. There seems to be agreement on some of the had more speech problems at the beginning of the
signs of AoS, but even with respect to these signs there administration of the test due to starting problems, or at
is discussion regarding whether they should really be the end due to, for example, fatigue, which could lead to
seen as purely signs of AoS. All of the eight signs that are a bias in the presence of specific symptoms. However,
evaluated in the DIAS were mentioned as signs of AoS in given the fact that no specific sign was the most common
the literature. The assertion that not all eight signs need in the participants with AoS, it seems unlikely that more
to be present in all individuals with AoS has been shown in symptoms would be shown in the first or final test for the
this study and was also confirmed by Strand et al. (2014). group of participants with AoS.
Strand and colleagues recently showed that it is possible
to reliably score the presence of signs of AoS and to validly In this study, it was shown that, by assessing the
diagnose (progressive) AoS on the basis of the presence specific signs of AoS, AoS can be distinguished from
of these signs, also without the necessity of all signs being aphasia and dysarthria. The possibility of differentially
present for a group of individuals with (progressive) AoS diagnosing AoS from aphasia and dysarthria is important
(Strand et al., 2014). in clinical practice. S-LPs will be able to connect their
treatment properly to the actual deficit(s), creating a
In line with the findings of Strand et al. (2014), the better basis for treatment. In addition, by knowing which
current study indicates that the discussion about signs are present in a specific patient, better choices can
the differential diagnosis with respect to aphasia and be made in setting priorities for therapy. Administration
dysarthria should not be about finding signs that are of the test and scoring of the responses can be done
present in all AoS patients. When the division of the in roughly 90 minutes. S-LPs are able to do the scoring

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Acknowledgements
The Dutch Aphasia Foundation (SAN) and the
Beatrixoord Noord Nederland Foundation sponsored
this study. We would like to thank the participants and
the S-LPs that took part in this study. Furthermore, we
would like to thank Dörte de Kok and Matt Coler for their
comments on an earlier version of this article.
Declaration of interest
Two of the authors were involved in the development
of the Diagnostic Instrument for Apraxia of Speech (DIAS;
Feiken & Jonkers, 2012).
Authors’ Note
Correspondence concerning this article should be
addressed to Roel Jonkers, Department of Linguistics,
University of Groningen, P.O. Box 716, 9700 AS Groningen,
The Netherlands. Email: [email protected].

Appendix A
Items of the Subtests
Articulation of phonemes
Consonants Vowels
1. /t/ /oo/
2. /f/ /ee/
3. /s/ /u/
4. /h/ /a/
5. /p/ /ie/
6. /k/ /o/
7. /r/ /uu/
8. /l/ /i/
9. /j/ /eu/
10. /b/ /ei/
11. /n/ /oe/
12. /g/ /aa/
13. /m/ /ui/
14. /d/ /e/
15. /w/ /ou/
Diadochokinesis
1. Pa pa pa
2. Pa ta ka
3. Mok mok mok
4. Mok sok hok
5. Dam dam dam
6. Dam das dak
7. Schel schel schel
8. Schel stel spel
9. Vlok vlok vlok
10. Vlok stok brok
11. Stank stank stank
12. Stank blank drank
Articulation of words
a. One syllable, not complex
1. sok (sock)
2. web (web)
3. kat (cat)
4. noot (nut)
5. veer (feather)
6. tas (bag)
b. Two syllables, not complex
1. kanon (canon)
2. minuut (minute)
3. banaan (banana)
4. debuut (début)
5. zadel (saddle)
6. gebak (cake)
c. One syllable, CC, 3 phonemes
1. knie (knee)
2. vlo (flea)
3. trui (sweater)
4. sla (salad)
5. prei (leek)
6. twee (two)
d. One syllable, CC, 4 phonemes
1. tand (tooth)
2. wesp (wasp)
3. punt (point)
4. gans (goose)
5. koord (cord)
6. bank (bank)

e. One syllable, CCC, 4 phonemes
1. arts (doctor)
2. sprei (bedspread)
3. angst (fear)
4. stro (straw)
5. oogst (harvest)
6. eerst (first)
f. One syllable, CCC, 5 phonemes
1. spraak (speech)
2. schrik (fright)
3. dorst (thirst)
4. schroef (screw)
5. kunst (art)
6. streep (line)
g. Two syllables, C-C, 5 phonemes
1. oksel (armpit)
2. pasta (pasta)
3. advies (advice)
4. omdat (because)
5. asbak (ashtray)
6. afweer (defense)
h. Three syllables, C-C, 8 phonemes
1. impulsief (impulsive)
2. abnormaal (abnormal)
3. aantasten (affect)
4. verwonden (wound)
5. onwaarheid (untruth)
6. inpalmen (to charm)
i. 4 syllables, not complex, 8 phonemes
1. televisie (television)
2. limonade (lemonade)
3. vitamine (vitamin)
4. politica (politician; fem.)
5. mayonnaise (mayonnaise)
6. apparatuur (apparatus)
j. not complex, 8\9-11 phonemes
1. fotocamera (photo camera)
2. kilometer (kilometre)
3. honorarium (fee)
4. figureren (figure; verb)
5. papegaaien (parrot; verb)
6. telefoneren (telephone; verb)
h. complex, 9-11 phonemes
1. invloedrijk (influential)
2. handtastelijk (palpable)
3. fietstassen (cycle-bags)
4. gras groeit (grass grows)
5. herfstblad (autumnal leaf)
6. eerstejaars (first-year student)

Appendix B
Determination of the Cut-off Scores
The articulation of phonemes subtest was used to assess two signs. To detect whether or not participants produce
inconsistent realizations of phonemes, the number of inconsistencies within a three-time repetition was calculated (range:
0–30). To detect whether participants produced more errors in consonants than in vowels, the scores for correctly produced
consonants and vowels were subtracted from each other (range: 0–15).
The diadochokinesis test was used to assess two signs. First, it was evaluated whether participants experience more
difficulties in alternating than sequencing syllables and words, and secondly, it was observed whether participants show visible
or auditory groping. For the assessment of the first symptom, the number of correct realizations in the repeating sequence
(/pa-pa-pa/) was compared to those in the alternating sequence (/pa-ta-ka/). If the participants were able to perform the
single repetition, they were asked to produce as many repetitions as possible in eight seconds. The number of correct
realizations for the alternating sequence was then divided by the correct realizations for the repeated sequence, where a run
of three syllables constituted a sequence. The obtained scores were increased by 1 in order to circumvent nil scores (range:
unlimited). A score below 1 indicates a poorer performance on the alternating sequences.
The diadochokinesis test was also used to score the symptom of groping. This was done by scoring the presence of this
symptom during the repetition of the alternating sequences.
The four remaining signs (initiation problems, syllable segmentation, segmentation of consonant combinations, and
effect of articulatory complexity) were captured in the articulation of words subtest. Sixty-six words were divided into 11
blocks of increasing complexity. To prevent reliance on one single instance of a symptom, but also to keep scoring time within
proportional limits, the presence of the signs was scored per block of six words. Initiation problems were scored in all blocks,
so the highest score is the presence of 11 signs in 11 blocks (score 11/11 = 1). The other signs were only observed in a selected
group of blocks. Syllable segmentation can only be observed in the polysyllabic words. There were 36 polysyllabic words,
used in six blocks, so the highest score is 6/6 (score = 1). Segmentation of consonant clusters can only be observed in words
including a consonant cluster. This was the case for 30 words, used in five blocks. The highest score is 5/5 (score = 1).
The effect of articulatory complexity was determined by comparing words of similar length but different articulatory
complexity; two blocks contained non-complex words, two blocks contained a two-consonant cluster, and two blocks
contained words with a three-consonant cluster. To account for an effect of articulatory complexity, the score of the third
block was subtracted from the mean score of the three blocks.
PHOPHLO Canadian Journal of Speech-Language Pathology and Audiology (CJSLPA)
KEY WORDS
Development of a Tool to Screen Risk of Literacy Delays in
literacy
French-Speaking Children: PHOPHLO
spelling
oral language
Développement d’un outil pour dépister le risque de retard
screening
dans l’acquisition des habiletés de littératie chez les enfants
speech perception
francophones : PHOPHLO
speech production
phonological
awareness
morphology
Susan Rvachew
Susan Rvachew
School of Communication Phaedra Royle
Sciences and Disorders, Laura M. Gonnerman
McGill University,
Montréal, QC,
Brigitte Stanké
CANADA Alexandra Marquis
Centre for Research on Brain, Alexandre Herbay
Language and Music,
Montréal, QC,
CANADA
Phaedra Royle
École d’orthophonie et
d’audiologie,
Montréal, QC,
CANADA
Centre for Research on Brain,
Language and Music,
Montréal, QC,
CANADA
Laura Gonnerman
School of Communication
Sciences and Disorders,
McGill University,
Montréal, QC,
CANADA
Brigitte Stanké
d’audiologie,
Montréal, QC,
CANADA
Abstract
Alexandra Marquis
Literacy is crucial for success, both professionally and personally. Oral language skills are closely
d’audiologie, related to literacy development in children. When a child has weak oral language skills, they will
Université de Montréal, have difficulty achieving reading and writing competencies within the expected time frame. In this
Montréal, QC, paper, we present results from a longitudinal and cross-sectional study of the relationship between
CANADA oral language skills in pre-literate children, and one aspect of their literacy skills in early elementary
United Arab Emirates school—specifically, spelling. The study was conducted with French-speaking children and
University, Abu Dhabi,
French-language learners from Quebec, a population that has been understudied in this area. We
UNITED ARAB EMIRATES
developed a predictive tool that will allow teachers and other professionals to assess oral language
Alexandre Herbay skills in young children and to predict those children at risk for literacy difficulties. Specifically,
School of Communication we screened children’s speech perception, speech production, phonological awareness, and
Sciences and Disorders,
McGill University,
morphology production abilities at entry to first grade and predicted spelling skills at the end of
Montréal, QC, second grade. The screening tool that we developed proved to have a sensitivity of 71% and a
CANADA specificity of 93% as a screen for poor spelling abilities.
321 Development of a Tool to Screen Risk of Literacy Delays in French-Speaking Children: PHOPHLO Volume 41, No. 3, 2017
Revue canadienne d’orthophonie et d’audiologie (RCOA) PHOPHLO
Abrégé
La littératie est un élément crucial du succès à la fois professionnel et personnel. Les habiletés
de langage oral sont intimement liées au développement de la littératie chez les enfants. En effet,
lorsqu’un enfant a de faibles habiletés de langage oral, il aura plus de difficulté à développer ses
habiletés de lecture et d’écriture dans les délais prévus. Nous présentons les résultats d’une étude
longitudinale et transversale qui explore les liens entre les habiletés de langage oral chez des enfants
n’ayant pas appris à lire ou à écrire et leurs habiletés de littératie au premier cycle du primaire.
Cette étude a été menée auprès d’enfants franco-québécois natifs et non natifs, une population
peu étudiée dans ce domaine. Nous avons créé un outil prédictif qui permettra aux enseignants
et autres professionnels d’évaluer les habiletés de langage oral des enfants et de prédire ceux qui
sont à risque de présenter des difficultés de littératie. Plus spécifiquement, nous avons évalué
les habiletés de perception et de production de la parole, de conscience phonologique et de
production morphologique d’enfants débutant leur première année du primaire. Nous avons prédit
leurs habiletés d’orthographe à la fin de leur deuxième année (fin du premier cycle du primaire).
L’outil développé a démontré une sensibilité de 71% et une spécificité de 93% pour dépister les
faibles habiletés d’orthographe.

