introduction to reported speech

Reported Speech – Rules, Examples & Worksheet

| Candace Osmond

Candace Osmond

Candace Osmond studied Advanced Writing & Editing Essentials at MHC. She’s been an International and USA TODAY Bestselling Author for over a decade. And she’s worked as an Editor for several mid-sized publications. Candace has a keen eye for content editing and a high degree of expertise in Fiction.

They say gossip is a natural part of human life. That’s why language has evolved to develop grammatical rules about the “he said” and “she said” statements. We call them reported speech.

Every time we use reported speech in English, we are talking about something said by someone else in the past. Thinking about it brings me back to high school, when reported speech was the main form of language!

Learn all about the definition, rules, and examples of reported speech as I go over everything. I also included a worksheet at the end of the article so you can test your knowledge of the topic.

What Does Reported Speech Mean?

Reported speech is a term we use when telling someone what another person said. You can do this while speaking or writing.

There are two kinds of reported speech you can use: direct speech and indirect speech. I’ll break each down for you.

A direct speech sentence mentions the exact words the other person said. For example:

• Kryz said, “These are all my necklaces.”

Indirect speech changes the original speaker’s words. For example:

• Kryz said those were all her necklaces.

When we tell someone what another individual said, we use reporting verbs like told, asked, convinced, persuaded, and said. We also change the first-person figure in the quotation into the third-person speaker.

Reported Speech Examples

We usually talk about the past every time we use reported speech. That’s because the time of speaking is already done. For example:

• Direct speech: The employer asked me, “Do you have experience with people in the corporate setting?”

Indirect speech: The employer asked me if I had experience with people in the corporate setting.

• Direct speech: “I’m working on my thesis,” I told James.

Indirect speech: I told James that I was working on my thesis.

Reported Speech Structure

A speech report has two parts: the reporting clause and the reported clause. Read the example below:

• Harry said, “You need to help me.”

The reporting clause here is William said. Meanwhile, the reported clause is the 2nd clause, which is I need your help.

What are the 4 Types of Reported Speech?

Aside from direct and indirect, reported speech can also be divided into four. The four types of reported speech are similar to the kinds of sentences: imperative, interrogative, exclamatory, and declarative.

Reported Speech Rules

The rules for reported speech can be complex. But with enough practice, you’ll be able to master them all.

Choose Whether to Use That or If

The most common conjunction in reported speech is that. You can say, “My aunt says she’s outside,” or “My aunt says that she’s outside.”

Use if when you’re reporting a yes-no question. For example:

• Direct speech: “Are you coming with us?”

Indirect speech: She asked if she was coming with them.

Verb Tense Changes

Change the reporting verb into its past form if the statement is irrelevant now. Remember that some of these words are irregular verbs, meaning they don’t follow the typical -d or -ed pattern. For example:

• Direct speech: I dislike fried chicken.

Reported speech: She said she disliked fried chicken.

Note how the main verb in the reported statement is also in the past tense verb form.

Use the simple present tense in your indirect speech if the initial words remain relevant at the time of reporting. This verb tense also works if the report is something someone would repeat. For example:

• Slater says they’re opening a restaurant soon.
• Maya says she likes dogs.

This rule proves that the choice of verb tense is not a black-and-white question. The reporter needs to analyze the context of the action.

Move the tense backward when the reporting verb is in the past tense. That means:

• Present simple becomes past simple.
• Present perfect becomes past perfect.
• Present continuous becomes past continuous.
• Past simple becomes past perfect.
• Past continuous becomes past perfect continuous.

Here are some examples:

• The singer has left the building. (present perfect)

He said that the singers had left the building. (past perfect)

• Her sister gave her new shows. (past simple)
• She said that her sister had given her new shoes. (past perfect)

If the original speaker is discussing the future, change the tense of the reporting verb into the past form. There’ll also be a change in the auxiliary verbs.

• Will or shall becomes would.
• Will be becomes would be.
• Will have been becomes would have been.
• Will have becomes would have.

For example:

• Direct speech: “I will be there in a moment.”

Indirect speech: She said that she would be there in a moment.

Do not change the verb tenses in indirect speech when the sentence has a time clause. This rule applies when the introductory verb is in the future, present, and present perfect. Here are other conditions where you must not change the tense:

• If the sentence is a fact or generally true.
• If the sentence’s verb is in the unreal past (using second or third conditional).
• If the original speaker reports something right away.
• Do not change had better, would, used to, could, might, etc.

Changes in Place and Time Reference

Changing the place and time adverb when using indirect speech is essential. For example, now becomes then and today becomes that day. Here are more transformations in adverbs of time and places.

• This – that.
• These – those.
• Now – then.
• Here – there.
• Tomorrow – the next/following day.
• Two weeks ago – two weeks before.
• Yesterday – the day before.

