Journal of Fluency Disorders 50 (2016) 72–84

Contents lists available at ScienceDirect

Journal of Fluency Disorders

Long-term Consequences of Childhood Bullying in Adults

who Stutter: Social Anxiety, Fear of Negative Evaluation,
Self-esteem, and Satisfaction with Life
Gordon W. Blood (Ph.D) ∗ , Ingrid M. Blood (Ph.D)
The Pennsylvania State University, United States

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

Article history: Purpose: Psychosocial disorders have been reported in adults who stutter, especially social
Received 10 August 2016 anxiety disorder. Social anxiety has been linked to childhood victimization. It is possible
Received in revised form that recalled childhood victimization could be linked to psychosocial problems reported in
28 September 2016
some adults who stutter.
Accepted 6 October 2016
Method: Participants were 36 adults who stutter and 36 adults who do not stutter (mean
Available online 15 October 2016
age = 21.9 years). The Retrospective Bullying Questionnaire was completed for primary
school, secondary school and university environments for physical, verbal, relational and
Keywords:
cyber bullying. Participants were categorized into one of five groups (bully, victim, bully-
Bullying
Psychosocial factors victim, bystander and uninvolved) based ontheir responses. Participants completed four
Adults who stutter psychosocial scales: social interaction anxiety, fear of negative evaluation, self-esteem and
satisfaction with life scales.
Results: The two groups differed with adults who stutter having higher social interaction
anxiety, fear of negative evaluation and satisfaction with life. Analyses of variance revealed
that victims had the highest scores among both groups on all four scales.
Conclusion: Adults who recalled being victimized during childhood were more likely,
regardless of whether they stutter or did not stutter, to have poorer psychosocial scale
scores. These results show the lingering effects of childhood victimization, common in some
children who stutter, may contribute to the reported psychosocial problems in adulthood.
The need for early intervention for children who are bullied and future research with larger
samples is warranted.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction

Stuttering is a speech motor social disorder in which fluency disruptions (e.g., sound and syllable repetitions, prolon-
gations) may interfere with functional communication. It is a multidimensional, communication disorder which includes
cognitive, affective and social components (Boyle & Blood, 2015). Developmental in nature, with an early onset, it involves
the speech motor behaviors, thoughts and feelings of the speaker, as well as the responses from communication partners and
on-lookers. Individuals who stutter report a perceived “loss of control” sometimes before, during or after the stuttering event

∗ Corresponding author at: Department of Communication Sciences and Disorders, 404 Ford Building, The Pennsylvania State University, University
Park, PA 16802, United States.
E-mail address: [email protected] (G.W. Blood).

http://dx.doi.org/10.1016/j.jfludis.2016.10.002
0094-730X/© 2016 Elsevier Inc. All rights reserved.
 G.W. Blood, I.M. Blood / Journal of Fluency Disorders 50 (2016) 72–84 73

(Perkins, Kent, & Curlee, 1991). As a social communicative disorder, public reactions’ and responses’ impact the perceived
negative stereotypes and stigmatization for individuals who stutter (Boyle & Blood, 2015). Social experiences play a role in
the progression and maintenance of stuttering. These negative stereotypes and related stigma may interfere with building
and maintaining strong peer networks and social skills. The lack of these social supports may increase the likelihood of being
targeted and victimized by bullies not only for their speech disruption but also co-occurring social difficulties which may
make them appear to be different (Hartley, Bauman, Nixon & Davis, 2015; Hymel & Swearer, 2015). Research also suggests
that psychological distress, stigmatization, anxiety, and an adverse impact on quality of life are potential consequences of
stuttering in some adults who stutter (Blumgart, Tran, & Craig, 2010; Boyle & Blood, 2015; Iverach et al., 2009a, 2009b;
Iverach & Rapee, 2014; Tran, Blumgart, & Craig, 2011). This may be due to the variability, unpredictability and chronicity of
stuttering in persons who stutter (PWS) combined with the negative stereotypes, prejudice and stigmatization by society
(Boyle & Blood, 2015).

1.1. Bullying, Disability and Stuttering

Bullying is typically defined as an intentional and harmful act of physical, verbal, relational or cyber aggression repeatedly
perpetrated by an individual (the bully) with more power over a targeted victim (Olweus, 1993; Mishna, 2012; Smith, 2014).
The number of school-age children involved in the bullying dynamic (i.e., bullies, victims and bully-victims) varies from
approximately 30% to 50%, especially when bystanders and on-lookers are included in these estimates (Nansel, Overpeck,
Pilla, Ruan, Simons-Morton & Scheidt, 2001; Wang, Iannotti & Nansel, 2009). The negative psychological, social, academic and
physical effects of bullying have been well documented in children and adolescents. Some of these include poorer academic
performance, increased likelihood of depression, personality problems and social anxiety, digestive and respiratory health
related problems, lower self-confidence and self-esteem, and poorer peer relationships (Hymel & Swearer, 2015).
Children and adolescents with behavioral (Bear, Mantz, Glutting, Yang & Boyer, 2015; Farmer, Petrin, Brooks, Hamm,
Lambert & Gravelle, 2012; Maag & Katsiyannis, 2012; Mishna, 2003); communication (Blood & Blood, 2004, 2007; Cook
& Howell, 2014; Hughes, 2014; Knox & Conti-Ramsden, 2003; Langevin, 2015; Murphy, Quesal, Reardon-Reeves & Yaruss,
2013), emotional (Bond, Carlin, Thomas, Rubin, & Patton, 2001), intellectual (Didden, Scholte, Korzilius, De Moor, Ver-
meulen, O’Reilly. . . & Lancioni, 2009; Maïano, Aimé, Salvas, Morin, & Normand, 2016); Reiter & Lapidot-Lefler, 2007), physical
(Twyman, Saylor, Saia, Macias, Taylor, & Spratt, 2010), sensory (Rose, 2011; Rose, Monda-Amaya & Espelage, 2011; Rose,
Simpson & Moss, 2015) and social disabilities (Cappadocia, Weiss, & Pepler, 2012; Van Roekel, Scholte & Didden, 2010) are
reported to be at greater risk for victimization and bullying than children without these disabilities. Recently, Hartley et al.
(2015) examined victimization in 13,177 students (grades 5 through 12) from 12 different states through a web-based,
self-report survey. Of those reporting being victimized two, three or more times a month, the odds for children with dis-
abilities were 2 to 4 times higher than children without disabilities. Similarly, Rose, Simpson and Moss (2015) reported on
the prevalence rates of specific subgroups of students with disabilities (i.e. specific learning disability, other health impair-
ment, intellectual disability, emotional behavioral disability, autism spectrum disorder and children with speech or language
impairment, deafness, orthopedic impairment, visual impairment or traumatic brain injury) in a large-scale cross-sectional
study with 13,325 students without disabilities and 1,183 students with disabilities in Grades 6 through 12. They found that
students with disabilities displayed higher rates of victimization, online victimization, relational victimization, bullying,
fighting, and aggression when compared with students without disabilities. Although a number of studies have reported
higher rates of victimization for specific groups of children and adolescent with disabilities (e.g., children with learning dis-
abilities, emotional disorders and attention deficit disorders), the current research presents conflicting results about specific
rates of victimization in children with disabilities (Bear, Mantz, Glutting, Yang, & Boyer, 2015; Blake, Kim, Lund, Zhou, Kwok,
& Benz, 2016; Blake, Lund, Zhou, Kwok, & Benz, 2012; Maïano et al., 2016; Rose et al., 2015; Son, Parish, & Peterson, 2012;
Son, Peterson, Pottick, Zippay, Parish, & Lohrmann, 2014). Authors believe that not only the type of disability but the sever-
ity, visibility, school environment, social economic status, and support networks may play a critical role in the differences
described and reported.
Similarly, children, adolescents and adults who stutter are reported to be more frequently victimized than individuals
who do not stutter (Blood & Blood, 2004, 2007; Blood, Blood, Tramontana, Sylvia, Boyle & Motzko, 2011; Davis, Howell
& Cooke, 2002; Hugh-Jones & Smith, 1999; Langevin, 2015; Mooney & Smith, 1995). Research has also suggested ways of
coping and dealing with victimization in PWS (Blood & Blood, 2004, 2007; Blood, Blood, Tramontana et al., 2011; Cook &
Howell, 2014; Erickson & Block, 2013; Evans, Healey, Kawai & Rowland, 2008; Langevin, 2015; Langevin, Bortnick, Hammer
& Wiebe, 1998; Langevin & Prasad, 2012; Murphy & Quesal, 2002; Murphy, Quesal, Reardon-Reeves & Yaruss, 2013; Murphy,
Yaruss & Quesal, 2007; Plexico, Plumb & Beacham, 2013).

