Experiences of violence at school from the stuttering patients’ perspective

Purpose: to characterize school-aged patients with persistent stuttering regarding their self-reported experiences of violence at school. Methods: the sample comprised 10 patients with persistent stuttering, 10 to 17 years old, regardless of their sex and stuttering characteristics, who received care at a flu ency outpatient center in the heart of São Paulo State, Brazil. The collection instrument was an 11-question, multiple-choice, self-administered questionnaire. The data were descriptively analyzed based on the frequency of the answers. Results: almost half of the stuttering patients reported suffering bullying, in which they were given nicknames, defamed, blamed for everything that happened, physically attacked, and mocked. The classroom was the most mentioned environment where bullying took place. The following reactions to violence were mentioned: “talking to friends, teachers/principals, and relatives”, “sadness”, and “desire to change schools”. Conclusion: despite the small sample size, it was possible to note alarming data and the importance of educative/preventive actions in the school environment, approach ing both bullying and stuttering.


INTRODUCTION
Bullying is a term used to describe either direct (physical) or indirect violent behaviors that take place in the school environment [1][2][3] . Bullying is made up of three elements: intention, repetition, and power imbalance 1,4 . Violent behavior is considered bullying when it occurs more than once a month 5 .
This type of intentional, repetitive, and persistent violence is directed against weaker people, without any apparent reason 1,2 . Violent behavior can involve nicknames, rejection, provocations, and even beatings 6 . The most frequent type of bullying is verbal, followed by social, physical, and virtual (Internet) 7 .
It is quite evident that all victims of bullying suffer from aggression to a greater or lesser degree. Many people bear the marks of such suffering until they are adults, possibly needing psychological and/or psychiatric follow-up 2 . The most common consequences to the victims of bullying are uninterest in school, frequent absences, difficulties having or making friends, feeling of loneliness 8 , difficulties getting asleep, nightmares 9 , behavioral problems, anorexia, bulimia, increased anxiety, psychic problems, depression, and so forth. In more serious and recurrent cases, suffering bullying can lead to suicidal ideations 2,7,10 .
The findings of the Pesquisa Nacional de Saúde do Escolar (PeNSE -National Student Health Research), which investigated Brazilian students that were either bullies or victims of bullying, indicated a higher rate of bullying among boys aged 11 to 14 years, and a lower rate in preschool and high school 11 .
A risk group for bullying is that of schoolers with a disability, such as communication difficulties or language disorders 3,6,12,13 . Stuttering people, for instance, are more likely to be victims of bullying than those who do not stutter 3,5,[14][15][16][17] . Moreover, they are two times more likely to be victims of violent crimes than their peers 13 .
The characteristics observed in the speech of a stuttering person, such as repeated sounds or syllables, prolonged sounds, and interrupted and blocked words 18 , inhibit or hinder the child's verbal activities at school, increasing the possibility of rejection 14 .
The negative social consequences of stuttering can start in preschool and continue throughout their whole life 19 . The literature has revealed a prevalence of reports of bullying ranging from 26% to 61% 3,15,16,20 . Preschoolers consider it negative when a classmate stutters, whom they may ignore, interrupt, mock, and even avoid 19 . The difficulties grow more intense with the years at school since communication is increasingly important in the educational and social context.
Regarding the type of bullying they suffer, most of the teasing is more verbal than physical. Most of the time, the adolescents have their stuttering imitated 20 or they are nicknamed 3 . As for the consequences of having suffered bullying, the following were mentioned: feeling anxious, sad, depressed, irritated, timid, embarrassed, and being unwilling to go to school and overall dissatisfied with life 16 .
Understanding stuttering beyond its clinical aspects is particularly important. The need for more scientific research in Brazil has been noticed, as well as the dissemination of stuttering patients' bullying-related experiences and feelings in the school environment. Based on such dissemination, educative and protective actions towards this risk group for bullying is expected to increase. This study aimed to characterize schoolage patients with persistent stuttering, who received care at an outpatient center in the heart of São Paulo State, Brazil, regarding their self-reported experiences of violence at school.

METHODS
The research began after the approval by the Human Research Ethics Committee of the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo -HCFMRPUSP, SP, Brazil (evaluation report number 2.358.935/CAAE 77105317.6.0000.5440). All the participants signed the informed consent form, as well as those legally responsible for them.
The inclusion criteria were: 1) presenting a diagnosis of stuttering, following Andrade's protocol 21 for the assessment of speech fluency; 2) undergoing therapeutic follow-up at a fluency outpatient center in the municipality of Ribeirão Preto, São Paulo, Brazil; 3) being 10 to 17 years old; 4) attending school (middle or high school); 5) knowing how to read, according to self-reported information; 6) agreeing to participate in the study. Patients that were undergoing speechlanguage-hearing follow-up for any reason other than stuttering and those that did not want to participate were excluded.
The sample comprised 10 patients diagnosed with stuttering. Nine of them were boys, the youngest was 10 years old, and the oldest, 17 (mean 12.7 years). The predominant age group was 10 to 12 years old (60%), followed by 13 to 15 years old (20%), and 16 years old or more (20%). Most of them attended public schools (80%) and were in middle school (80%).
The data were collected at the therapist's office, taking approximately the last 20 minutes of the appointment, using an 11-question self-administered questionnaire, developed based on the Brazilian Portuguese version 22 of the original Training and Mobility of Researchers (TMR) questionnaire 23 . Of the 11 questions, five were open-ended and referred to the patient's personal data, and the other six were closedended and referred to their feelings and experiences of violence in the school environment, which is the object of this study. The closed-ended questions allowed the participant to answer with more than one option.
The answers to the questionnaire were tabulated in an Excel spreadsheet, and the data were descriptively analyzed based on the frequency of the answers.