Literacy skills are essential for success in modern life, report revealed significant difficulties in children’s writing
at the level of the individual and at the level of broader abilities in primary and secondary school (Gouvernement
society. Stronger literacy skills are associated with a du Québec, 2006). Even more worrying, students’ writing
greater likelihood of school completion (Hernandez, 2011); skills at the end of sixth grade were statistically weaker in
furthermore, individuals with higher literacy skills have an 2005 than those of their peers five years earlier (Jalbert,
employment and earnings advantage even after controlling 2007). Subsequently, the Ministère de l’éducation [Ministry
for educational attainment (Organization for Economic of Education] introduced a new approach to literacy
Cooperation and Development [OECD], 2011). Literacy education in Quebec that included a competency-based
is also an important social determinant of mental and approach to the teaching and assessment of reading
physical health (Dewalt, Berkman, Sheridan, Lohr, & Pignone, and writing.
2004; Marcus, 2006). At the society level, communities
with a greater proportion of highly literate individuals The literacy skills of Quebec school children are
enjoy a greater quality of life, not only in economic terms assessed through obligatory province-wide writing
but also through enhanced social cohesion, as literacy is assessments administered in primary school (fourth and
associated with greater civic participation (OECD, 2011). sixth grade), with additional tests in secondary school. Over
Speech-language pathologists (S-LPs) play a pivotal role several days, the students read and discuss a variety of texts
in ensuring these positive outcomes for individuals and and then write a narrative (in primary school) or explanatory
society, because oral language skills are the foundation of text (in secondary school). These written texts are graded
literacy and because S-LPs are key members of the team for relevance, organization, syntax and punctuation,
of professionals responsible for literacy outcomes in the vocabulary, and orthography. Each of these five areas
school environment (Justice, 2006; Lefebvre, Trudeau, is rated separately as very satisfactory, satisfactory,
& Sutton, 2008; Roth & Baden, 2001). In this paper, we acceptable, somewhat satisfactory, or unsatisfactory,
highlight the close relation between oral and written according to specific criteria. For example, syntax and
language skills and introduce a new screening tool to identify punctuation is scored globally, so that an “unsatisfactory”
French-speaking children who are at risk for literacy delays rating indicates that sentence structure and punctuation
without additional support. In Quebec, high dropout rates rarely met expectations throughout the text. However,
from secondary school are recognized as “a major problem” orthography is scored by counting the exact number of
that is correlated with poor written language performance errors on a word-by-word basis, taking into account spelling
(Fortin, Royer, Potvin, Marcotte, & Yergeau, 2004). and grammatical errors at the word level; scoring grids
Screening, assessment and intervention tools that are are provided by grade and text length, such that a “very
adapted for the particular needs of the Canadian French- satisfactory” fourth-grade text would contain less than 4%
speaking population are urgently needed. incorrect words. Provincial reports focus on rate of success
(percentage of students receiving at least “acceptable”
Written language skills in Quebec school children ratings), as well as percentage of “unsatisfactory” ratings,
which indicate the need for special resources in the system.
With respect to literacy, French-speaking Canadian
children tend to underperform compared to their English- A report on recent student performance on the
speaking counterparts across Canada, as revealed by the obligatory writing tests from June 2009 (Charest, 2010)
Programme international de recherche en lecture scolaire revealed that boys scored significantly lower than girls on
(PIRLS; Labrecque, Chuy, Brochu, & Houme, 2012), which average and across all scoring criteria. The rate of success
tracks fourth-grade reading competence on a regular basis, declined with age (from 81% to 68%). The decline with age
permitting comparisons across language groups, genders, was particularly marked for orthography; furthermore, for
and provinces. PIRLS results from 2011 show that Canada as both younger and older children, the disparity between
a whole and Quebec as a province score significantly higher boys and girls was most noticeable in this area. In the
than the world average. However, Quebec students from primary grades, the lowest rate of success was for syntax
French-language school boards underperform compared and punctuation but “unsatisfactory” ratings occurred
to the Canadian average and the average of students in most often for orthography. The distribution of scores in
English-language schools in Quebec. (As an aside, students the orthography category was noticeably bimodal, with
in minority French-language school boards elsewhere in many children achieving “very satisfactory” scores but a
Canada underperform compared to the Canadian French- substantial group showing “unsatisfactory” performance
language average). The state of literacy in Quebec has been in this area (grade school: 3% of girls and 9% of boys; high
a major concern for some years now, since a government school: 5% of girls and 10% boys). Motivation to read was
a significant predictor of outcomes for younger children, Schatschneider, 2002; Dickinson, McCabe, Anastasopoulos,
and perceived competence in reading and writing were Peisner-Feinberg, & Poe, 2003; Dickinson & Porsche, 2011;
significant predictors of outcomes for older children. Hulme, Nash, Gooch, Lervag, & Snowling, 2015; Sénéchal
& LeFevre, 2002; Snowling & Melby-Lervåg, 2016; Speece,
In this report we will focus on spelling as the literacy Roth, Cooper, & de la Paz, 1999; Storch & Whitehurst, 2002).
skill of interest given that it emerged as a particular area of These studies show that oral language skills exert both
difficulty on the obligatory literacy assessment in Quebec indirect and direct effects on literacy. First, phonological
(Charest, 2010). Furthermore, it is an early marker of more awareness emerges from accumulating knowledge in the
generalized difficulties with writing and literacy overall. phonological and lexical domains; in turn, phonological
Spelling may be a particularly sensitive indicator of literacy awareness (which emerges implicitly) and letter-sound
problems; several studies have shown that at-risk children knowledge (which must be taught explicitly) combine to
who have poor reading skills are usually poor at spelling, underpin the child’s acquisition of decoding skills. In this
whereas some children are poor spellers while having way, oral language skills exert an early indirect effect on
relatively good reading skills (Holm, Farrier, & Dodd, 2008; the earliest stages of literacy acquisition. Later, when the
Lewis, Freebairn, & Taylor, 2000; Pennala et al., 2010). child is “reading to learn”, oral language abilities—such as
Furthermore, follow-up of participants being treated for vocabulary, syntax, and oral narrative abilities—directly
dyslexia indicates the persistence of spelling and writing support written language comprehension (Griffin, Hemphill,
difficulties long after resolution of the reading impairment, Camp, & Palmer Wolf, 2004; Nation & Snowling, 2004). An
in children (Berninger, Nielsen, Abbott, Wijsman, & Raskind, indirect effect remains because speed and automaticity
2008) and in adults (Connelly, Campbell, MacLean, & in the decoding process support comprehension when
Barnes, 2006). Finally, some studies have demonstrated reading sentence and passage level text. Oral language
a positive impact of spelling instruction on reading and skills also support the child’s writing abilities at every level,
other literacy skills (Graham & Santangelo, 2014; Weiser & including spelling, syntax, and narrative structure (Stothard,
Mathes, 2011). Snowling, Bishop, Chipchase, & Kaplan, 1998).
Oral language foundations of literacy Prediction of spelling abilities