Here are some examples.

• Direct speech: “I am baking cookies now.”

Indirect speech: He said he was baking cookies then.

• Direct speech: “Myra went here yesterday.”

Indirect speech: She said Myra went there the day before.

• Direct speech: “I will go to the market tomorrow.”

Indirect speech: She said she would go to the market the next day.

Using Modals

If the direct speech contains a modal verb, make sure to change them accordingly.

• Will becomes would
• Can becomes could
• Shall becomes should or would.
• Direct speech: “Will you come to the ball with me?”

Indirect speech: He asked if he would come to the ball with me.

• Direct speech: “Gina can inspect the room tomorrow because she’s free.”

Indirect speech: He said Gina could inspect the room the next day because she’s free.

However, sometimes, the modal verb should does not change grammatically. For example:

• Direct speech: “He should go to the park.”

Indirect speech: She said that he should go to the park.

Imperative Sentences

To change an imperative sentence into a reported indirect sentence, use to for imperative and not to for negative sentences. Never use the word that in your indirect speech. Another rule is to remove the word please . Instead, say request or say. For example:

• “Please don’t interrupt the event,” said the host.

The host requested them not to interrupt the event.

• Jonah told her, “Be careful.”
• Jonah ordered her to be careful.

Reported Questions

When reporting a direct question, I would use verbs like inquire, wonder, ask, etc. Remember that we don’t use a question mark or exclamation mark for reports of questions. Below is an example I made of how to change question forms.

• Incorrect: He asked me where I live?

Correct: He asked me where I live.

Here’s another example. The first sentence uses direct speech in a present simple question form, while the second is the reported speech.

• Where do you live?

She asked me where I live.

Wrapping Up Reported Speech

My guide has shown you an explanation of reported statements in English. Do you have a better grasp on how to use it now?

Reported speech refers to something that someone else said. It contains a subject, reporting verb, and a reported cause.

Don’t forget my rules for using reported speech. Practice the correct verb tense, modal verbs, time expressions, and place references.

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• English Grammar
• Reported Speech

Reported Speech - Definition, Rules and Usage with Examples

Reported speech or indirect speech is the form of speech used to convey what was said by someone at some point of time. This article will help you with all that you need to know about reported speech, its meaning, definition, how and when to use them along with examples. Furthermore, try out the practice questions given to check how far you have understood the topic.

Table of Contents

Definition of reported speech, rules to be followed when using reported speech, table 1 – change of pronouns, table 2 – change of adverbs of place and adverbs of time, table 3 – change of tense, table 4 – change of modal verbs, tips to practise reported speech, examples of reported speech, check your understanding of reported speech, frequently asked questions on reported speech in english, what is reported speech.

Reported speech is the form in which one can convey a message said by oneself or someone else, mostly in the past. It can also be said to be the third person view of what someone has said. In this form of speech, you need not use quotation marks as you are not quoting the exact words spoken by the speaker, but just conveying the message.

Now, take a look at the following dictionary definitions for a clearer idea of what it is.

Reported speech, according to the Oxford Learner’s Dictionary, is defined as “a report of what somebody has said that does not use their exact words.” The Collins Dictionary defines reported speech as “speech which tells you what someone said, but does not use the person’s actual words.” According to the Cambridge Dictionary, reported speech is defined as “the act of reporting something that was said, but not using exactly the same words.” The Macmillan Dictionary defines reported speech as “the words that you use to report what someone else has said.”

Reported speech is a little different from direct speech . As it has been discussed already, reported speech is used to tell what someone said and does not use the exact words of the speaker. Take a look at the following rules so that you can make use of reported speech effectively.

• The first thing you have to keep in mind is that you need not use any quotation marks as you are not using the exact words of the speaker.
• You can use the following formula to construct a sentence in the reported speech.
• You can use verbs like said, asked, requested, ordered, complained, exclaimed, screamed, told, etc. If you are just reporting a declarative sentence , you can use verbs like told, said, etc. followed by ‘that’ and end the sentence with a full stop . When you are reporting interrogative sentences, you can use the verbs – enquired, inquired, asked, etc. and remove the question mark . In case you are reporting imperative sentences , you can use verbs like requested, commanded, pleaded, ordered, etc. If you are reporting exclamatory sentences , you can use the verb exclaimed and remove the exclamation mark . Remember that the structure of the sentences also changes accordingly.
• Furthermore, keep in mind that the sentence structure , tense , pronouns , modal verbs , some specific adverbs of place and adverbs of time change when a sentence is transformed into indirect/reported speech.

Transforming Direct Speech into Reported Speech

As discussed earlier, when transforming a sentence from direct speech into reported speech, you will have to change the pronouns, tense and adverbs of time and place used by the speaker. Let us look at the following tables to see how they work.