RESULTS
The feelings of the stuttering patients towards the school and their schoolmates are shown in Table 1. The presence or absence of the sensation of having already been mistreated, threatened, or abused by schoolmates, as well as having already provoked or mistreated their peers, is described in Table 2. The participants were also asked about possible measures to avoid violence at school, in case they were the principal. The results are described in Table 4. Table 3 describes the demographic profile of stuttering schoolchildren that mentioned having been mistreated, threatened, or abused by schoolmates, as well as the characteristics of this type of violence. growing up, which decreases their vulnerability and improves their coping strategies 8 . These stuttering schoolchildren that suffered violence were mainly given nicknames, defamed, and blamed for everything that happened. Being given nicknames was also reported in another study 3 , reinforcing that most of the violence is verbal 7 .
Also, in the present research, most of the violence took place in the classroom, followed by the schoolyard. This corroborates the study by Lopes Neto 25 , which reports that the classroom was the environment mentioned by more than half of the students that suffer bullying in Brazil. On the other hand, in the study by Santos and Kienen 26 , the place where most of the bullying took place was the schoolyard, followed by the classroom.
In the present study, violence was motivated by the desire to "make fun/tease", or because "they had a hard time speaking", "they took too long to speak", "they were weaker than the others", or "they were different from the others". Hence, it is noticed that stuttering is a motivating factor for bullying 3 . The reluctance or difficulty to participate in verbal activities can affect their social interaction and the manner how they are seen by their peers, who oftentimes label these schoolchildren as timid or introvert 14 . Being timid and having relationship difficulties, in their turn, are two characteristics perceived in the victims of bullying 5 .
Concerning the reactions of those who reported suffering bullying, "talking to the teacher/principal" was frequently mentioned, unlike what was described in the researched literature 20,25 . On the other hand, in the present study, the teacher was little mentioned as the person who intervened in cases of violence, which can suggest unaware, unprepared, or uninvolved teachers in the fight against victimization due to bullying 9 . The role of intervening when violence occurred was given to the friends, which once again reinforces the importance of strengthening the support network among

DISCUSSION
Concerning the school-related feelings, although most of the stuttering schoolchildren mentioned they "felt well" or "very well" and had many friends, the quality of the interaction was considered average. Likewise, in the study by Nagib et al. 3 , most of the subjects stated they felt very well at school and with friends. In the school environment, bonding with peers is a protective factor against the serious forms of bullying 9 , as they build mutual confidence when facing challenges that help them overcome their vulnerability. For this reason, the number of friends and the quality of their interactions must be always investigated by relatives, and school and health professionals.
Regarding the sensation of violence in the school environment, almost half of the schoolchildren reported the sensation of abuses, mistreatments, or threats. This finding agrees with other studies that showed that schoolers that stutter or have another communication difficulty are more likely to suffer bullying than those without such impairments 3,6,12-14 . As for the four participants that reported being victims of violence, half of them stated that this practice occurred more than once a month, which can be characterized as bullying. An important aspect to highlight is that such frequency may have been underreported, as, for many students, violence is already a natural, integral part of school life 24 .
Those who reported suffering from school violence were from 10 to 15 years old, mean 13 years. Research reports that bullying takes place increasingly less often as they grow older and advance in school grades 6,7-10when they are 16, 17 years old, the students tend not to suffer bullying, whereas when they are 13 years old or younger, they are more likely to suffer such violence 8,11 . This can be explained by their increase in physical strength and cognitive and social gain that result from This study also pointed out that four out of 10 schoolage stuttering patients reported episodes of violence at school, which reinforces the need to seriously broaden the educative actions at school, engaging teachers, schoolmates, and parents 6,14 , especially in middle school. Not only victims but also bullies and spectators must be involved in the discussion around this theme and that of management of thoughts and feelings that motivate bullying 27 . As for stuttering, it is essential to instruct the schoolchildren about the condition, making them feel it and think about it, and include in the activities those with communication difficulties, teaching them to use assertive responses when intimidated. It is also necessary to teach their schoolmates and spectators about the relationship between stuttering and bullying, for them to be attentive to it, and instruct administrators and parents that bullying is the problem, not stuttering 28 .
Assistive, preventive, and/or educative actions in the school environment targeting students, teachers, and administrators have been described as effective in the fight against bullying, able to achieve a relevant reduction in victimizations 9 . Investing in actions to discuss and implement strategies to fight bullying is the whole community's duty since this type of violence is a public health issue, which does not affect the student alone. It is academia's role to invest in research to help develop and implement these strategies in various contexts 4 .
A limitation of the study was the small sample size of stuttering preadolescents and adolescents undergoing speech-language-hearing follow-up. This is to be expected, given that the first signs and symptoms of stuttering manifest in childhood 29 when there is a greater demand for speech-language-hearing health care. Another limitation perceived regarding the sample was the use of a questionnaire instead of an interview, which might have furnished more qualitative information to the study. It is suggested that further studies be carried out focused on the bullying of students that stutter or have other communication disorders.

CONCLUSION
In this study, although the stuttering patients felt well at school and had many friends, the quality of the interaction with their peers was considered average. Almost half mentioned they had the sensation of being abused, mistreated, or threatened at school, especially in the classroom and with verbal attacks. Having communication difficulties and being considered weaker than their peers were some of the motivations reported by those who suffered bullying.
These findings reinforce the need for additional study on the theme and the importance of the speechlanguage-hearing therapists' investment in their own social role of instructing the population about stuttering and bullying, inside and outside the therapists' office.