特別支援教育実践センター研究紀要

第13号，1-9，2015＜Original Article＞

Evaluation of Speech-Related Attitude
by Means of the KiddyCAT, CAT, and BigCAT,
within a Larger Behavior Assessment Battery Framework
for Children and Adults Who Stutter
VANRYCKEGHEM, Martine* and KAWAI, Norimune **Abstract
The assessment of a child or adult who stutters should not be limited to the investigation of theindividual’s disfluencies.   Given the abundance of data indicating that stuttering is not solely a speech
impediment, the constituents that surround stuttering need to be evaluated during the initial assessment.  
This paper presents information on an assessment battery for school-age children and one for adults, theBehavior Assessment Battery, which investigates the affective, behavioral and cognitive sequelae thatframe the stuttering disorder.   More specifically, the focus of this paper will be on the cognitive
component of the stuttering syndrome, not only among school-age children and adults, but even among
the very young, incipient stutterer.   The internationally-based research on the KiddyCAT, CAT and
BigCAT assessment tools is being summarized.   In addition, the current status of studies on attitude
toward communication of individuals in Japan is introduced.
Key words: speech-associated attitude, communication attitude, KiddyCAT, CAT, BigCAT

Ⅰ．Introduction“syndrome” (Cooper, 1984, 1999), should not be dealt
with in a mono-dimensional way, and that one should

Whether we are dealing with a child or adult
who stutters, through research, clinical experience,

refrain from seeing stuttering in a “tunnel-visionview” (Conture, 2001, p.126).  

anecdotal information and self-report information

The views about the dimensions of this speechfrom the individual, we have learned that talking

disorder, which can have a debilitating impact on aabout “stuttering” does not tell the complete story.  

person’s quality of life (Yaruss & Quesal, 2006),

Stuttering does not capture what occurs within thewarrant in the first place a thorough exploration of

person who stutters (PWS).  It does not give the fullits elements.   Aside from the observation of apicture.   The complete story is more complex andperson’s type and frequency of fluency failures,

encompasses more than just the perceived

discovering the all-encompassing aspects of thedisfluencies that interrupt the forward flow ofdisorder warrant more than only clinician

speech.  It is common knowledge that stuttering is,observation of the visible or audible correlates.  

in most cases, accompanied by preceding or co-

Obviously, analyzing the characteristics of theoccurring events and phenomena.  As a result, many

disfluencies, their locus, their acoustical distinctive

co-workers have agreed that this multi-dimensionalfeatures, are a vital part of what a thoroughdisorder (Barber Watson, 1995; Brutten &evaluation of the PWS should entail.   However, as

Vanryckeghem, 2003a,b, 2007; Guitar, 2014; Manning,has become more and more evident, it is equally

2010; Van Riper, 1982; Williams, 1979), the stuttering

important to incorporate the information provided
by the individual suffering from the speech*University of Central Florida, USA**Hiroshima University, Japan

impediment into our assessment of the person
experiencing it all (Perkins, 1990).   This intrinsic―1―

VANRYCKEGHEM, Martine and KAWAI, Norimune

information can be obtained by engaging the PWS

The uniqueness of the BAB lies in the fact thatin a detailed interview, and through an anamnestic

each of its sub-tests, explore the ABC components inintake conversation.  However, a more thorough anda non-confounded way.   In other words, each test

standardized way to obtain this information makes

separately discovers the affective, coping andalso use of standardized and normed self-reportattitudinal reactions, and their impact on a CWS or

tests.

PWS.  The various reactive and behavioral elements

Ⅱ．Behavior Assessment Battery

which Affect, Behavior and Cognition plays a role in

1. Overview

ABC profile, the specific items contained in each test

serve to generally profile the distinctive extent to
the disorder that is stuttering.   In turn, within thisA normed standardized test instrument that

pinpoint to treatment targets.

aims to obtain information from within the individual
who stutters, whether a child (CWS) or adult (PWS)

2. Speech Situation Checklist

is the Behavior Assessment Battery (BAB) (Brutten

The Speech Situation Checklist (SSC), is one of& Vanryckeghem, 2003a,b, 2007).   The BAB’s self-

the BAB sub-tests that explores both the affective

report tests tap into the Affective, Behavioral andand behavioral aspects of the stuttering disorder.  