Literacy includes a host of interconnected skills Given the heightened and continuing concern about
involving print: letter and letter-sound knowledge, the written language skills of French-speaking children in
decoding and sight word reading, spelling, grammatically Quebec, a targeted funding program was implemented
correct and coherent writing of sentences and passages, to encourage research in this area. Consequently, we
reading fluency, reading comprehension, and ultimately embarked on a project to develop a screening tool that
the ability to gain new knowledge and solve problems could be used to identify children at school entry who
using print materials, whether in paper or digital form. would potentially be at risk for slower acquisition of writing,
These written language skills are learned through direct or more specifically in this context, spelling at the end of
teaching and practice, beginning in preschool but with second grade. For predictors, we chose four aspects of
particularly explicit attention devoted to the teaching of oral language abilities that are known to be correlated with
reading and writing during the early school years. However, spelling specifically and literacy more generally. These
the foundation for literacy is formed during the preschool predictors are discussed in turn below: speech perception,
period with the acquisition of oral language skills, beginning speech production, phonological awareness, and
with language-specific shaping of perceptual knowledge morphology production.
during the first year of life. Every aspect of literacy has
been shown to be closely correlated with oral language Speech perception skills are a known correlate of
skills, including decoding, reading fluency, and reading emergent literacy skills, reading ability, and spelling
comprehension (Durand, Loe, Yeatman, & Feldman, 2013). (Anthony, Lonigan, Driscoll, Philips, & Burgess, 2003;
Furthermore, children who have speech and language Boets, Wouters, van Wieringen, De Smedt, & Ghesquière,
impairments are at risk for delayed acquisition of literacy 2008; Overby & Bernthal, 2008). For example, the ability
(Puranik, Petcher, Al Otaiba, Catts, & Lonigan, 2008). to discriminate short versus long vowels was found to
be associated with literacy skills in Finnish children, with
Longitudinal studies have linked oral language second-grade spelling abilities being the strongest correlate
development during the preschool period to the acquisition (Pennala et al., 2010). A speech perception test that uses
of literacy skills after school entry (Cooper, Roth, Speece, & a word identification procedure appropriate for young

children, and which was previously validated as a predictor were particularly difficult for French-speaking children on
of phonological awareness and emergent literacy skills in their writing tests. Furthermore, expressive morphology
English—the Speech Assessment and Interactive Learning is an aspect of structural language development that has
System (SAILS)—was modified for the French context and been previously linked to literacy development in general
used in this study (Rvachew & Grawburg, 2006). (Speece et al., 1999). Morphological awareness emerges in
early primary grades to aide reading and writing (Duncan,
Speech production accuracy also influences children’s Colé, & Casalis, 2009; Pacton & Deacon, 2008; Wolter,
spelling abilities. For example, articulatory similarity of Wood, & D’zatko, 2009). For example, Sénéchal, Basque,
vowels explains spelling confusions in English and in French and Leclaire (2006) showed that morphological awareness
(Caravolas & Bruck, 2000; Ehri, Wilce, & Taylor, 1987). was correlated with the ability to spell morphological
Furthermore, underlying organization of phonological and lexical words in grade 4 French-speaking children.
structure also explains common error patterns in early Metalinguistic knowledge of inflectional and derivational
spelling (Bourassa & Treiman, 2001), such as, for example, morphology is particularly helpful to spelling, but explicit
the omission of word-internal nasals or liquids that are morphological awareness is more reliably assessed in
represented as vocalic rather than consonantal elements second and third grade compared to early first grade
(e.g., “hand” → “had”). Many studies have shown that (Bédard, Marquis, Royle, Gonnerman, & Rvachew, 2013).
children who present with a speech sound disorder are Therefore, we included a measure of productive morpheme
at risk for future difficulties with spelling, even when their knowledge that we have used previously to describe the
language abilities are within the average range (Bird, Bishop, development of morphology in young Quebec children with
& Freeman, 1995; Lewis, Freebairn, & Taylor, 2002; Overby, and without language impairments (Jeu de Verbes; Marquis,
Masterson, & Preston, 2015). Therefore, we included a Royle, Gonnerman, & Rvachew, 2012; Royle, 2007; Royle &
test of speech production accuracy that has been used Thordardottir, 2008). This test assesses the child’s ability
to describe the speech abilities of monolingual and to produce French verbs in the passé composé (perfect
bilingual children in primary school (the Test de Dépistage past) form, using the auxiliary avoir (“to have”) or être (“to
Francophone de Phonologie [TDFP]; Rvachew et al., 2013), be”) and a past participle of the verb. We used this specific
as well as the speech errors produced by preschoolers with structure because it is acquired early (Thordardottir &
a phonological disorder (Brosseau-Lapré & Rvachew, 2014; Namazi, 2007) and it can be reliably elicited in children
Paul, 2009). Moreover, performance on this test has been as young as age 3;2 (years;months; Royle, 2007). In
shown to be closely related to phonological awareness contrast, many aspects of morphology are highly irregular
performance (Brosseau-Lapré & Rvachew, 2017). or are variably produced in oral French (Kresh, 2008;
Legendre et al., 2009). Other aspects of morphology that
Phonological awareness is well recognized as an involve allomorphy (e.g., liaison, elision, and contraction;
excellent predictor of reading and spelling abilities (Holm Béchara, 2015) were not tested because they confound
et al., 2008; Schneider, Roth, & Ennemoser, 2000). morphological and phonological processes.
For example, Speece et al. (1999) found that strong
phonological skills in kindergarten were associated with We chose spelling at the end of second grade as
strong spelling abilities in first grade. We selected a measure our outcome, given that spelling is an area of particular
of implicit phonological awareness skills, requiring no spoken weakness, and spelling may be an early indicator of the
responses, so that the children’s performance would writing difficulties identified throughout the school years
be independent of their speech accuracy. The English on the province-wide literacy competency assessment.
version of this test predicts reading and spelling ability Therefore, word and phrase level spelling was tested from
(Bird et al., 1995; Rvachew, 2007). The French version—the dictation, using the Batterie d’évaluation de lecture et
Test de Conscience Phonologique Préscolaire (TCPP)— d’orthographe (BELO; George & Pech-Georgel, 2006), as
has previously been used to describe and differentiate the final outcome at the end of second grade. The BELO
phonological awareness skills of children receiving speech was standardized on a sample of 371 early-grade children
therapy from children with normally developing speech and and found to have excellent reliability and convergent
language skills (Rvachew & Brosseau-Lapré, 2015; Brosseau- validity. In particular, the BELO was validated against the
Lapré & Rvachew, 2017). Alouette (Lefavrais, 2006) on 100 children (Pech-Georgel
& George, 2010). This task was chosen because it is
The fourth target of our screening protocol was adapted to the age level and language of our participants
knowledge of grammatical morphemes, specifically the and evaluates phono-orthographic abilities (non-word
past tense. As previously mentioned, aspects of grammar syllables), basic orthographic abilities for known words
(real words), and basic grammatical abilities (sentences). of Quebec (Canada). The particular area from which the
Although the test is based on dictation rather than free children were recruited, according to the most recent
narrative (as is developmentally appropriate for second- census, is an area of high immigration with 61% of the total
grade spellers; see Alamargot, 2007), the coding is similar to population speaking French as the mother tongue and 28%
that used in the provincial writing assessment, in that each speaking neither English nor French as the mother tongue.
word is scored as spelled correctly or incorrectly, capturing Less than 13% of the population speaks English regularly
spelling and grammatical abilities simultaneously. at home. By law, immigrant children must be educated in
French in Quebec.
Overview and objectives
All children in the kindergarten and first-grade
The screening test was developed in a two-phase classrooms were eligible for participation regardless of their
process. This research project will be described in relation language background or the presence of developmental
to the objectives for each of the two phases, as follows: difficulties, as long as the parent consented and the child
assented and was able to cooperate with the testing
Phase I, Objective 1: Administer the full battery of
procedures. A telephone interview was conducted with
assessments to kindergarten and first-grade children in
each child’s parent to obtain demographic, literacy, health,
order to test whether our measures of speech perception,
and language information via standard questionnaires.
speech production, phonological awareness and
Parents identified possible developmental concerns
morphology production would differentiate children likely
for some children but we did not verify these concerns
to differ in writing abilities as consequence of variations
via diagnostic testing or by obtaining confirmatory
in grade, language background, perceived risk, and overall
documentation. Language status was based on parental
test performance.
reports of their own language use with and around their
Phase I, Objective 2: Using item-level discriminability child, siblings’ language use, other caregivers’ language use,
and difficulty statistics, select a smaller set of items from and radio and television exposure. A 90% criterion of French
among these measures to form a screening test, which is exposure from birth was used to determine monolingual
hypothesized to predict future spelling abilities while being status of children placed in the monolingual (ML) group. The
shorter than the full test battery. remaining children were placed in the bilingual (BL) group
(i.e., either simultaneous BL with exposure to two languages
Phase II, Objective 3: Administer the screening test, from birth, or sequential BL with no French exposure until
Prédiction des Habiletés Orthographiques Par des Habiletés preschool). The languages represented besides French
Langage Oral (PHOPHLO), to first-grade children, followed were diverse, including English, Arabic, Spanish, Haitian
by a spelling test, BELO, to the same children in second grade, Creole, Italian, Greek, Lao, Polish, Romanian, Asu, and Khmer.
in order to determine the specificity and sensitivity of the Teachers were also asked to rate each child as being “at-
PHOPHLO as a predictor of BELO performance. risk” or “not-at-risk” for developing writing difficulties, on the
basis of their own opinion with no specific criteria provided
Phase II, Objective 4: Examine the contribution of each
(for more information about the teacher ratings, see Kolne,
of the four subtests in the screener to the identification of
Gonnerman, Marquis, Royle, & Rvachew, 2016).
children who proved to have poor spelling performance at
the end of second grade, with the expectation that the test Children were tested individually in a quiet room inside
as a whole and the individual subtests will contribute to the the school. The assessment protocol in both phases
prediction of spelling abilities. was administered by native French-speaking graduate
level research assistants under the supervision of a post-
General Method doctoral fellow, the fifth author. All scoring, transcription,
Testing protocols were approved by the internal review and reliability coding was subsequently completed by native
boards from both the Université de Montréal and McGill French-speaking graduate students in speech-language
University Faculties of Medicine. The children were recruited pathology with training in clinical phonetics and phonology,
from their school by sending letters home and asking under the supervision of the first and second authors.
parents to return a signed consent form if they agreed to
their child’s participation. Phase I: Development of screening test
The study participants were drawn from a French public Method