1.2. Long-Term Effects of Bullying

Recent research suggests that the negative impact of bullying and victimization may linger well into adulthood (De Lara,
2016). The consequences of being bullied during childhood may include increased social anxiety, isolation, depression, phys-
ical problems, economic adversities, personality disturbances and suicidal ideation decades after childhood victimization
has ceased (Boden, van Stockum, Horwood & Fergusson, 2016; De Lara, 2016; Klomek et al., 2016; Sansen, Iffland & Neuner,
2014, Takizawa, Maughan & Arseneault, 2014). De Lara (2016) labeled the negative and oftentimes traumatic memories
74 G.W. Blood, I.M. Blood / Journal of Fluency Disorders 50 (2016) 72–84

and symptoms (e.g., self-esteem and shame issues, difficulties in relationships and trust; emotional and anxiety problems;
people-pleasing tendencies) as adult post-bullying syndrome (APBS). She suggests the symptoms may mimic post-traumatic
stress syndrome (PTSD) with some major differences. These include that individuals with APBS try to “turn their misfortunes
into something positive” and individuals with APBS do not show “event/reaction immediacy such as unexpected outbursts
of anger and aggression observed in PTSD· · ·.but rather seem more inclined to take no action and instead ruminate on past
and present events” (p. 28). Although APBS is not a diagnostic category, deLara encourages the topic in discussions about
the aftermath of childhood bullying.
As early as 1999, Hugh-Jones and Smith examined the recalled bullying school experiences of 276 persons who stutter
(PWS) (mean age = 38.2 years) from the British Stammering Association. They developed a 19-item mailed questionnaire.
The authors reported that an alarming 83% of PWS reported they had been “teased or bullied at school”. Although no specific
or formal outcome measures were administered the authors concluded that the results paralleled anecdotal reports of
long-term effects of bullying by PWS, even 30 years after the incidents. Since that time, numerous authors have shown the
negative lingering effects of childhood bullying. Bond, Carlin, Thomas, Rubin and Patton (2001) initially suggested a causal
relationship between peer victimization and anxiety in victims. Other researchers have also linked peer victimization to
the development of chronic and social anxiety as a short-term response in adolescents and long-term outcome in adults
(Copeland, Wolke, Angold & Costello, 2013; McCabe, Antony, Summerfeldt, Liss & Swinson, 2003; McCabe, Miller, Laugesen,
Antony & Young, 2010; Gladstone, Parker & Malhi, 2006; Sourander et al., 2007).
Schäfer et al. (2004) reported on the long-term correlates of victimization in primary school, secondary school, college and
workplace and overall functioning in adult life. They designed and standardized the Retrospective Bullying Questionnaire
(RBQ) which included 46 detailed questions about victimization and bullying experiences. Three types of victimization
(physical, verbal and relational) were included. The authors used specific criteria based on perceived and reported frequency
(e.g., How many times a week did this happen?) and intensity (i.e., Did it happen once, seldom, constantly?) of the bullying
episodes to categorize their 884 participants from three countries. They reported on the stability of bullying during the
school years and into the workplace, as well as, relationships with lower self-esteem, higher emotional loneliness, increased
fear in relationships, difficulties in maintaining friendships, and lingering negative effects of victimization and bullying. The
RBQ has been used in other studies and serves as a seminal work in this area for other researchers in the field of retrospective
correlates for bullying (Hunter, Mora-Merchan & Ortega, 2004; Menesini, Modena & Tani, 2009; Sesar, Barišić, Pandža, &
Dodaj, 2012; Valmaggia et al., 2015).
Stapinski et al. (2014) examined the relationship between peer victimization during adolescence and subsequent anxiety
diagnoses in adulthood in 6,208 adolescents from the Avon Longitudinal Study of Parents and Children. Parents and their
13-year old children were participants assessed at Time 1 and then followed-up at 18 years of age for the youth. The Clinical
Interview Schedule–Revised was used to assess anxiety disorders. Adjustments were made for confounding variables (e.g.,
family, support, co-morbidity) and results showed that adolescents who were bullied at 13 years of age were two to three
times more likely to develop anxiety disorders than those students who were not victimized.
In addition to the psychosocial long-term consequences of childhood bullying, researchers have also reported on the neg-
ative health and physical sequelae of childhood bullying. Takizawa, Maughan and Arseneault (2014) reported on the health
outcomes of childhood victimization using data from a five-decade longitudinal British birth cohort study. Respondents
who were bullied during childhood had poorer social relationships, greater economic adversities, and a higher number of
health-related problems at ages 23 and 50 years compared to those who had not been bullied as child. These data suggest
that for many children who are bullied during the school years the physical, psychological, personal, vocational and social
consequences persists long into adulthood and negatively affect their perceived quality of life.
It is important to note that some authors suggest that recall and retrospective research studies are time-sensitive for
respondents. However, the research clearly shows that traumatic events are reported with great reliability and accuracy
(Chapell et al., 2006; Cooper & Nickerson, 2013; Rosen et al., 2012; Schäfer et al., 2004; Valmaggia et al., 2015). There are
numerous studies that use retrospective questionnaires and Brewin, Andrews, and Gotlib (1993) concluded that when “
individuals are questioned about the occurrence of specific events or facts that they were sufficiently old and well placed to
know about, the central features of their accounts are likely to be reasonably accurate” (p. 94). Victimization and bullying,
especially for the college-age students who were in primary school during these events suggest that the recall of the events
(incidents) can be accurate.
The evidence clearly show that serious psychosocial problems are associated with childhood bullying and can continue
into adulthood long after the bullying has stopped (Boden, van Stockum, Horwood & Fergusson, 2016; De Lara, 2016; McCabe
et al., 2010; Klomek et al., 2016; Schäfer et al., 2004). It should also be noted some victims of childhood bullying possess or
develop sources of resilience and protection (e.g., behavioral inhibition, social support, peer and parental influences, cultural
backgrounds, self-efficacy) which serve to mediate these negative outcomes. Current research is being conducted to examine
both risk and protective factors of childhood victimization.