Here are some tips you can follow to become a pro in using reported speech.

• Select a play, a drama or a short story with dialogues and try transforming the sentences in direct speech into reported speech.
• Write about an incident or speak about a day in your life using reported speech.
• Develop a story by following prompts or on your own using reported speech.

Given below are a few examples to show you how reported speech can be written. Check them out.

• Santana said that she would be auditioning for the lead role in Funny Girl.
• Blaine requested us to help him with the algebraic equations.
• Karishma asked me if I knew where her car keys were.
• The judges announced that the Warblers were the winners of the annual acapella competition.
• Binsha assured that she would reach Bangalore by 8 p.m.
• Kumar said that he had gone to the doctor the previous day.
• Lakshmi asked Teena if she would accompany her to the railway station.
• Jibin told me that he would help me out after lunch.
• The police ordered everyone to leave from the bus stop immediately.
• Rahul said that he was drawing a caricature.

Transform the following sentences into reported speech by making the necessary changes.

1. Rachel said, “I have an interview tomorrow.”

2. Mahesh said, “What is he doing?”

3. Sherly said, “My daughter is playing the lead role in the skit.”

4. Dinesh said, “It is a wonderful movie!”

5. Suresh said, “My son is getting married next month.”

6. Preetha said, “Can you please help me with the invitations?”

7. Anna said, “I look forward to meeting you.”

8. The teacher said, “Make sure you complete the homework before tomorrow.”

9. Sylvester said, “I am not going to cry anymore.”

10. Jade said, “My sister is moving to Los Angeles.”

Now, find out if you have answered all of them correctly.

1. Rachel said that she had an interview the next day.

2. Mahesh asked what he was doing.

3. Sherly said that her daughter was playing the lead role in the skit.

4. Dinesh exclaimed that it was a wonderful movie.

5. Suresh said that his son was getting married the following month.

6. Preetha asked if I could help her with the invitations.

7. Anna said that she looked forward to meeting me.

8. The teacher told us to make sure we completed the homework before the next day.

9. Sylvester said that he was not going to cry anymore.

10. Jade said that his sister was moving to Los Angeles.

What is reported speech?

What is the definition of reported speech.

Reported speech, according to the Oxford Learner’s Dictionary, is defined as “a report of what somebody has said that does not use their exact words.” The Collins Dictionary defines reported speech as “speech which tells you what someone said, but does not use the person’s actual words.” According to the Cambridge Dictionary, reported speech is defined as “the act of reporting something that was said, but not using exactly the same words.” The Macmillan Dictionary defines reported speech as “the words that you use to report what someone else has said.”

What is the formula of reported speech?

You can use the following formula to construct a sentence in the reported speech. Subject said that (report whatever the speaker said)

Give some examples of reported speech.

Given below are a few examples to show you how reported speech can be written.

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Reported Speech

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Reported Statements

Here's how it works:

We use a 'reporting verb' like 'say' or 'tell'. ( Click here for more about using 'say' and 'tell' .) If this verb is in the present tense, it's easy. We just put 'she says' and then the sentence:

• Direct speech: I like ice cream.
• Reported speech: She says (that) she likes ice cream.

We don't need to change the tense, though probably we do need to change the 'person' from 'I' to 'she', for example. We also may need to change words like 'my' and 'your'. (As I'm sure you know, often, we can choose if we want to use 'that' or not in English. I've put it in brackets () to show that it's optional. It's exactly the same if you use 'that' or if you don't use 'that'.)

But , if the reporting verb is in the past tense, then usually we change the tenses in the reported speech:

• Reported speech: She said (that) she liked ice cream.

* doesn't change.

• Direct speech: The sky is blue.
• Reported speech: She said (that) the sky is/was blue.

Click here for a mixed tense exercise about practise reported statements. Click here for a list of all the reported speech exercises.

Reported Questions

So now you have no problem with making reported speech from positive and negative sentences. But how about questions?

• Direct speech: Where do you live?
• Reported speech: She asked me where I lived.
• Direct speech: Where is Julie?
• Reported speech: She asked me where Julie was.
• Direct speech: Do you like chocolate?
• Reported speech: She asked me if I liked chocolate.

Click here to practise reported 'wh' questions. Click here to practise reported 'yes / no' questions. Reported Requests

There's more! What if someone asks you to do something (in a polite way)? For example:

• Direct speech: Close the window, please
• Or: Could you close the window please?
• Or: Would you mind closing the window please?
• Reported speech: She asked me to close the window.
• Direct speech: Please don't be late.
• Reported speech: She asked us not to be late.

Reported Orders

• Direct speech: Sit down!
• Reported speech: She told me to sit down.
• Click here for an exercise to practise reported requests and orders.
• Click here for an exercise about using 'say' and 'tell'.
• Click here for a list of all the reported speech exercises.