school board located in a suburb of Montréal in the province The Phase I experiment involved cross-sectional

assessments of children in kindergarten and first-grade (according to the teacher rating) and grade (kindergarten
classrooms. The children were tested at the end of the versus grade 1) and overall performance (using a split-half
school year. Although the final screening test is intended procedure for total test score regardless of child’s age or
to identify children who may be at risk for written language grade or risk status).
problems prior to onset of formal reading instruction, a group
of children who were expected to have beginning reading Speech perception. The Speech Assessment and
skills were included in the Phase I sample (that is, children Interactive Learning System (SAILS; Rvachew, 2009)
assesses speech perception with a two-alternative,
at the end of the first-grade year). This was so that the
forced-choice word identification task. The child hears
items for the screener could be selected that discriminated
natural speech recorded from adults and typically
performance across a broad range of skill levels.
developing children. The words are presented in blocks of
10 items, five representing the target and five representing
Participants
a misarticulated version of the target word. The child
The children recruited to the Phase I experiment listens to each word and points to a picture of the target
comprised 43 children from kindergarten classrooms with when a correct pronunciation is heard and an X when
a mean age of 6 years and 1 month, including 21 boys (22 a misarticulation is heard. A laptop was used to run the
girls) and 24 ML (19 BL) speakers of French. From a first- software that ensures random ordering of stimuli within
grade classroom, 18 children were recruited with a mean blocks. The child listened to the stimuli over headphones,
age of 7;2, including 11 boys (seven girls) and 12 ML (six BL) presented at the loudest comfortable level. The examiner
speakers of French. On average, the number of years of used a mouse to activate the hotspot selected by the child
maternal education was 14.48 (SD = 2.06). Developmental on the computer screen and responses were recorded
diagnoses were suspected but not confirmed by automatically by the software. A reinforcement image was
professional assessments for four kindergarten children presented after each response, regardless of whether
(autism spectrum disorder, intellectual disability, and the child’s response was correct or not. An experimental
attention deficit disorder). A heart defect was reportedly French version of SAILS was developed for this study, which
diagnosed for one child and language impairment for included two blocks of gris ([ɡʁi] – “grey”) stimuli recorded
another. Parents reported concerns about hearing due to from preschool-aged children, two blocks of serpent
otitis media for five children and about fine motor skills for ([sɛʁpã] – “snake”) stimuli recorded from adults, and two
three children. blocks of poisson ([pwasɔ͂ ] – “fish”) stimuli recorded from
adults. Erroneous tokens represented commonly occurring
Procedure misarticulations, including omissions (e.g., gris → [ɡi],
poisson → [pasɔ͂ ], serpent → [sɛpã]) and substitutions
The four different language assessment tasks
of consonants (e.g., gris → [ɡji], poisson → [bwasɔ͂ ]) and
were administered over two separate sessions pairing
vowels (e.g., serpent → [sɛʁpɑ]). Each test was preceded by
phonological awareness and speech perception in one
10 practice trials involving an easy contrast (e.g., [ɡʁi] versus
20-minute session, and morphology production and
[mi]), during which the examiner could help the child to
phonological production in another 20-minute session,
understand the task. The test comprises 60 items, of which
with order counterbalanced within session and across
30 are practice items. The test is scored as percentage of
participants. Evaluation sessions occurred within a
items correct out of the remaining 30.
maximum of two weeks from each other. Sessions were
recorded with a Zoom1 stereo digital recorder at a sampling Speech production. The Test de Dépistage
frequency of 44 kHz and a quantization rate of 24 bits. Francophone de Phonologie (TDFP), described in complete
Responses to the speech perception and phonological detail in Rvachew et al. (2013), comprises eight colour
awareness tasks were automatically recorded by the test photos, presented digitally with verbal prompts used to elicit
device, whereas responses to the speech production 30 spoken words from the child. The words were selected to
and morphology production tasks were transcribed from be known by children aged 2 to 8 and to be representative
audio recordings. Subsequently, 16% of all audio recordings of the distribution of phonemes, syllable shapes, and word
for these two production tasks were retranscribed to lengths characteristic of Quebec French. Consonants
obtain estimates of transcription reliability. Following data appear in four syllable positions: singleton syllable onset
collection and coding, the children’s performance on (e.g., the first consonant in niche [niʃ] – “doghouse”),
each test item was examined to reveal item difficulty and branching onsets (e.g., the two consonants at the beginning
item discrimination scores when differentiating risk status of the word clown [klun] – “clown”), glide in the nucleus (e.g.,
glide following the /v/ in avion [avjɔ͂ ] – “plane”) and the coda e.g., fini – “finished”); seven with a participle –u (/y/; e.g.,
(e.g., the /ʁ/ in the words serpent [sɛʁpã] and hélicoptère mordu – “bitten”); and seven with other non-paradigmatic,
[elikɔptɛʁ] – “helicopter”). The test is scored as percentage or opaque, forms (e.g., ouvert – “opened”). All items are
of consonants correct with every consonant in every word conjugated with avoir. The expected pronoun is il (“he”) or
considered, therefore 94 consonants within 30 words. Inter- elle (“her”), but was not counted as incorrect if a gender
rater point-by-point transcription agreement for narrow error occurred. The items are described in more detail in
transcription of consonants was 95.9%. Marquis et al. (2012). One point was given for each correct
production of the full passé composé (i.e., the pronoun
Phonological awareness. The Test de Conscience clitic, auxiliary, and past participle; for example, (Marie), elle
Phonologique Préscolaire (TCPP; Brosseau-Lapré & a caché – (Marie), she AUX hid.pp). The total score was out
Rvachew, 2008) was modeled on the phonological of 24. Coding reliability for correct production of 25% of
awareness test developed by Bird et al. (1995), adapting it tested children was 98.8%.
for French and implementing it on a computer using HTML
software code. It consists of three subtests but only the first
Results and Discussion
(rime matching) and third subtests (onset segmentation
and matching) were administered to the children in this The children’s performance, on average, for the four
study. (The second subtest also targets onset matching oral language tests, is shown in Table 1 by subtest for the
and was omitted to reduce testing time because this is a full group and for contrasting subgroups, specifically
very long assessment). In the rime matching subtest, the kindergarten versus first-grade children, boys versus girls, BL
child is presented with an animal and its name, and told vs. ML children, at-risk versus not-at-risk children according
that it “likes things that sound like his name”. In the onset to teacher report, and low-scoring versus high-scoring
and segmentation subtest the child is told the animal “likes children. The low- versus high-scoring subgroups were
things that start with the same sound as his name”. For each identified by transforming the scores on all four tests to
trial the child is presented with four pictured items (the z-scores, taking the mean of the z-scores across the four
target and three distractors) and these items are named for tests, and then splitting the whole group (kindergarten and
the child on every trial. There are five practice items at the first grade combined) at the median z-score. Differences
beginning of each subtest during which corrective feedback in means across pairs of subgroups were assessed against
can be provided as necessary. The task was presented by the standard deviation of subtest scores for the full group
computer although the examiner provided extra support, of children. If one considers a half-standard deviation
especially during the practice items. The child responded by difference in means to be of interest, Table 1 shows that the
touching the appropriate picture and the software recorded tests were generally discriminating. Specifically, the speech
responses automatically. The total test score is the number perception test (SAILS) differentiated sub-groups on the
of correct items out of 24 (14 rime matching and 10 onset basis of grade and overall test score (i.e., low vs. high scores).
segmentation, excluding practice trials). Speech production accuracy (TDFP) also differentiated
kindergarten from first-grade children and the low-scoring
Morphology production. The children’s ability to from high-scoring subgroups. Phonological awareness
produce passé composé forms was assessed with an (TCPP) differentiated groups well with differences
elicited production task for verbs using an interactive between mean scores sometimes more than a standard
Android platform. The application simulated a storybook deviation apart and differences apparent between grades,
where the children are asked to complete short stories risk subgroups and low- versus high-scoring subgroups.
by responding to questions from the experimenter. The Morphology production (Jeu de verbes) differentiated the
adults would read three short sentences presenting the BL versus ML subgroups.
target verb in order to induce the perfect past. For example,
along with an image of a girl hiding her dolls under a box, Given that each of the four domains assessed proved
the script presented was: Marie va cacher ses poupées. to have some value for differentiating subgroups of
Marie cache toujours ses poupées. Qu’est-ce qu’elle a fait children who might be expected to present with varying oral
hier Marie? (“Marie will hide (infinitive) her dolls. Marie hides language skills, it was decided to include all four subtests
(present, 3rd person singular) her dolls every day. What after item analyses to reduce the length of testing. Detailed
did she do yesterday, Marie?”) The tasks had four types item analyses, including discriminability and difficulty
of verbs with seven items each (four of which were used indexes and item-total correlations, were used to select
as practice items): seven verbs with a past participle in –é a smaller subset of items from each subtest to create
(/e/; e.g., caché – “hidden”); seven with a participle in –i (/i/; a pilot screening tool that could be administered in a