1.3. Social Anxiety and Fear of Negative Evaluation

According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association,
2013), people with a social anxiety disorder (SAD) display persistent and extreme fear to social or performance situations
in which they expect to be scrutinized, judged, evaluated, excluded, or humiliated by others. A core characteristic of SAD is
 G.W. Blood, I.M. Blood / Journal of Fluency Disorders 50 (2016) 72–84 75

the fear of negative evaluation by others. It is a common mental health condition (prevalence around 7% for children and
adults in the United States) with an onset during childhood (usually 8 to 15 years of age). This intense fear of evaluation has
a severe negative impact in school, work and social environments (National Institute of Mental Health, 2016).
Recently, Wong and Rapee (2016) proposed a new model of SAD including the potential etiological factors, as well as
the maintaining factors for the disorder. Their Integrated Aetiological and Maintenance (IAM) model describe the social
evaluative threat at the core of SAD and incorporated research based evidence on five factors which contributed to the
development and maintenance. These included: 1) inherited tendencies (i.e., temperament), 2) parenting behaviors (i.e.,
parent/child interactions), 3) peer experiences associated with negative evaluation (i.e., teasing, ostracism, bullying) 4) life
events (i.e., highly stressful, traumatic or adverse experiences with a social threat) and 5) culture (i.e., degree the culture
displays for social rules, penalties, negative self/group evaluation). They also discussed the effects of continual destructive
self-evaluations leading to social performance deficits. The cycle is quite insidious. If negative self-evaluations are developed
because of specific inherited tendencies coupled with perceived negative parental relationships, negative peer experiences,
and apparent high stress demands by the culture, then the susceptible child or adolescent fails to develop appropriate social
skills and knowledge. Without these foundational knowledge and skills the individual with SAD continues to be exposed
daily to social situations which result in new negative social experiences from others’ responses. The disorder is reinforced
and the negative self-evaluations are feared and strengthened. The authors acknowledge some of the factors cannot be
easily changed (e.g., biological or genetic tendencies) while others are dealt with by colleagues in psychology, psychiatry
and rehabilitation counseling (e.g., moving away from a culture, learning to reinterpret past relationships with parents or
harmful peer evaluations). The model suggests that no one factor is responsible for the development and maintenance of
SAD. Multiple risk factors occurring at critical times without adequate coping strategies contribute to development and
maintenance of SAD and fear of negative evaluation. It should also be noted that the primary and secondary characteristics
of specific disabilities may actually preclude the individual’s ability to access and acquire this foundational knowledge and
coping skills. For some people with disabilities (e.g., epilepsy, autism spectrum disorder, asthma, stuttering) SAD may be a
co-occurring problem that should be evaluated and if present, subsequently treated.

1.4. Social Anxiety and Stuttering

The extant literature suggests there is an increased likelihood of social anxiety in some adults who stutter (Alm, 2014;
Blumgart, Tran & Craig, 2010; Craig, 1990; Ezrati-Vinacour & Levin, 2004; Craig & Tran, 2014; Gronhovd, 2014; Iverach,
Menzies, O’Brian, Packman & Onslow 2011; Iverach, O’Brian et al., 2009; Iverach & Rapee 2014; Kraaimaat, Vanryckeghem &
Van Dam-Baggen, 2002; Mahr & Torosian, 1999; McAllister, 2015; Menzies, Onslow & Packman, 1999; Messenger, Onslow,
Packman & Menzies 2004; Stein, Baird & Walker,1996). Manning and Beck (2013) question some of these findings based on
test administration and test choice. Qualitative and mixed design research studies have also reported psychosocial issues
including anxiety, as well as shame, guilt, identity construction, continued fear of speaking and difficulties in coping and
social interactions related directly to stuttering (Bleek, Reuter, Yaruss, Cook, Fabere & Montag, 2012; Beilby, Byrnes, Meagher
& Yaruss, 2013; Corcoran & Stewart, 1998; Daniels & Gabel, 2004; Daniels, Gabel & Hughes, 2012; Plexico, Manning & Levitt,
2009a; Plexico, Manning & Levitt, 2009b).
Menzies, Onslow, Packman and O’Brian (2009) suggested that the development of social anxiety could be related to
negative conditioning experiences in children who stutter including bullying. They also reported that bullying was shown
to increase the risk of later anxiety disorders. Iverach and Rapee’s (2014) critical review of the current status and future
directions of social anxiety disorder and stuttering stated that “It is likely that the communication difficulties and negative
consequences faced over the lifespan for those who stutter may contribute significantly to the development of social anxiety
disorder. It is also plausible that the presence of social anxiety disorder in stuttering may exacerbate existing behavioural
deficits in social situations and reduce opportunities for social interaction, which in turn may increase functional impair-
ment.” (p.77). The authors summarized studies providing evidence of disturbingly higher rates of SAD among some adults
who stutter. They argued for a comprehensive and collaborative approach to assessment and treatment to enhance our
understanding of stuttering and its relationship to anxiety. Stuttering and anxiety may share a bi-directional relationship
in some subgroups of PWS. It is also possible that the long-term lingering effects of being victimized during childhood and
adolescence may contribute to social anxiety and other personality problems in some adults with chronic stuttering.

