Children who stutter
Children who stutter (CWS) are placed at risk for being teased and bullied in primary school due to negative peer attitudes and perceptions [
1‐
4]. Negative attitudes and interactions result in CWS being viewed as different or disabled, leading to social rejection [
3]. Social rejection may lead to long term negative consequences such as reduced academic and social interactions, depression, and negative self-perceptions [
5,
6] which are harmful if not urgently addressed. These consequences are particularly prevalent in the adolescent population due to stress and rapid changes of emotion at this age [
3].
Attitudes and attitude change
Attitudes and perceptions overlap [
7] which is important to consider as negative peer attitudes may lead to negative perceptions towards CWS [
1‐
4]. While the relationships between attitudes, attitude change and behaviour change are complex and multifaceted [
8], this study focusses on attitude as the precursor for behaviour change [
9] but does not focus on behaviour change. The underpinning of attitudes for this study considers how literature characterises it. Attitudes are described as an individual’s evaluation of issues, objects and other individuals [
8]. As such, the evaluation of another person or object can be positive or negative [
10]. It is additionally reported that attitude formation is known to continuously change over time, [
11] as it is learnt and shaped [
7].
Stuttering intervention
The International Classification and Functioning of Disability (ICF) framework [
12] considers holistic management of the CWS. It advocates for classroom-based interventions to reduce teasing and bullying [
12‐
14,
15] because children spend a large amount of time with their teachers [
16]. Classroom-based interventions therefore aims to advocate for CWS and to empower teachers as communication partners of Speech-Language Therapists (SLTs) and CWS as guided by population-based stuttering interventions.
International public education is another population-based campaign that was studied. It addresses stuttering-related stigma [
9] through reducing the debilitating nature of stuttering and improving social environments and reactions [
17]. These publicised campaigns have, however, not documented effectiveness [
9]. Despite these findings,, the potential for classroom-based interventions to change attitudes towards stuttering are emerging [
18‐
22] and supported by the following studies: the Public Opinion Survey of Human Attributes- Stuttering (POSHA-S) internationally and in South Africa and the Teasing and Bullying: Unacceptable Behaviour (TAB). The international POSHA-S study showed that negative attitudes are in fact prevalent in school-aged children [
23]. A follow-up study conducted in South Africa, using the POSHA-S, showed that teachers were also requesting assistance with managing negative attitudes towards stuttering [
24]. Another tool used to address peer negative attitudes towards stuttering was the TAB which included teacher administered activities and yielded positive results pre- and post- intervention [
14,
15,
25]. The TAB was, however, not suitable for South African classrooms due to time and technology constraints as well as contextual, cultural and linguistic differences.
This led to the development of the South African specific intervention, the CCR intervention. It was developed and has been refined since 2009 as part of a series of the University of Cape Town (UCT) projects. The CCR intervention yielded positive results at 1 month post-intervention within the lower and higher quintile population respectively [
18,
26] and more so at 6 months’ post-intervention [
19]. The feasibility of a future Randomised Controlled Trial (RCT) study additionally reported potential effectiveness of the CCR intervention at 1 and 6 months’ post-intervention as well as procedural aspects [
19]. The findings were however inconclusive as it called for a more rigorous design method [
19]. It was also reported that a RCT was feasible despite concerns regarding the retention of participants as stringent methods could be put in place [
19]. A RCT was thus recommended as the next stage in these projects [
19].
The CCR intervention addresses pro-social behaviours and skills, including but not limited to the promotion of positive behaviour change, peer support and resilience through intervention [
16] in the areas of Positive Social Distance (PSD), Verbal Interaction (VI) and Social Pressure (SP) in the CCR intervention and Stuttering Resource Outcomes Measure (SROM). The areas of PSD, VI and SP are additionally measured using the SROM. PSD represents the overall ease, acceptance of and comfort a child feels when around CWS [
14,
15] e.g. ‘I would let a child who stutters hang out with us’. VI evaluates peer’s negative thoughts, emotions and feelings, e.g. frustration experienced towards a CWS [
14,
15]. SP evaluates general thoughts regarding CWS through examining social pressure and subjective norms [
13]. An example is ‘I would be ashamed to be seen with a child who stutters’. The promotion of these pro-social behaviours and skills may facilitate the prevention of anxiety and depression [
16] especially as CWS are placed at a high-risk of being teased and bullied due to their stutter [
1‐
4].