Table 1. Results Obtained for the Four Oral Language Tests Administered in Phase I by Subgroup
Speech Speech Phonological Morphology

Production Perception Awareness Production
Subgroup N M SD M SD M SD M SD
All children 61 87.32 8.24 90.69 6.84 17.11 5.24 13.61 7.27
Kindergarten, vs. 42 85.97 8.94 89.60 7.48 15.23 5.01 12.74 7.42
First grade 18 90.56 5.14 93.28 4.07 21.61 2.15 15.67 6.63
Boys, vs. 29 86.88 6.81 90.31 6.47 17.16 5.23 14.59 7.01
Girls 32 87.82 9.68 91.10 7.31 17.07 5.25 12.52 7.52
L2 French, vs. 36 85.73 9.74 88.96 7.91 15.92 5.51 11.52 7.41
L1 French 25 88.43 6.95 91.89 5.80 17.94 4.96 15.16 6.90
At-risk, vs. 29 85.40 9.78 89.17 6.18 14.48 5.11 14.03 7.44
Not-at-risk 32 89.06 6.21 92.06 7.30 19.50 4.16 13.22 7.21
Low score, vs. 23 82.32 4.79 88.35 7.53 15.43 5.14 13.26 7.60
High Score 38 90.35 8.46 92.11 6.05 18.13 5.11 13.82 7.16
Note. Speech Perception is scored as percent correct over 30 items; Speech Production is scored as percent correct over 30 words and 94
consonants; Phonological Awareness is scored as number correct over 24 items; Morphology Production is scored as number correct over 24 items.
Bold lettering highlights subgroup means that differ by more than one-half standard deviation (calculated from all children by test).
single test session. Specifically, items with relatively poor The game Écoute (“Listen”) tests speech perception
discriminability and difficulty indexes were eliminated from with a 10-item word recognition procedure targeting the
each subtest, using the top and bottom quarter of the word gris in which five items are correctly produced ([ɡʁi])
sample, based on total subtest scores (Burton, 2001; Kelley, and five items are misarticulations as follows: [ɡi], [ɡi], [ɡi],
1939; Gelman & Park, 2001). For example, with respect to [ɡji], [ŋɡi]. All items are produced by different child talkers
the speech perception test, many of the poisson items so that even though some items are phonetically the same,
were identified correctly by all of the children and therefore each item is acoustically distinct. A practice block of 10 trials
did not discriminate high- and low-scoring subgroups; in precedes the test block. A screenshot of a single practice
contrast, the five items that were ultimately selected for trial is shown in Figure 1. During test trials, caterpillars
identification as incorrect exemplars of the word gris were turn into butterflies with each completed item, providing
associated with an average discrimination index of 0.37. noncontingent feedback that helps the child gauge progress
Similarly, when considering the morphology production toward game completion.
test, the verb item couvrir (“to cover”) was eliminated
with a discrimination index of 0.15, reflecting the extreme The game Qu’est-ce que c’est? (“What is it?”) tests
difficulty of this item for both high- and low-scoring children; speech production accuracy by presenting children with
by contrast, the item remplir (“to fill”) was retained with colour drawings of 10 items for naming. There are no
a discrimination index of 0.85. This process was applied practice trials but additional verbal prompts are available if
to each item in all four subtests, with the result described the child does not know the name of the item. Specifically, if
below by subtest. the child produces no response or the wrong word, the first
Figure 1. Screen shots from the four PHOPHLO subtests: Speech Perception, Écoute “Listen” (top left); Speech Production,
Qu’est-ce que c’est? “What is it?” (top right); Phonological Awareness, Ils aiment quoi? “What do they like?” (bottom left);
and Morphology Production, Qu’est-ce qu’ils font? “What are they doing?” (bottom right).
prompt provides a semantic hint and the second hint prompts screenshot showing the layout from one of the test items is
for delayed imitation of the target word. The consonants in shown in Figure 1. Disappearing pizza slices mark progress
the word are presented on screen so that the examiner can toward the end of the game, indicating trial completion
then identify consonants that were misarticulated by the child, without regard for response accuracy.
or, alternatively, the entire word can be marked as correct.
The software provides a response grid to the examiner for The game Qu’est-ce qu’ils font? (“What are they doing?”)
recording production errors, yielding a count of correctly prompts production of passé composé verb forms using
produced consonants out of 36 in total. The 10 items are the procedure previously described. Ten items target the
niche, tournevis (“screwdriver”), serpent, clown, araignée verbs rire (“to laugh”), sentir (“to smell”), remplir, ouvrir
(“spider”), enveloppe (“envelope”), garde-robe (“closet”), (“to open”), conduire (“to drive”), battre (“to beat/win”),
parapluie (“umbrella”), hélicoptère, and camion (“truck”). défendre (“to defend”), perdre (“to lose”), mordre (“to bite”),
A screenshot of the item hélicoptère is shown in Figure 1. and boire (“to drink”), most ending in –i or –u and one having
Daisy petals are added with each item to help the child an idiosyncratic form. Tablet icons permit the examiner to
gauge progress toward completion of the game. indicate which parts of the child’s response were correct
(subject + auxiliary + participle). The software provides
The game Ils aiment quoi? (“What do they like?”) tests detailed information about the child’s performance (i.e.,
rime awareness using the procedure previously described in subject, auxiliary, and participle for each item), but the
which the child identifies the item that matches the rime of total score tabulated by the software reflects the number
the name of the animal. Five practice trials using the names of complete items produced correctly, out of 10. Scoring
Guy ([ɡi]) and Jeanne ([ʒan]) are provided for teaching the thus reflects the child’s ability to produce not only the past
task. Subsequently, 14 test items target the names Lou ([lu]), participle morpheme but to produce it in context including
Paul ([pɔl]), Lucas ([luka]), and Plé ([plɛ]), in each case the subject and auxiliary. Again, feedback marking trial
with four pictures shown representing the answer and three completion is noncontingent except for the practice trials.
distractors. The software records the child’s picture touch One trial from this game is shown in Figure 1 (specifically the
responses and sums correct responses for the test items. A trial that elicits Il a mordu – “He bit”).