Cognitive, or ABC, components of this amalgamated

The first section of this test, Emotional Reaction

speech disorder.  Affective reactions are explored as(SSC-ER) investigates the extent to which negative

it relates to sounds, words and particular speechemotional reaction, such as fear, anxiety, worry, issituations.  The behavioral aspect is not only limited

being reported to 51 (adult test) and 55 (children

to the speech disruption itself, but also to thosetest) described speech situations.   On a five-point

behaviors being used in order to cope with thescale, ranging from ‘not’ afraid, no worry . . . . . to . . .

stuttering.   A person’s cognition, thinking, belief‘very much’ afraid or worried, the child or adultabout his or her speaking ability and act of speaking,evaluates speech settings like: talking to someone

also warrants exploration.   These associated

you don’t know, trying to make a good impression,

attitudinal and affective reactions, and behaviors ofgiving your name, reading an unchangeable passage

avoidance and escape are seen by many as vital

aloud, as it relates to his or her level of negative

components worth investigating (Barber Watson,

emotional response.   In the Speech Disruption

1988, 1995; Brutten & Shoemaker, 1967; Brutten &section (SSC-SD), the client rates the extent of

Vanryckeghem, 2003a,b, 2007; Conture, 2001;

speech disruption (part-word and mono-syllabic word

Cooper, 1979; Guitar, 1976, 2014; Manning, 2010;

repetitions, oral and silent sound prolongations) in

Riley, 1994; Smith & Kelly, 1997; Yaruss & Quesal,

the very same speech situations found in the SSC-

2006).

ER section.   The answers range from ‘no’ speech

The BAB, is a multi-dimensional and evidence-

disruption . . . . to . . . . . speech is ‘very much’ disrupted.  

based approach to diagnostic and therapeutic

Aside from a total score, which gives a generaldecision making which uses the “inside view”

picture of the extent to which anxiety and speech(2003a,b, 2007) provided by the CWS and PWS.   Itdisruption is present in particular circumstances,assists in differential diagnosis of various fluency

each item’s score indicates which speech situations

disorders by pointing to different and differential

need to be targeted in treatment in terms ofaspects (Silverman, 2004), helps determine

desensitization and speech practice.   The SSC for

individualized strategies and tactics of therapy, andchildren and adults has a wide range ofmeasures therapeutic effectiveness.  For the purpose

psychometric data.   Repeatedly, it has been shownof this paper, only the venue of self-report will bethat CWS and PWS score statistically significantly

dealt with.   Patient history, clinician observation ofhigher on this test compared to their nonstutteringspeech during reading and extemporaneous speech,

peers.  Also the validity and reliability measures areinterview, etc., which are also intricate elements of asolid (Brutten & Vanryckeghem, 2003a,b, 2007;

fluency evaluation, will not be described here.

Vanryckeghem & Verghese, 2004).  
―2―

Evaluation of Speech-Related Attitude by Means of the KiddyCAT, CAT, and BigCAT

3. The Behavior Checklist

improved attitude toward speech (Andrews &The other branch of the behavioral dimension

Cutler, 1974), and that stuttering relapse was more

encompasses those behaviors that are secondary tooften associated with negative speech-associatedthe stuttering.  The Behavior Checklist (BCL) is theattitude than was a positive belief (Guitar, 1976;

test that provides information about a client’s

Guitar & Bass, 1978).  

speech-associated avoidance and escape behaviors
specific to sounds, words and situations.   The BCL

5. ‌Communication Attitude Test for School-Age

lists 50 (children test) and 95 (adult test) behaviors

Children (CAT)that might be associated with or exhibited during

Data that relate to speech-associated attitude

the act of speaking to avoid or escape negatively

among children was, however, non-existent or very

charged speech situations and/or words.  It explores

rudimentary until the eighties when Brutten

the number and type of coping behaviors that adesigned the Communication Attitude Test (CAT).  

client reports to employ as a means of aiding speech.  

The CAT (Brutten & Vanryckeghem, 2003a, 2007)

The test deals with the use of word substitutions,

was designed to specifically investigate the speech-

interjections, bodily adjustments, breathing patterns,

associated belief system of grade-school children as

just to name a few.   The BCL has shown toa purely cognitive measure.  Youngsters (age 6 - 16)differentiate individuals who stutter from those who

who stutter are asked to reflect directly on their

do not to a statistically significant extent, and to

attitude toward speech.  Research with the CAT on

have good validity and reliability (Brutten &an international scale is abundant.   Repeatedly, it

Vanryckeghem, 2003a,b, 2007; Vanryckeghem,

has been documented that school-age children who

Brutten, Uddin, & Van Borsel, 2004; Vanryckeghem

stutter score statistically significantly higher on the& Herder, 2004).  The resulting BCL data provide anCAT, indicating that they think negatively about

inventory of the avoidance and escape responses

their speech (Bernardini, Vanryckeghem, Brutten,

that a client uses to cope with stuttering, and that

Cocco, & Zmarich, 2009;  Brutten & Vanryckeghem,2003a, 2007; De Nil & Brutten,   1990, 1991; Gacnick &warrant the attention of the clinician.