1.5. Psychosocial Problems and Stuttering

In addition to social anxiety and fear of negative self-evaluation, there is also a body of research suggesting stuttering
has a detrimental effect on PWS’ quality and satisfaction of life (Boyle, 2015; Craig, Blumgart, & Tran, 2009), self-esteem,
perceived and real social and vocational limitations, (Beilby, Byrnes & Yaruss, 2012; Bricker-Katz, Lincoln, & McCabe, 2009;
Gabel, Blood, Tellis, & Althouse, 2004; Plexico, Manning, & DiLollo, 2005; Yaruss & Quesal, 2004). Studies are also being
conducted to determine what are the risk and protective factors for ensuring a better quality of life for PWS. For example,
Boyle (2015) examined protective factors (i.e., social support, empowerment, self-help support group participation, and
group identification) on the quality of life of 249 PWS using a web-based survey. He concluded that increased self-esteem
and self-efficacy, as well as social support from family members, were related to better quality of life in adults who stutter.
76 G.W. Blood, I.M. Blood / Journal of Fluency Disorders 50 (2016) 72–84

These co-occurring psychosocial factors in some PWS not only need to be recognized but then optimal treatments plans
must be developed to enhance their overall quality of life.
Studies also have reported that co-occurring anxiety, peer rejection, self-esteem, speech and non-speech related issues
may occur in subgroups of some children and adolescents who stutter suggesting that this may be a developmental issue for
some PWS (Blood & Blood, 2007, 2015; Blood, Blood, Maloney, Meyer & Dean Qualls, 2007; Blood, Blood, Tellis & Gabel, 2003;
Blood, Blood, Dorward, Boyle & Tramontana, 2011; Craig et al., 1996; Davis, Howell & Cooke, 2002; Erickson & Block, 2013;
Gunn et al., 2014; Guttormsen, Kefalianos & Næss, 2015; Langevin, Packman & Onslow, 2009; McAllister, Kelman & Millard,
2015; Smith, Iverach, O’Brian, Kefalianos & Reilly, 2014). Current research by Messenger, Packman, Onslow, Menzies and
O’Brian (2015) is attempting to determine the onset of anxiety as a co-occurring problem in some children and adolescents
who stutter to develop better assessment and treatment protocols.
As Ratner (2014) stated so eloquently, “We have come a long way since early hypotheses about the role of personality
factors in the etiology of stuttering, to a more reasoned understanding that reflects how basic human traits (such as how the
child responds to novelty, change or challenge) may predict how clients respond both to their communication difficulties
as well as to family and therapist efforts to assist in helping the client manage speaking and stuttering more effectively”
(p.66). Considering the chronic, variable and unpredictable nature of stuttering, potential accompanying stressors, negative
stereotypical responses of communication partners, private and public related stigma and the overall influence on the
identity and quality of life for PWS, protective and risk factors must continue to be examined for improved collaborative
assessments and treatments.

1.6. Rationale for this Study

This review suggests the possibilities of relationships among co-occurring stuttering, anxiety, fear of negative evaluation,
psychosocial factors and peer bullying. With this new information about associations among stuttering and related issues,
PWS will have new information to continue to make their own personal, informed decisions on treatments. The decision of
whether or not they desire to acquire more fluent patterns of speech, alter their present cognitions and thoughts about living
with stuttering and elect how stuttering “fits” in the overall framework of their lives must be based on the most current,
relevant and integrative information. If lingering childhood victimization is a component of the psychosocial problems for
some PWS, this information may provide potential explanations and avenues for necessary counseling and the development
of greater resilience for both lingering victimization and current chronic stuttering.
In an attempt to better understand the complex relationship between chronic stuttering and psychosocial factors, the
Retrospective Bullying Questionnaire (RBQ) (Schäfer et al., 2004) was used with PWS and persons who do not stutter (PWNS)
to categorize participants into bullies, victims, bully-victims, bystanders and uninvolved based on their perceived frequency
and intensity of their bullying remembrances. Specifically, the following questions were asked:

1 Are there differences in the number and percentages of bullies, victims, bully-victims, bystanders and uninvolved members
in groups of PWS and PWNS when categorized using a valid and reliable measure of bullying/victimization remembrances
based on frequency and intensity of bullying incidents from primary, secondary and university schooling?
2 Are there differences between PWS and PNWS who are members of these bullying type categories and specific psychosocial
outcomes (i.e., social interaction anxiety, fear of negative evaluation, satisfaction with life and self-esteem) as measured
by using standardized self-report scales?

2. Methods

This study is part of a larger and ongoing project examining the psychosocial sequelae of childhood bullying and victim-
ization in individuals with communication and social disabilities. PWS and PWNS were recruited through university research
websites and posting flyers and advertisements about the study throughout the campus of a large, research university in
the northeastern United States. Ethics approval was obtained from the Institutional Review Board prior to commencement
of the study.

2.1. Participants

Participants included 36 PWS and 36 PWNS with each group consisting of 31 males (86.1%) and 5 (13.9%) females matched
on gender, race/ethnicity and age. Each group consisted of 3 (8.3%) African Americans, 3 (8.3%) Hispanic Americans, 2
(5.6%) Asian Americans and 28 (77.8%) white, non-Hispanic adults. The mean age of participants was 21.9 years (SD = 3.4)
with a range between 18 and 33 years. The sample was restricted to participants who self-reported no history of physical,
neurological, psychological, reading, behavioral, and learning disabilities in the past or currently, as these conditions could
influence the results of the psychosocial scales. Socioeconomic status (SES) was determined using two questions from the
Hollingshead’s Four Factor Index (1975) which utilizes parents’ years of education and employment. Analyses suggested the
participants were middle to upper class. There were no significant differences between mean Index scores for the groups.
PWNS reported no personal or family history of stuttering.
 G.W. Blood, I.M. Blood / Journal of Fluency Disorders 50 (2016) 72–84 77

All PWS had been enrolled in formal speech therapy services either during their primary, secondary or university educa-
tional programs. We did not obtain information about the specific type of therapy/treatment received. PWS were assessed
by the lead author and also provided self-reports of onset, development and chronicity of stuttering. They were assessed in
monologue, reading and conversational speech samples. Stuttering severity was also obtained using the Stuttering Severity
Instrument (SSI-3) (Riley, 1994). Results revealed that 10 (27.8%) PWS displayed mild stuttering, 18 PWS (50%) moderate
stuttering, 4 PWS (11.1%) severe stuttering and 4 PWS (11.1%) very severe stuttering.