This process of item selection by subtest resulted in a as the outcome of the Phase I study, in a single session
64-item screener (44 test trials and 20 practice trials) that lasting approximately 20 minutes. As the children were
correlated with the full test battery, r = .89, p < .0001. Test approaching the end of second grade, the BELO (George
order is fixed but item order may be randomized within & Pech-Georgel, 2006) was administered to the children
each test. The screener was subsequently developed in small groups of three or four, in order to assess their
as an integrated software tool that can be accessed and spelling ability. A standard dictation procedure was used:
implemented on multiple digital platforms (Android or the examiner presented the items live-voice; the children
iPad tablets, or Windows or Macintosh computers). All wrote down what they heard on paper marked with familiar
visual and auditory stimuli are presented by the software, primary school line markings. The test was not timed and
noncontingent visual feedback is provided for every child therefore each item was presented when the entire group
response, and these are recorded and tabulated by or had completed their transcription of the previous item.
with the assistance of the software. After the screening In the first section there were 10 non-word items: five
is complete, a complete record of the child’s responses single-syllable items (e.g., fir) and five two-syllable items
is provided along with an indication of whether the child (e.g., palon). Next, 15 real word items were presented,
passed or failed according to the criteria developed in including 10 high-frequency words and five low-frequency
Phase II of the project. words with simple (e.g., fam in famille – “family”), complex
(e.g., ille in famille), and contextual grapho-phonemic
Phase II: Testing of an oral language screen as a
correspondences (e.g., g in rouge [ʁuʒ] – “red”). A third
longitudinal predictor of spelling
writing task elicited four sentences that were seven to 11
Method words in length, for a total of 35 words in sentences. The
final score was calculated as the percentage of words
The Phase II experiment involved longitudinal
spelled completely and correctly out of a total of 60.
assessments of children tested during the first term of
grade 1, using the PHOPHLO screener that was developed in
Results and Discussion
Phase I, and again during the final term of grade 2, using the
BELO test of spelling. Table 2 describes the children’s performance, in first
grade, on the four subtests of the PHOPHLO. Speech
Participants perception performance, expressed as perception trials
correct, ranged from random selection of response
The children recruited to the Phase II experiment
alternatives to perfect accuracy. Speech production
comprised 91 children from first-grade classrooms with a
accuracy, presented as percent consonants correct, was
mean age of 6;9, including 36 boys (55 girls) and 52 ML (39
very high on average—as is expected for French—but some
BL) speakers of French, with mean maternal education 14.55
children scored very far below the mean. Phonological
years (SD = 2.08). Concerns about the children’s development
awareness, shown as number of correct items out of 14, also
were raised in several areas, specifically language learning
ranged from random guessing to perfect performance. The
(three children), hearing (two children), attention deficits (four
morphology test resulted in the full range of possible scores
children), fine motor skills (three children), dyslexia (three
from 0 to 10 items produced completely correct. Therefore,
children), social problems with peers (one child) and anxiety
with the exception of the speech production test, the
(one child). At the end of the second grade, 78 children were
effective floor and ceiling was observed in the children’s
located to receive the outcome assessment. Some children
responding but the mean scores were not at floor or ceiling.
were lost to follow-up because they moved out of the school
district. Some children were included in a pilot study that Table 3 describes the performance of the 78 children
involved first-grade administration of the BELO (Kolne et al., who wrote the spelling test at the end of second grade. In
2016), and therefore these children were excluded from the this case, some children achieved a perfect score on one or
Phase II experiment. The 78 remaining participants were aged more subtests but no child achieved a perfect total score
8;2 on average, with the group composed of 30 boys (48 girls) of 60 points. All children were able to spell some non-words
and 45 ML (33 BL) speakers of French, and mean maternal and real words correctly. The descriptive data presented in
education 14.46 years (SD = 2.09). Tables 2 and 3 were used to define pass and fail criteria for
PHOPHLO subtests and for BELO performance specifically
Procedure for this sample, so as to take into account the particular
At the beginning of first grade, the children were characteristics of this sample including demographics,
assessed with the PHOPHLO screening test, described varied language background—more specifically Quebec
Table 2. Children’s Performance in First Grade on PHOPHLO Subtests (n = 91)
Game Construct Min Max M SD Cut-Off Score
Écoute Speech perception 50 100 91.10 13.94 80
Qu’est-ce que c’est? Speech production 78 100 96.94 3.97 91
Ils aiment quoi? Phonological awareness 5 14 11.95 2.14 10
Qu’est-ce qu’ils font? Morphology production 0 10 7.00 2.99 3
Note. The four games comprise the screening test Prédiction des Habiletés Orthographiques Par des Habiletés Langage Oral (PHOPHLO), with
each scored as follows: Speech Perception was scored as percent correct over 10 items; Speech Production was scored as percent correct over
10 words and 36 consonants; Phonological Awareness was scored as number correct over 14 items; Morphology Production was scored as number
correct over 10 items (excluding 20 practice items overall). The cut-off scores are approximately 1.25 standard deviations below the mean, with
rounding and some adjustments for skewed distributions.
Table 3. Children’s Performance in Second Grade on BELO Subtests (n = 78)
BELO Subtest Min Max M SD M - 1.25 SD
Nonwords 3 10 8.60 1.26 7.03
Words 2 15 10.88 3.07 7.04
Words in Sentences 9 35 28.15 4.68 22.30
Total Score 14 59 47.55 8.23 37.26
Note. The subtests comprise the spelling test Batterie d’évaluation de lecture et d’orthographe (BELO; George & Pech-Georgel, 2006).
French as first or second language—and the literacy other words, all children who scored 38 or above passed
teaching practices in the province. Subsequently, we and all children who scored 37 or below failed). The risk
examined BELO performance as a function of PHOPHLO of significantly poor spelling performance at the end of
performance more directly. In Table 4, number of children second grade, given poor PHOPHLO performance at the
who passed or failed each PHOPHLO subtest is shown along beginning of first grade, is shown. For example, the last row
with the corresponding mean score, using the cut-off score of Table 4 indicates that 68 children passed the PHOPHLO
for each PHOPHLO subtest as shown in Table 2 (children in first grade, achieving a mean score of 49 on the BELO in
who obtained a score below the cut-off failed the subtest). second grade with only 3% of this group failing the BELO.
Ultimately 68 children passed the PHOPHLO screen (i.e., In other words, two children who passed the PHOPHLO in
passed at least three subtests) and 10 children failed (i.e., first grade failed the BELO in second grade; in contrast, 10
failed two or more subtests). children failed the PHOPHLO in first grade and five of these
10 (50%) also failed BELO in second grade.
Table 4 shows the mean and the standard deviation of
the BELO score for the children who passed the PHOPHLO As indicated in Table 4, BELO performance is lower
and the children who failed the PHOPHLO in first grade, for children who failed than for children who passed
with a total score of 38 (approximately -1.25 SD below the the PHOPHLO subtests. The mean differences were
mean) being the cut-off for passing the spelling test (in submitted to nonparametric randomization tests