Vanryckeghem, 2014; Green, 1998; Jacksic-Jelcic, &4. Cognition and Speech-Associated Attitude

Brestovci, 2000; Johannisson, Wennerfeldt, Havstam,Cognition is an integral component of theNaeslund, Jacobson, & Lohmander, 2009; Kawai, Healey,

experiences of CWS and PWS.   The importance ofNagasawa, Vanryckeghem, 2012; Vanryckeghem,

the relationship between cognition and stuttering

1995; Vanryckeghem & Brutten: 1992, 1995, 1997,

and its role in the onset and development of the

2003a).  Psychometric research into the reliability ofdisorder has long been recognized (Barber Watson,

the CAT (Boutsen & Brutten, 1990; Brutten

1995; Lincoln, Onslow & Menzies, 1996).   When

& Dunham, 1989; De Nil & Brutten, 1990;

cognitions become irrational, they can strengthen

Vanryckeghem & Brutten, 2003a) resulted in thestuttering behavior and prohibit CWS and PWS toomission of two of the CAT’s original items and thedeal with problems in a constructive manner.  Theseestablishment of the current 33-item True-False self-

cognitions can stabilize to a more permanent totality

report test (Brutten & Vanryckeghem, 2003a, 2007).  

of negative thoughts and anticipations and lay the

The CAT has also shown to have a good internal as

foundation for negative communication attitude.  

well as test-retest reliability and sensitivity.

The link between attitude and stuttering has been

In addition to the psychometric studies that

documented predominantly among adults who

have occurred globally with the CAT, the test has

stutter.   Pretreatment attitude e.g.   was seen as aalso been used to explore associated issues.  One ofgood prognostic measure of the instatement andthem relates to the link between speech-associatedmaintenance of fluency (Guitar, 1976).   In the same

attitude and negative emotional reaction.  By meansmanner, it was stated that long-term maintenance ofof the CAT, Vanryckeghem, Hylebos, Brutten andfluency that resulted from an operant treatment

Peleman (2001) were able to document a strong andprogram used was at least partially dependent on

statistically significant (.89) relationship between mal-―3―

VANRYCKEGHEM, Martine and KAWAI, Norimune

attitude and negative emotion among CWS, which isdevelopmental scales and inventories (Byrne,

supportive of the view that attitude and negative

Backman, and Smith, 1986; Goldstein, 1985; Miller,

emotion tend to influence each other and are a part

Manhal, & Mee, 1991); or as it relates to family, drug-of the stuttering syndrome.  

and work attitudes of young adult children

The relationship between attitude and stuttering(Thompson, Acock, & Clark, 1985).   By means ofseverity was documented in a study by Vanryckeghem

administration of the CAT to school-age children

and Brutten (1996).   Stuttering severity, which wasand an adaptation of this test to the parents,

measured during reading and extemporaneousreflecting on their CWS’ attitude, it was discovered

speech, was found to correlate to a limited (r=.33, .39,

that the concordance between the children’s CAT

respectively), though statistically significant extent.  

scores and those of their mother or father was

The limited shared variance indicates that thesestatistically significant but low, ranging from .29 tomeasured variables reflect somewhat different.34 (Vanryckeghem, 1995).   This common used

aspects of what constitutes stuttering.   Using theparental child-related report “gold standard” might

SSI-3, Kawai, Healey, Nagasawa and Vanryckeghem

thus be questioned, given the limited shared(2012) found a significant difference in the speech-

variance between a child’s reported speech-

associated attitude of their CWS with mild, moderateassociated attitude and that reported by the parents.

and severe stuttering.  
The differential effect of grade was studied by

6. Studies with the CAT in Japan

Kawai, Healey, Nagasawa and Vanryckeghem (2012).  