2.2. Bullying Type Categorization

As mentioned earlier, Schäfer et al. (2004) reported on the long-term correlates of victimization in primary school, sec-
ondary school, college and workplace and overall functioning in adult life by designing and standardizing the Retrospective
Bullying Questionnaire (RBQ). The RBQ consists of 46 detailed questions about three types of victimization and bullying
experiences (physical, verbal and relational). With permission from the authors, we adapted the RBQ by adding a fourth
type of bullying (cyber bullying) using the same questions about frequency (e.g., How many times a week did this happen?)
and intensity (i.e., Did it happen once, seldom, constantly?) of the bullying episodes. The RBQ begins with demographic
questions. The participants are then provided the following written definition as a reference: “Bullying is intentional hurtful
behavior. It can be physical or psychological. It is often repeated and characterized by an inequality of power so that it is
difficult for the victim to defend him/her self.” Each of the next three sections asks specific questions about the type (physical,
verbal, relational and cyber), seriousness (rated on a 5-point Likert scale), frequency and intensity of the bullying. Questions
are also asked about the gender and number of bullies. Section 1 of the recalled bullying experiences consists of the questions
for primary school, while Section 2 focuses on secondary school and Section 3 focuses on the previous six months of the
university environment. Section 4 of the RBQ deals questions about general bullying experiences.
The authors outline a classification system using the responses to the questions. Participants are classified as victims if 1)
they report being bullied in one or more ways (i.e., physical, verbal, relational or cyber), 2) responded to frequency question
“Did this happen?”, by selecting from the top three of the five choices (‘i.e., “sometimes”, “frequently or “constantly”) and 3)
responded to the intensity measurement question “How serious did you consider these bullying-attacks to be?” by selecting
from the top two of the five choices (i.e., “quite serious” or “extremely serious”). The final criteria for this classification was
that participants must have indicated they had not bullied others.
Four other classifications are also provided including bullies, bully-victims, bystanders and uninvolved. The criteria
included: 1) Bully: Bullied others “sometimes”, “frequently or “constantly” and was not a victim. 2) Bully-Victim: Being
bullied “sometimes”, “frequently or “constantly”, perceived the experience to be “quite serious” or “extremely serious” and
also bullied other children. 3) Bystander: I wasn’t involved but I saw it happen “sometimes”, “frequently or “constantly”. 4)
Uninvolved: I wasn’t involved at all, and I never saw it happen.
At the beginning of the primary, secondary, university, and general subsections, these questions were asked. Therefore,
a participant could have been a bully during the primary school years but not during secondary and university. Similarly, a
participant could have been victimized in primary school, secondary school and university. It is also possible that a participant
was bullied during primary school and began a bully-victim during secondary school and university. Status changes in
category classifications could be examined from childhood to adulthood.

2.3. Psychosocial Scales

2.3.1. Social Interaction Anxiety Scale-S

The Social Interaction Anxiety Scale (SIAS) scale was developed by Mattick and Clarke (1998) as a 20-item self-report
scale to measure anxiety in groups and dyads. It uses a 5-point Likert scale to rate items from 0 (not at all characteristic)
to 4 (extremely characteristic). Rodebaugh, Woods and Heimberg (2007) and Rodebaugh et al. (2011) completed studies on
the SIAS recommending using only the 17 straightforward items of the scale as the reverse scored items were problematic
for participants and scoring. The 17-item straight-forward scoring adaptation was labelled the SIAS-Straightforward (i.e.,
SIAS-S). It has excellent internal consistency and construct validity in both undergraduate and clinical samples (Rodebaugh
et al., 2004, 2007, 2011). Rodebaugh and colleagues also developed normative data for SIAS-S for clinical and community
samples stratified by age, gender, and ethnicity, as well as 4,282 undergraduate students. Short form versions have been
used and reported in both adolescents and adults. Total scores range from 0–68 with clinical samples of individuals with
social anxiety, social phobias and generalized anxiety disorders earning the highest scores. They suggested a cutoff score of
28 should be used for probable SAD (Rodebaugh et al., 2011).

2.3.2. Brief Fear of Negative Evaluation-S

The Fear of Negative Evaluation scale was developed by Watson and Friend in 1969 as a true-false, 30-item scale to
measure the fear and worrying of being judged and evaluated by other people. In 1983, Leary shortened the scale to 12 items
(8 positively worded items and 4 negatively worded items) and standardized the scale using Likert scale choices from (1)
“not at all characteristic of me” to (5) “extremely characteristic of me” and referred to the scale as the Brief Fear of Negative
Evaluation (BFNE). Similar to the SIAS, researchers began examining the psychometric properties of the BFNE (Carleton,
Collimore & Asmundson, 2007; Rodebaugh et al., 2004, 2011). Rodebaugh et al. (2004) reported excellent intercorrelations
78 G.W. Blood, I.M. Blood / Journal of Fluency Disorders 50 (2016) 72–84

Table 1
Number and percentages of the 36 people who stutter (PWS) and 36 people who do not stutter (PWNS) classifications (bully, victim, bully-victim, bystander
and uninvolved) based on participants’ responses to the Retrospective Bullying Questionnaire.

Group Bullying Type

Bully Victim Bully-Victim Bystander Uninvolved

PWS
Primary School 1 (2.8%) 11 (30.6%) 2 (5.6%) 20 (55.5%) 2 (5.6%)
Secondary School 1 (2.8%) 10 (27.8%) 2 (5.6%) 22 (61.1%) 2 (5.6%)
University 1 (2.8%) 4 (11.1%) 2 (5.6%) 27 (75%) 2 (5.6%)
PWNS
Primary School 4 (11.1%) 5 (13.9%) 2 (5.6%) 24 (66.7%) 1 (2.8%)
Secondary School 4 (11.1%) 5 (13.9%) 2 (5.6%) 24 (66.7%) 1 (2.8%)
University 4 (11.1%) 3 (8.3%) 2 (5.6%) 26 (72.2%) 1 (2.8%)

for the positively scored and worded items and much poorer correlations for the reversed scored and worded items. After
continued testing, Rodebaugh et al. (2011) concluded that the straightforward scoring of the eight positively worded items
revealed superior psychometric properties. Rodebaugh et al. (2011) also developed normative data for BFNE-S for clinical
and community samples community samples stratified by age (age 18 years and older), gender, and ethnicity, as well as
4,282 undergraduate students. The adapted measure demonstrated excellent test–retest reliability, internal consistency,
and convergent validity.