Table 4. Second-Grade BELO Performance as a Function of Passing or Failing PHOPHLO in First Grade
Spelling Performance (BELO Scores) in Second Grade
Game Construct Pass PHOPHLO Fail PHOPHLO
M SD n* Fail BELO n,% M SD n† Fail BELO n,%
Écoute Speech perception 48.17 6.97 70 4, 6% 42.13 15.12 8 3, 38%
Qu’est-ce que c’est? Speech production 48.40 7.13 68 5, 7% 41.80 12.63 10 2, 20%
Ils aiment quoi? Phonological awareness 48.35 8.15 65 4, 6% 43.54 7.74 13 3, 23%
Qu’est-ce qu’ils font? Morphology production 48.97 6.86 63 3, 5% 41.60 10.83 15 4, 27%
PHOPHLO Fail 2 or more subtests 49.01 3.37 68 2, 3% 37.60 12.32 10 5, 50%
Note. PHOPHLO = Prédiction des Habiletés Orthographiques Par des Habiletés Langage Oral; BELO = Batterie d’évaluation de lecture et d’orthographe; *
*this column indicates the number (n) of students who passed the PHOPHLO (sub)test and is the denominator for the percentage (%) of students who
failed the BELO, given that they passed the PHOPHLO (sub)test in first grade; †this column indicates the number (n) of students who failed the PHOPHLO
(sub)test and is the denominator for the percentage (%) of students who failed the BELO, given that they failed the PHOPHLO (sub)test in first grade.
(Edgington & Onghena, 2007) because the sample sizes were Some details about the children who failed either the
very different and therefore the assumption of homogeneity PHOPHLO screening in first grade or the BELO spelling
of variance was not met, precluding parametric tests. For the test in second grade are shown in Table 6. It is instructive
subtest Écoute, t = -0.641, p = .26, d = 0.374; for Qu’est-ce que to consider the cases of successful and unsuccessful
c’est?, t = -2.44, p = .01, d = 0.413; for Ils aiment quoi?, t = -1.96, prediction separately, especially in relation to the language
p = .04, d = 0.298; for Qu’est-ce qu’ils font?, t = -3.31, p = .002, background of the students. Although this group of
d = 0.476; and for the PHOPHLO, t = -4.60, p < .001, d = 0.779. children is very small, some patterns in these data inform
Therefore, it can be seen that the mean differences in BELO hypotheses for future research.
performance were statistically significant for three subtests:
Considering the children who failed the PHOPHLO
those targeting speech production, phonological awareness,
and the BELO (the true positives), three of the
and morphology production. The largest effect size was
children demonstrated difficulties with phonological
obtained when total screening test performance was taken
representations, specifically failing the speech
into account.
perception test along with either the speech production
The information about the probability of passing the or phonological awareness subtests. The remaining
BELO, given a failure on the PHOPHLO approximately 18 two children had difficulty with phonological and non-
months prior, yields a sensitivity of 71% (i.e., proportion phonological language skills, that is, the phonological
of true positives identified) and specificity of 93% (i.e., awareness and morphology production subtests of the
proportion of true negatives identified) for the PHOPHLO PHOPHLO. Three of the five children were male and all
as a screen for spelling difficulties in this sample. The data were monolingual speakers of French. The parents of three
for these calculations are provided in Table 5, along with the children reported concerns that the children might be at risk
likelihood ratio, indicating that a second-grade poor speller for dyslexia due to a family history, and a fourth child had
was 10 times more likely to have failed the PHOPHLO in first reported issues with conductive hearing loss. In first grade,
grade than a good speller. the average teacher rating of risk for future writing problems
Table 5. Performance of the PHOPHLO as a Screening Tool
Fail BELO Pass BELO Row Totals
Fail PHOPHLO 5 5 10
Pass PHOPHLO 2 66 68
Column Totals 7 71 78
Likelihood Ratio 0.71 0.07 10.14
Note. PHOPHLO = Prédiction des Habiletés Orthographiques Par des Habiletés Langage Oral; BELO = Batterie d’évaluation de lecture et
d’orthographe.
Table 6. Test Scores of Children who Failed the BELO or the PHOPHLO
BELO BELO Speech Speech Phonological Morphology PHOPHLO

Language
Status Total Perception Production Awareness Production Status
Fail 32 100 100 7 0 Fail ML
Fail 30 90 100 7 1 Fail ML
Fail 37 60 100 9 8 Fail ML
Fail 14 70 86 10 0 Fail ML
Fail 26 50 78 11 10 Fail ML
Fail 32 100 100 10 0 Pass ML
Fail 30 100 94 11 9 Pass ML
Pass 52 50 100 12 2 Fail ML
Pass 49 50 91 8 0 Fail BL
Pass 52 100 89 8 1 Fail BL
Note. PHOPHLO = Prédiction des Habiletés Orthographiques Par des Habiletés Langage Oral; BELO = Batterie d’évaluation de lecture et
d’orthographe; ML = monolingual; BL = bilingual; blue shading indicates that the child failed the subtest by scoring below the cut-off scores shown in
Table 2.

was 2.8, higher than the mean rating of 1.6 for monolingual predict the child’s future response to formal instruction
children in this study (see Kolne et al., 2016 for details of the in school, independently of variations in access to direct
teacher ratings). literacy instruction in the home or preschool environment.
Therefore, we conducted a two-phase study to develop
Two other children failed the BELO in second grade a screening procedure that is focused on oral language
despite passing the PHOPHLO in first grade. The parents of abilities for the purpose of identifying children who may
these male children reported concerns about their child, struggle to learn to read and spell in the early school years.
specifically a history of language comprehension problems In this study, we screened children’s speech perception,
that were treated in preschool in one case and significant speech production, phonological awareness, and
concerns about social problems with peers and aggressive morphology production abilities at entry to first grade
behavior with respect to the other child. The teacher ratings and predicted spelling skills at the end of second grade.
of concern about future writing difficulties were relatively The results of the study will be discussed in relation to our
high at 3.5. objectives first. Subsequently, the limitations of the study
Five other children failed the PHOPHLO but passed will be discussed in detail.
the BELO in second grade: all five failed the morphology
production subtest of the PHOPHLO and four failed the Development and performance of the PHOPHLO
phonological awareness subtest. Four of the five children Objective 1. Given that oral language abilities predict
were drawn from the BL subsample, in other words speaking the acquisition of literacy skills in general and spelling
a language that was not French at home. The parents of in particular (Pennala et al., 2010; Speece et al., 1999),
these five female children reported no concerns about the first objective was to examine the role of speech
their development. Their teachers provided a mean rating perception, speech production, phonological awareness,
of concern about their future writing skills of 3.2, however— and morphology production in differentiating children who
higher than the mean rating for BL children of 2.0. should differ in literacy skills. In Phase I, we tested 61 children
with the full versions of our tests, and found that certain
Table 6 shows that the failures of sensitivity occurred subtests differentiated children with higher versus lower
within the subgroup of ML children such that two of performance overall. Phonological awareness performance
seven MLs who failed the BELO were not identified by the was especially discriminating but speech perception and
PHOPHLO. These two children who proved to be poor production were also effective. ML versus BL children
spellers after passing the PHOPHLO screen highlight the performed differently on the morphology production test.
fact that this screening test does not measure the child’s Therefore the Phase I results suggested that it was prudent
performance in all domains of knowledge that are known to to continue the development of the screener with all four
predict literacy outcomes. constructs represented.
The failures of specificity were largely due to BL Objective 2. A second important objective in the first
language exposure. It seems that children who are not fully phase was to reduce the total number of items to create a
competent in their French language skills at school entry screening test that could be administered in a much shorter
can achieve good spelling skills by second grade. This may period of time while covering the same four constructs.
occur because ML and BL children have received similar Ultimately the number of items was reduced from 152 to
exposures to written language instruction whereas these 64 items in a screener that contained 44 test items and
two groups have had quite different experiences in the 20 practice items. The correlation between the shorter
oral language domain. It is not certain that the BL children screening test and the longer test battery was .89. However,
who failed the PHOPHLO at school entry will be successful future studies are necessary to establish the reliability of
on the provincial literacy exam in fourth grade given that it this screening test within and across screeners, especially
requires integration of written language skills across a variety those with different training and preparation, and in varied
of areas including reading comprehension as well as overall school environments.
coherence, syntax, punctuation, spelling, and grammar
when writing a narrative. Objective 3. The primary objective of Phase II was to
determine the sensitivity and the specificity of the screener
General Discussion to predict spelling performance at the end of second grade.
Oral language skills are readily observable at or before For our sample of suburban Quebec children in which a
the onset of formal reading and writing instruction and may large proportion were bilingual, the PHOPHLO proved to
have a sensitivity of 71% and a specificity of 93% as a screen Subsequently, follow-up studies with more varied samples,
for poor spelling abilities. Clearly, further study is required to including children with lower maternal education, for
replicate this result as will be discussed further. example, would be advisable.
Objective 4. Questions about the contribution of the Another subgroup analysis that would be enabled by
four constructs to the utility of the screening test continued a larger validation sample would concern the emergence
into the second phase of the study. PHOPHLO performance of possible gender differences in literacy skills during the
in first grade was associated with BELO performance primary grades. Although significant gender differences are
in second grade, especially with respect to speech observed on the obligatory written language competency
production, phonological awareness, and morphology exam in Quebec, we did not observe any gender differences
production. The subtest targeting speech perception did in PHOPHLO performance at school entry. Our sample
not differentiate children with respect to mean BELO score. was too small and unbalanced to explore this issue further.
It is possible that this subtest is particularly vulnerable to Limbrick, Wheldall, and Madelaine (2012) found that boys
poor performance due to extraneous variables that do and girls do not differ in any aspect of literacy performance
not elevate the child’s risk of spelling difficulties; these in the early school grades and suggested that gender
may include a noisy environment, poor comprehension of differences emerge over time because of an increasing gap
instructions, poor attention, or transient hearing problems between school expectations and boys’ behaviour.
on the part of the child. On the other hand, examination of
A second limitation of the study, also related to its
the individual child data in Table 6 suggests that, in some
scope, is the restriction of the predictor and outcome
cases, poor speech perception performance may combine
variables to a narrow range, specifically oral language
with poor speech production and phonological awareness
predictors and spelling as the outcome variable. With
skills to indicate a generalized problem with phonological
respect to the predictor variables it is known that there are
representations or phonological processing. Ramus,
other types of predictors that are useful as predictors of
Marshall, Rosen, & Van der Lely (2013) have suggested that
literacy outcomes. For younger children, print concepts
children with dyslexia fall into two profiles: those who have
in general and letter knowledge especially is an effective
difficulty with phonological representations (as revealed
predictor (Erdos, Genesee, Savage, & Haigh, 2011; Storch
by speech perception and production tasks), and those
& Whitehurst, 2002). For older children, orthographic
who have difficulty with phonological and non-phonological
knowledge is another important correlate of reading and
language skills (as revealed by phonological awareness and
spelling abilities (Binamé & Poncelet, 2016; Bourgoin,
language production tasks). Therefore, it seems worthwhile
2014; Commissaire, Pasquarella, Chen, & Deacon, 2014;
to continue research with all four subtests so as to
Cunningham, Perry, & Stanovich, 2001). Stanké, Flessas,
accumulate data from a larger group of true positives.
and Ska (2008) describe tests of orthographic processing
that are available for testing French-speaking children.
Limitations and future directions
A necessary future step would be to determine if the
A significant limitation of this study is the small sample PHOPHLO provides any predictive value over and above
size for assessing the predictive validity of the PHOPHLO. that offered by screening tests such as the Outil de
Clearly replication samples are required to confirm our dépistage d’élèves à risque de présenter des difficultés
estimate of the sensitivity and specificity of the PHOPHLO d’apprentisage du langage écrit (ODLÉ; Stanké & Flessas,
as a screen for spelling impairments in second grade. We 2013). The ODLÉ assesses phonological awareness,
feel that the mixed language background of our sample is visual memory, and orthographic memory, and has been
a strength of the study given the increasingly multilingual normed on large samples of French speaking children
and multicultural characteristic of the school population. from kindergarten and first-grade classes in Quebec. A
However, a larger sample of children for validation of the combination of oral language and orthographic screening
screening tool would provide greater confidence in the might offer improved sensitivity over oral language
sensitivity and specificity results, while permitting an screening alone. This raises another limitation of our study,
exploration of differences in predictive accuracy within and that is the single time point for screening being first-
different subsets of the validation sample. Certainly, grade entry. However, a more adequate screening protocol
exploration of differences across ML versus BL groups would likely involve layered screenings, for example oral
would require a very large sample. A first priority would language screening in kindergarten followed by orthographic
be to cross-validate the results with a larger sample of screening in first grade (after the children have received
children with similar composition to that described here. systematic exposure to written language instruction).