Although the CAT has been used in many

Aside from the fact that their data indicate thatcountries around the world, there is a limited

CWS score statistically significantly higher comparednumber of published studies on the CAT in Asian

to CWNS across first to sixth grade, they found thatcountries (Kawai et al., 2012).   In 1995, Kawai

for CWS as well as CWNS, the first graders scoredtranslated the CAT-R (De Nil & Brutten, 1991) into

statistically significantly lower compared to children

Japanese.   This instrument, CAT-J, included thein higher grades.  From second grade onwards, thesame 32 items as the CAT-R.   Using the CAT-J,

scores were not significantly different within each

Kawai conducted a pilot study of the speech-

group.  
had documented that mal-attitude of CWS tends toassociated attitude among 32 CWS and 70 CWNS,thth
who were in 4 through 6 grade of elementary
school.  Kawai (1995) found a statistically significant

increase with age, whereas an opposite trend is seendifference in speech-related attitude between CWS

among CWNS.   This between-group disparity

and CWNS.  However, it was observed that Japanese

increases with age.   Equally important was the

CWNS demonstrated a more negative attitude

observation that, from age 6 on, mal-attitude istoward speech compared to CWNS in the United

significantly more likely to be present among CWS

States and European countries (Kawai, 1995, 1997).  

Previously, Vanryckeghem and Brutten (1997)

than it is among CWNS.  This phenomenon intrigued

Subsequently, in order to investigate the efficacy of

the researchers and warranted a new line of

their cognitive component of stuttering therapy,

research with even younger children.   However,

Nagasawa and Kawai (1998) used the CAT-J toprior to this, Vanryckeghem (1995) studied how

determine attitude change of Japanese CWS.  They

reliable parents are in reporting on their children’s

administered the CAT-J to 64 CWS four times withspeech-associated attitude.  It is standard practice ofan interval of three months in the course of theirclinicians to question the parents of very young

treatment.   Thirty-five out of the 64 CWS received

children being assessed relative to their children’s

stuttering modification therapy, the others weredevelopment, symptomatology, emotional reactions,subjected to fluency shaping treatment.   The

attitudes, etc.  However, data stemming from related

researchers found that the CWS who received

fields show only a low-to-moderate degree ofstuttering modification therapy showed a significant

concordancy between parental report and theincrease in positive communication attitude asperformance of their child, as measured by means oftherapy went on, whereas those who received―4―Evaluation of Speech-Related Attitude by Means of the KiddyCAT, CAT, and BigCAT

fluency shaping intervention did not show akindergarten CWS.  By means of a 12-item “yes”-“no”

significant attitude change in the nine months ofverbally presented self-report test (e.g.  do mom andtheir treatment.   As indicated above, Kawai et al.  

dad think that you speak well; is talking hard for(2012) found that CWS have a significantly moreyou), and a play-type administration, the researchers

negative communication attitude than CWNS, awere able to document that CWS, as young as three,result that is similar to the data by Vanryckeghem

score statistically significantly higher on the(1997) and Vanryckeghem and Brutten, (1996) for

KiddyCAT compared to CWNS (Vanryckeghem &children in Belgium.  

Brutten: 2007; Vanryckeghem, Brutten &The results of the Kawai et al.   study (2012)

Hernandez, 2005).  In the meantime, data pointing toappear to be a valid reflection of the speech-

a mal-attitude among young children has been

associated attitude of Japanese children who stutter,

confirmed in other cross-cultural investigations

given that a reasonably large sample of 80 CWS was(Bernardini, Cocco, Zmarich, Di Pietro, Vanryckeghem,obtained for this investigation.   This sample is& Brutten, 2012; Clark, Conture, Frankel, & Walden,

similar to the sample size of the De Nil and Brutten

2012; Vanryckeghem & Vanrobaeys, 2013; Węsierska,(1991) study.  Nevertheless, the findings of this study

Vanryckeghem, Jeziorczak, & Wilk, 2014).  

need to be replicated using a larger number of

The KiddyCAT has shown to be internallyparticipants in both the CWS and CWNS group.  In

reliable (Vanryckeghem & Brutten, 2007) and isparticular, one of the limitations of this study was

based on one single factor ‘‘speech difficulty’’ (Clark

the lack of administration of the SSI-3 to CWNS.  

et al., 2012).   Similar to the CAT, the KiddyCATThis would have served to separate participants into

allows the clinician to determine if a child’s speech-

two distinct categories.  Future research in this area

associated attitude is typical of what is usuallyshould include the SSI-4 measure for CWNS.  

observed among CWNS, or is atypical and more like7. ‌Communication Attitude Test for Preschoolers

associated attitude at a preschool age, together withthat of CWS.   The presence of a negative speechand Kindergartners (KiddyCAT)

the knowledge that communication attitude among

The seemingly limited usefulness of parental

CWS only becomes more negative with age,comments about their child’s speech-associatedwarrants the attention of the clinician.  It highlights

attitude and the previously reported data pointing to

the importance of assessing communication attitude

the presence of significant negative thinking of CWS

and, when appropriate, to include attitude change as

about their speech, as of the age of six, which only

an aspect of therapy (Conture, 2001; Zebrowski &increases with age, led the CAT test authors into