2.3.3. Rosenberg Self-Esteem Scale

A global measure of the judgement of oneself was completed using the Rosenberg Self-Esteem Scale (RSES) (Rosenberg,
1965, 1979). Scores are the mean rating for 10 items concerning feelings of self-worth. Five of the items are positively worded
(e.g., “I feel I have a number of good qualities”), and five items are negatively worded and reverse-scored (e.g., “I feel I do not
have much to be proud of”). Ratings are on a 4-point response scale ranging from (1) Strongly agree to (4) Strongly disagree
with total possible scores from 10 to 40. Higher scores indicate higher or more positive self-esteem. The scale can be used
with adolescents (13-17 years); adults (18-64 years) and elderly adults (65+ years). The scale is one of the most commonly
used scales for measuring general self-esteem with good reported reliability and validity (Blascovich & Tomaka, 1991; Lorr
& Wunderlich, 1986).

2.3.4. Life Satisfaction

A global measure of a person’s life satisfaction was completed using the Satisfaction With Life Scale (SWLS) (Diener,
Emmons, Larsen & Griffin, 1985). The scale has five items (e.g., “In most ways my life is close to my ideal”) using a 7-point
rating scale ranging from (1) Strongly disagree to (7) Strongly agree. Scores range from 5 to 35 with higher scores indicating
greater overall satisfaction. The scale was developed and norms are available for 18–65 year olds (Kobau, Sniezek, Zack,
Lucas, & Burns, 2010). The SWLS has been completed on 13,118 college student from 30 countries, shows good sensitivity,
validity and reliability (Diener, Inglehart & Tay, 2013; Pavot & Diener, 2009; Tay, Kuykendall & Diener, 2015).

2.4. Procedures

The questionnaire packets were provided to all participants individually. They were assured there were no right or wrong
answers and asked to complete all sections of the questionnaires. Testing was completed during one session and multiple
breaks were provided to all participants. A stuttering assessment was initially conducted for all PWS. Upon confirmation of
the diagnosis questionnaires and scales were distributed. Participants first completed the demographic questions followed
by administration of the RBQ. The order of the psychosocial scales was randomized.

3. Results

3.1. Number and Percentages of Participants in Bullying Categories

Table 1 reveals that the majority of PWS (55.6%) and the majority of PWNS (66.7%) were initially in the bystanders’
category. This category increased in size from primary school to the university environment. The stability of the classification
over time can also be observed in Table 1. For example, there were no changes in the numbers of participants classified in
the bully, bully-victim or uninvolved categories from primary school to the university environment. Only 1 (2.8%) PWS was
in the bully category while 4 (11.1%) PWNS were in the bully category. Although this is a small sample, it suggests that PWS
are less likely to be bullies than PWNS. Another contrast was found in the victim categories. While 11 (30.6%) PWS were in
the victim category, only 5 (13.9%) of PWNS were in the victim category. The victim category for PWS did show decreases in
victim status from primary school (11; 30.6%) and secondary school (10; 27.8%) to the university setting (4; 11.1%). These
data support research that suggests PWS are more likely to be victims of peer bullying than PWNS.
 G.W. Blood, I.M. Blood / Journal of Fluency Disorders 50 (2016) 72–84 79

Table 2
Means and standard deviations (S.D.) for the scores on the Social Interaction Anxiety Scale (SIAS-S), Brief Fear of Negative Evaluation (BFNE-S), Rosenberg
Self-Esteem Scale (RSES) and Satisfaction with Life Scale (SWLS) for persons who stutter (PWS) and persons who do not stutter (PWNS) in each of the five
bully-victim classification types.

Psychosocial Variable Bullying Type

Bully Victim Bully-Victim Bystander Uninvolved

Group** PWS PWNS PWS PWNS PWS PWNS PWS PWNS PWS PWNS

SIAS-S
Mean 20.0 14.0 32.2* 24.0* 20.5 14.5 18.8 14.3 19.5 16.0
S.D. *** 1.2 7.3 7.4 2.1 0.7 5.2 3.8 2.1 ***
BFNE-S
Mean 21.0 15.3 25.6* 25.0* 21.5 17.0 20.6 15.3 20.5 15.0
S.D. *** 2.4 5.4 3.1 0.7 2.8 4.4 2.8 0.7 ***
RSES
Mean 30.0 31.0 25.5* 25.2* 28.0 29.5 32.9 32.6 31.3 31.0
S.D. *** 1.4 3.1 2.2 2.8 2.1 1.8 2.3 2.9 ***
SWLS
Mean 20.0 24.0 16.1* 14.8* 20.5 23.0 22.1 26.5 21.0 24.0
S.D. *** 0.8 2.3 4.1 0.7 1.4 2.6 2.2 1.4 ***

*Significant mean scores differences for the victim group from the other bullying types at the p = .001 level of confidence.
**Significant mean scores between the two groups (PWS and PWNS) on the SIAS-S, BFNE-S and SWLS at the p = .01 level of confidence.
***Only one person in this cell so no standard deviation could be computed.

3.2. Group Differences

An independent-samples t-test was conducted to compare the mean scores of the Social Interaction Anxiety Scale-
Straightforward (SIAS-S) in PWS and PWNS. There was a significant difference in the scores for PWS (M = 23.1, SD = 8.3) and
PWNS (M = 15.7, SD = 5.3); t (71) = 7.33, p < 0.001, d = 1.07. Results suggest that PWS scored higher on the social interaction
anxiety scale when compared to PWNS.
An independent-samples t-test was also conducted to compare the mean scores of the BFNE-S between the two groups.
There was a significant difference in the scores for PWS (M = 22.2, SD = 5.0) and PWNS (M = 16.8, SD = 4.3); t (71) = 5.1, p <.001,
d = 1.16. Results suggest that PWS scored higher on fear and worry of being evaluated when compared to PWNS.
An independent-samples t-test was conducted to compare the mean scores of the RSES in PWS and PWNS. There was no
significant difference in the scores for PWS (M = 30.2, SD = 4.0) and PWNS (M = 31.2, SD = 3.3); t (71) = 1.25, p = .261.
Finally, an independent-samples t-test was also conducted to compare the mean scores of the SWLS between the two
groups. There was a significant difference in the scores for PWS (M = 24.4, SD = 4.7) and PWNS (M = 20.0, SD = 3.7); t (71) = 4.7,
p <.001, d = 1.04. Results suggest that PWS scored lower on the general satisfaction with life when compared to PWNS.