An investigation of the effectiveness of PHOPHLO as skills at school entry in the emergence of written language
a screening tool when used at an earlier age and in the competence in French-speaking elementary school
context of a more comprehensive screening protocol children in Canada.
would be desirable.
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(2011-ER-144359, Rvachew et al.) and MITACS (MITACS
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We thank the schools and all the children who
Rvachew, S., & Grawburg, M. (2006). Correlates of phonological awareness in
preschoolers with speech sound disorders. Journal of Speech, Language, and
participated in this project. We are also grateful to the
Hearing Research, 49, 74–87. doi:10.1044/1092-4388(2006/006) research assistants who collected and coded data,
as follows: Geneviève Beauregard-Paultre, Madeleine

Bellemare, Catherine Clémence, Tara Commandeur,
Kendall Kolne, and Catherine Lamirande. We also
acknowledge essential support from CRIM (Centre de
Recherche Informatique de Montréal), which supervised
the development of the PHOPHLO software.
Authors’ Note
English correspondence concerning this article should
be addressed to Susan Rvachew, School of Communication
Sciences and Disorders, McGill University, 2001 McGill
College Ave., 8th Floor, Montréal, Quebec, Canada, H3A 1G1.
Email: [email protected].
Les demandes en français au sujet de cet article doivent

être adressées à Phaedra Royle, École d’orthophonie et
audiologie, Université de Montréal, C.P. 6128, succursale
Centre-ville, Montréal, Québec, Canada. Courriel :
[email protected].

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CANADIAN JOURNAL OF SPEECH-LANGUAGE

PATHOLOGY & AUDIOLOGY | CJSLPA

REVUE CANADIENNE D’ORTHOPHONIE

Examining the Relationship Between Perceptions of a

Performance of Young, Middle-Aged, and Older Adults on Tests of Executive Function

Canadian-French Validation of Two Questionnaires That Measure the

Students’ Evaluation of Audiology Simulation Training

Diagnosing Apraxia of Speech on the Basis of Eight Distinctive Signs

Development of a Tool to Screen Risk of Literacy Delays in French-Speaking Children: PHOPHLO

EDITORIAL REVIEW BOARD

François Bergeron, Ph.D. Maxime Maheu, M.Sc.S. EDITORIAL ASSISTANTS

CJSLPA Reviewers Scope and Purpose OF CJSLPA

ISSN 1913-2018 | www.cjslpa.ca Revue canadienne d’orthophonie et d’audiologie (RCOA)

COMITÉ DE RÉVISION DE LA RÉDACTION

Réviseurs de la RCOA MISSION ET BUT DE LA RCOA

Article 1 237 Article 1 237

Article 2 253 Article 2 253

ISSN 1913-2018 | www.cjslpa.ca Revue canadienne d’orthophonie et d’audiologie (RCOA)

Examining the Relationship Between Perceptions of a Known

Explorer la relation entre la perception des individus envers

KEY WORDS Charles D. Hughes

pages 237-252 ISSN 1913-2018 | www.cjslpa.ca 238

pages 237-252 ISSN 1913-2018 | www.cjslpa.ca 240

Table 1. Categories of Survey Questions

Category Likert-type question (1 = strongly agree, 5 = strongly disagree)

Coping with Stuttering This person is a good communicator.

Table 2. Descriptive Statistics for Survey Items

I have a good relationship with this person. 2.16 (.931) 38 66 35 11 2

This person is important to me. 2.34 (.949) 33 50 55 12 2

This person appeared comfortable

I feel that stuttering has affected this

I feel that stuttering affected this person

I feel that stuttering has affected this

I feel that stuttering has not affected this

This person is a good communicator. 2.58 (.903) 10 75 38 27 2

The person is a competent speaker. 2.74 (.919) 8 62 47 32 3

This person stutters more frequently in

pages 237-252 ISSN 1913-2018 | www.cjslpa.ca 242

Table 3. Descriptive Statistics for Semantic Differential Scale Items

Known PWS Average PWS

2. Trustworthy-untrustworthy 2.20 (1.44) 2.66 (1.20)

3. Passive-aggressive 4.29 (1.46) 4.76 (1.26)

4. Secure-insecure 3.54 (1.72) 5.08 (1.27)

5. Introverted-extroverted 3.66 (1.41) 4.84 (1.19)

6. Intelligent-dull 2.76 (1.44) 3.47 (1.22)

7. Withdrawn-outgoing 2.81 (1.59) 4.59 (1.23)

8. Hesitant-daring 3.46 (1.42) 4.80 (1.25)

9. Intelligent-unintelligent 2.77 (1.63) 3.01 (1.28)

10. Composed-anxious 4.09 (1.58) 4.72 (1.24)

11. Sincere-insincere 2.45 (1.28) 2.90 (1.32)

12. Likable-unlikable 2.06 (1.32) 2.64 (1.25)

13. Shy-bold 3.89 (1.63) 5.36 (1.36)

14. Calm-nervous 4.28 (1.52) 5.26 (1.26)

15. Pleasant-unpleasant 2.36 (1.30) 3.13 (1.30)

16. Reliable-unreliable 2.95 (1.76) 2.88 (1.31)

17. Employable-unemployable 2.39 (1.59) 2.88 (1.33)

18. Fearless-fearful 3.80 (1.34) 4.55 (1.08)

19. Friendly-unfriendly 2.02 (1.19) 2.99 (1.23)

20. Open-guarded 3.25 (1.66) 4.49 (1.45)