Kelly, 2002).

exploring other means of investigating attitude
among younger children.  It resulted in the design of

8. Communication Attitude Test for Adults (BigCAT)

the Communication Attitude Test for Preschool and

The determination of communication attitude

Kindergarten Children who Stutter, or KiddyCAT

among adults who stutter, has been regular practice(Vanryckeghem & Brutten, 2007).   Research byfor many years.   Typically, the Erickson S-39 Scale

Grinager Ambrose and Yairi, (1994), and Ezrati,(Erickson, 1969) or the S-24 (Andrews & Cutler, 1974)

Platzky, and Yairi (2001) had already indicated that,were used for this purpose.  However, Vanryckeghemas a group, children as young as three show an

and Brutten’s line of investigation into communication

awareness of disfluency.   Clearly, the thought that

attitude of school-age (CAT) and, later, preschool andawareness, and the recognition of “stuttering” is akindergarten children (KiddyCAT), led in 2011 to themore advanced phenomenon, had been challenged.  

establishment of norms for the already clinicallyGiven their research on attitude with school-age

used Communication Attitude Test for Adults who

children, Vanryckeghem and colleagues wanted to

Stutter or BigCAT (Vanryckeghem & Brutten, 2011,

take these awareness data a step further and2012).   The BigCAT is, like the CAT, an un-

investigate if negative speech-associated attitudeconfounded cognition-based measure and consists ofmight already be present among preschool and35 true-false items that specifically explore speech-―5―

VANRYCKEGHEM, Martine and KAWAI, Norimune

associated belief.   A normative and comparative

treatment and maintenance of fluency is in part

investigation among PWS and PWNS with thedependent on acquiring a positive attitude.  

BigCAT revealed a highly significant between-groupdifference in the mean scores.   Moreover, theaverage score of PWS was found to be 5 ½ SD

Ⅲ．Conclusion
This paper dealt with different assessment

above mean score of the PWNS.   Contrary to theS-24, the BigCAT scores of CWS and CWNS show

tools: the BAB for children and adults, and themuch less in the way of overlap.   The BigCAT,

KiddyCAT, that allow for the determination ofwhich has also shown to have good internalfeelings, behaviors and speech-related attitude.  The

reliability, is clearly the more discriminatively

view from within, provided by the child or adult

powerful tool.  Its total test score and its items can

who stutters, augments the clinical observation andbe used to guide treatment that incorporates

permits a more fully rounded treatment.  It points tothe direction that therapy should take.  In addition,

attitude change.

its tests allow for pre- and post-treatment efficacy
9. BAB Summary

determination of the tactics used, and allocate a

The BAB self-report tests which investigate
negative emotional reaction and communication

greater involvement of the individual in the
management of his or her fluency disorder.  

disruption as it relates to sound, word and situational

As far as the research addressing communication

eliciting cues, the use of avoidance and escapeattitude among children who do and do not stutter

responses, mal-attitude, clearly provide a non-in Japan, additional studies are needed to confirm or

confounded multi-dimensional assessment of the

rebut the results of the Kawai et al.   (2012)

ABC components that make up or are associatedinvestigation, which indicates that Japanese CWS’with stuttering.   In turn, they lead to multi-modal

speech-related attitude becomes more negative as

treatment because the sub-tests’ item and total

they get older.   This can be accomplished byscores help the clinician pinpoint the targets ofcollecting CAT-J data on CWS who are in middle

therapy and guide the observation of change.  Aside(grades 7 through 9) and high school (grades 10

from solely focusing on stuttering behavior change

through 12).   In addition to further investigate

tactics, anxiety reduction and desensitization

children’s speech-associated attitude, it would beapproaches, awareness and omission of behaviors

equally important to develop a Japanese version of

secondary to stuttering are being addressed andthe complete BAB.  This would make it possible forcognitively, a more positive communication attitude

Japanese clinicians to apply a multidimensional

is being introduced.  

approach in the assessment of their clients who

Improved fluency depends, in part, on replacing
the disruptive effect of a negative speech-related
attitude with a belief system that is positive andsupportive of fluency.   In general, the link between
cognition and behavior has long been emphasized bycognitive behavior therapists (Bandura, 1969, 1986;

stutter, and to analyze the affective, behavioral andcognitive components of their stuttering.

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