3.3. Group and Bullying Category Differences

The presence of stuttering might contribute to increased social interaction anxiety, fear of negative evaluation, poorer
satisfaction with life, but those differences may differ across the bullying categories. A two group (PWS and PWNS) by five
bullying category (bully, victim, bully-victim, bystander and uninvolved) repeated measures analysis of variance (ANOVA)
was computed for each of the four psychosocial tests (SIAS-S, BFNE-S, RSES and SWLS). Using the Bonferroni correction, ␣
level was set at p = .0125 (.05/4).
A two-way ANOVA for the SIAS-S showed significantly higher levels of social interaction anxiety for PWS (F (1, 71) = 7.33,
p = .009, ␩2 = .225) than those PWNS. Members of different bullying groups also showed significantly different levels of social
interaction anxiety (F (4, 71) = 13.58, p = .001, ␩2 = .338). The interaction of group and bullying category was not significant
(F (4, 71) = 0.37, p = .826). Post hoc tests revealed that victims scored the highest social interaction scores for both PWS and
PWNS. Significant mean score differences were found for all bullying types between the PWS and PWNS groups at the p = .05
level of confidence. Inspection of Table 2 reveals that victims in both groups had the highest scores with the PWS victim
mean score above the cut-off score of 28. It appears that PWS, regardless of their classification showed higher social anxiety
scores. Childhood victim status and being a PWS appears to makes a major difference in increased social interaction anxiety.
Another way of analyzing the Social Interaction Anxiety Scale-Straightforward (SIAS-S) is examining the number of
participants who scored above the cut-off score > 28 which was recommended by Rodebaugh et al. (2011) for probable SAD
using the SIAS-S. Analyses showed that 10 (13.9%) participants earned scores of > 28. The group consisted of 8 (22.2%) PWS
and 2 (5.6%) PWNS. Of the 8 PWS, 7 (87.5%) were from the victim category while one PWS (12.5%) was from the bystander
category. Both the PWNS (100%) were from the victim category. Being victimized as a child appears to be a factor in higher
scores on the SIAS-S, and especially those above the cut-off for probable SAD.
A second result of two-way repeated ANOVA for the Brief Fear of Negative Evaluation Scale − Straightforward (BFNE-S)
also showed significantly higher levels of fear of negative evaluation for PWS (F (1, 71) = 7.76, p = .007, ␩2 = .155) than those
PWNS. Members of different bullying groups also showed significantly different levels of fear of negative evaluation (F (4,
80 G.W. Blood, I.M. Blood / Journal of Fluency Disorders 50 (2016) 72–84

71) = 9.97, p = .001, ␩2 = .587). The interaction of group and bullying category was not significant (F (4, 71) = 1.02, p = .404).
Post hoc tests revealed that victims displayed the highest scores for fear of negative evaluation for both PWS and PWNS.
Inspection of Table 2 reveals that victims in the PWNS showed a greater mean score difference (almost identical to level of
PWS) from the other bullying categories compared with PWS. Childhood victim status and being a PWS makes a difference
in increased levels of fear of negative evaluation.
Results for the SWLS also showed significantly lower levels of general life satisfaction for PWS (F (1, 71) = 7.08, p = .010,
␩2 = .123) than those PWNS. Members of different bullying groups also showed significantly different levels of satisfaction
with life (F (4, 71) = 36.23, p = .001, ␩2 = .371) (Table 2). The interaction of group and bullying category was also significant
(F (4, 71) = 4.48, p = .003, ␩2 = .064). Post hoc tests revealed that victims reported the lowest levels of satisfaction with life
for both groups. Victims in the PWNS group displayed lower mean levels of general life satisfaction compared with PWS. It
appears that childhood victim status and being a PWS makes a different in overall perceptions of life satisfaction.
Finally, the results for the 2 by 5 repeated measures ANOVA for the self-esteem revealed no significant differences between
PWS and PWS (F (1, 71) = 0.30, p = .585). Members of different bullying groups showed significantly different levels of self-
esteem (F (4, 71) = 29.01, p = .001, ␩2 = .669) (Table 2). The interaction of group and bullying category was not significant
(F (4, 71) = 0.19, p = .941). As seen in Table 2, victims reported poorer levels of self-esteem compared with bullies, victim-
bullies, bystanders and uninvolved for both PWS and PWNS. Childhood victim status appears to make a difference in adult’s
self-esteem.

4. Discussion

The present study compared the scores of PWS and PWNS on four psychosocial scales. Results suggest that PWS tended
to score significantly higher on the social interaction anxiety scale, the fear of negative evaluation scale and the satisfaction
with life scale. These results add evidence that some PWS display abnormally elevated social anxiety (Craig et al., 2009; Craig,
Blumgart, & Tran, 2015; Iverach & Rapee, 2014; Stein & Baird, 1996). When using the cut-off for probable SAD, eight (22.2%)
PWS and two (5.6%) PWNS could be classified with SAD using this screening tool. Although this suggests that social anxiety
many be higher in PWS, the percentages between the two groups suggests that this is more of a subgroup phenomenon and
not representative of the current sample of participants who stutter. These results for PWS are similar to those of reported in
other studies by Iverach et al., 2009a, 2009b, 2011. In contrast, these percentages are far below those reported by Blumgart
et al. (2010) who reported that the prevalence estimate of 46% for PWS and 4% for PWNS or Stein et al. (1996) with 44% of the
16 PWS meeting the criteria of SAD. Iverach and colleagues used a much larger sample size (n = 200 PWS; 200 PWNS), more
stringent tests and a diagnostic interview. It is interesting that even when using a shorter, simpler screening scale similar
outcomes were reported for PWS and PWNS in this study. The data support the fact that for some PWS, stuttering places
them at a risk for higher social anxiety scores and fear of negative evaluation. As other authors have indicated, the issue of
identifying social anxiety and then providing appropriate treatment for social anxiety in this subgroup of PWS is important
for a comprehensive treatment program. For approximately 22% of this sample, it would appear that optimal treatment plans
might include both speech therapy and some form of treatment for anxiety (e.g., CBT, mindfulness training). However, the
question presented over a decade ago by Messenger et al. (2004) still remains “whether social anxiety mediates stuttering
or is simply a by-product of the disorder” (p. 208). This is a critical issue in this area. As they indicated in their discussion,
if the anxiety is a by-product of stuttering, then the reduction of stuttering and stuttering severity should/could alleviate
the co-occurring social anxiety without accompanying anxiety management. However, if anxiety mediates the stuttering
condition, then co-treatment of anxiety and stuttering would be necessary for that subgroup of PWS.
The other results of the Brief Fear of Negative Evaluation Scale − Straightforward (BFNE-S) and the (Satisfaction with
Life Scale) SWLS support the idea that some PWS display higher levels of worrying about being evaluated and lower overall
satisfaction with life. These data support earlier studies reporting higher scores on the FNE for PWS (Bricker-Katz, Lincoln &
McCabe, 2009; Iverach et al., 2009a, 2009b; Mahr & Torosian, 1999; Messenger et al., 2004) and poorer overall SWLS scores
for PWS (Boyle, 2013). Similar findings were reported for the BFNE and the SWLS in terms of the subgroups of PWS and
victims of childhood bullying. These brief screening tests may provide a quick and easy way to screen adults for any potential
co-occurring problems and then make the appropriate referrals and/or begin collaborative team treatments, when required.
The most noteworthy contribution of this study is the addition of the apparent contributing factor of childhood victimiza-
tion and these lingering psychosocial consequences in both PWS and PWNS. Although the literature is replete with studies
about the lingering effects in PWNS, this study is the first to show that nearly 88% of PWS and 100% of PWNS with higher
anxiety scores were classified as victims based on their recalling bullying incidences during primary school, secondary school
and university environments. The next question for future research would be “Did the childhood victimization exacerbate
or even cause the anxiety in children who stutter or who do not stutter or did a visible display of social and communi-
cation anxiety make these children targets for bullies?” It is also possible that some children who are victimized develop
resilience skills, such as self-efficacy, social support and social integration skills, as discussed by Craig, Blumgart and Tran
(2011). These data support that majority of research which suggests the lingering effects of childhood victimization persist
into adulthood. These lingering effects in PWS may place children who stutter in a double-jeopardy situation. Not only are
children and adolescent who stutter dealing with the possibility of a chronic stuttering condition associated with negative
stereotypes and stigmatization but they may also be targeted by bullies for the manner in which they speak or deal with
social situations. It seems SLPs, classroom teachers, school counselors, administrators and IEP teams need to be aware of the
 G.W. Blood, I.M. Blood / Journal of Fluency Disorders 50 (2016) 72–84 81

potential for a complex interaction between stuttering, bullying and psychosocial problems (social anxiety, fear of negative
evaluations, low satisfaction with life) in primary and secondary school students who stutter. Attention at an early time (i.e.,
primary school) to these potential issues and their relationships may help prevent lingering and life-long problems in some
PWS.
As seen in Table 1, bullying categories remained relatively stable during primary school, secondary school and university
environments. These data provide compelling evidence of the need for early intervention by all school personnel, parent
groups, administrators, healthcare providers and community members. Although PWS tended to show less victimization
in the university setting when compared to PWNS, the other roles played by members of the bullying dynamic tended to
remain the same over time. With new anti-bullying initiatives and educational and healthcare systems becoming more
aware of the short-and long-term negative consequences, these roles might change and even be eliminated in the future. Of
course, the need for proactive strategies and peer support strategies for all students, especially children who stutter, remains
particularly critical (Blood, Boyle, Blood & Nalesnik, 2010; Cooper & Nickerson, 2013; De Lara, 2016; Hartley et al., 2015;
Hughes, 2014; Murphy & Quesal, 2002; Murphy, Quesal, Reardon-Reeves & Yaruss, 2013; Murphy, Yaruss & Quesal, 2007;
Smith, 2014).

4.1. Limitations of this Study

It should be noted that all these participants were students who had been admitted and were attending a competitive
major university in the northeastern United States. The convenience sample also introduces a bias in our results that needs
to be explored. It is possible that university students are more aware and sensitive to their surroundings and potential
negative outcomes. Of course, the opposite may also be true. Individuals who did not apply or were not admitted to a major
university may deal with these issues of social anxiety, fear of negative evaluation and bullying in completely different ways.
Future research studies need to examine the associations between level of education, occupation, support groups and overall
self-efficacy and achievement in PWS and the lingering effects of childhood victimization.
The small sample size makes these results preliminary and data collection is on-going at the present time. As can be seen
from the Tables, some of the cells had only one or two members and limits making any stronger conclusions at this time.
Second, as Craig (1990), Craig and Tran (2006), Iverach and Rapee (2014) suggest speech therapy may reduce anxiety and
negative expectancies in PWS. The results of the current screening tests could be influenced by this factor. All PWS in this
study had received treatment at some time in their lives. This factor limits the generalization of the data to individuals who
have not received therapy. We also did not request detailed information on the specific type of therapy which could also
have been a confounding factor in some of the results. Many comprehensive treatment programs for PWS work on attitudes,
cognitions and feelings, as well as speech behaviors. Finally, although social anxiety has been related to stuttering severity,
the current study did not examine this relationship due to the sample size and will add this question in future investigations.
Another limitation is that although the participants all responded to the primary, secondary and college experiences for
the four types of bullying (physical, verbal, relational and cyber), the stability of the bully-victim status could have varied
for some of the participants over time. Qualitative and mixed methods analyses with participants could examine this factor
in greater depth.
Finally, research confirms that victimization can cause mild to severe psychosocial problems in many community groups.
Future research needs to examine co-occurring disorders and other potential mediating factors. Bullying is a complex social,
educational and health problem. Early intervention and treatment protocols need to be designed for individuals with and
without chronic social and communication disabilities and conditions.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Gordon W. Blood is a professor in the Department of Communication Sciences and Disorders at The Pennsylvania State University. Dr. Blood is an
active researcher and an ASHA Fellow. His research focuses on the psychosocial factors associated with the quality of life in children, adolescents and
adults with communication and social disabilities, especially those in persons who stutter.

Ingrid M. Blood is a professor in the Department of Communication Sciences and Disorders at The Pennsylvania State University. Dr. Blood is an active
researcher and an ASHA Fellow. Her research focuses on the psychosocial factors associated with the quality of life in children, adolescents and adults
with communication and social disabilities, especially those in persons who stutter.