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Reported Speech (Indirect Speech) in English – Summary

How to use reported speech.

If you have a sentence in Direct Speech, try to follow our 5 steps to put the sentence into Reported Speech..

• Define the type of the sentence (statement, questions, command)
• What tense is used in the introductory sentence?
• Do you have to change the person (pronoun)?
• Do you have to backshift the tenses?
• Do you have to change expressions of time and place?

1. Statements, Questions, Commands

Mind the type of sentences when you use Reported Speech. There is more detailed information on the following pages.

• Commands, Requests

2. The introductory sentence

If you use Reported Speech there are mostly two main differences.

The introductory sentence in Reported Speech can be in the Present or in the Past .

If the introductory sentences is in the Simple Present, there is no backshift of tenses.

Direct Speech:

• Susan, “ Mary work s in an office.”

Reported Speech:

• Introductory sentence in the Simple Present → Susan says (that)* Mary work s in an office.
• Introductory sentence in the Simple Past → Susan said (that)* Mary work ed in an office.

3. Change of persons/pronouns

If there is a pronoun in Direct Speech, it has possibly to be changed in Reported Speech, depending on the siutation.

• Direct Speech → Susan, “I work in an office.”
• Reported Speech → Susan said (that)* she worked in an office.

Here I is changed to she .

4. Backshift of tenses

If there is backshift of tenses in Reported Speech, the tenses are shifted the following way.

• Direct Speech → Peter, “ I work in the garden.”
• Reported Speech → Peter said (that)* he work ed in the garden.

5. Conversion of expressions of time and place

If there is an expression of time/place in the sentence, it may be changed, depending on the situation.

• Direct Speech → Peter, “I worked in the garden yesterday .”
• Reported Speech → Peter said (that) he had worked in the garden the day before .

6. Additional information

In some cases backshift of tenses is not necessary, e.g. when statements are still true. Backshift of tenses is never wrong.

• John, “My brother is at Leipzig university.”
• John said (that) his brother was at Leipzig university. or
• John said (that) his brother is at Leipzig university.

when you use general statements.

• Mandy, “The sun rises in the east.”
• Mandy said (that) the sun rose in the east. or
• Mandy said (that) the sun rises in the east.

* The word that is optional, that is the reason why we put it in brackets.

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Reported speech

Daisy has just had an interview for a summer job. 

Instructions

As you watch the video, look at the examples of reported speech. They are in  red  in the subtitles. Then read the conversation below to learn more. Finally, do the grammar exercises to check you understand, and can use, reported speech correctly.

Sophie:  Mmm, it’s so nice to be chilling out at home after all that running around.

Ollie: Oh, yeah, travelling to glamorous places for a living must be such a drag!

Ollie: Mum, you can be so childish sometimes. Hey, I wonder how Daisy’s getting on in her job interview.

Sophie: Oh, yes, she said she was having it at four o’clock, so it’ll have finished by now. That’ll be her ... yes. Hi, love. How did it go?

Daisy: Well, good I think, but I don’t really know. They said they’d phone later and let me know.

Sophie: What kind of thing did they ask you?

Daisy: They asked if I had any experience with people, so I told them about helping at the school fair and visiting old people at the home, that sort of stuff. But I think they meant work experience.

Sophie: I’m sure what you said was impressive. They can’t expect you to have had much work experience at your age.

Daisy:  And then they asked me what acting I had done, so I told them that I’d had a main part in the school play, and I showed them a bit of the video, so that was cool.

Sophie:  Great!

Daisy: Oh, and they also asked if I spoke any foreign languages.

Sophie: Languages?

Daisy: Yeah, because I might have to talk to tourists, you know.

Sophie: Oh, right, of course.

Daisy: So that was it really. They showed me the costume I’ll be wearing if I get the job. Sending it over ...

Ollie: Hey, sis, I heard that Brad Pitt started out as a giant chicken too! This could be your big break!

Daisy: Ha, ha, very funny.

Sophie: Take no notice, darling. I’m sure you’ll be a marvellous chicken.

We use reported speech when we want to tell someone what someone said. We usually use a reporting verb (e.g. say, tell, ask, etc.) and then change the tense of what was actually said in direct speech.

So, direct speech is what someone actually says? Like 'I want to know about reported speech'?

Yes, and you report it with a reporting verb.

He said he wanted to know about reported speech.

I said, I want and you changed it to he wanted .

Exactly. Verbs in the present simple change to the past simple; the present continuous changes to the past continuous; the present perfect changes to the past perfect; can changes to could ; will changes to would ; etc.

She said she was having the interview at four o’clock. (Direct speech: ' I’m having the interview at four o’clock.') They said they’d phone later and let me know. (Direct speech: ' We’ll phone later and let you know.')

OK, in that last example, you changed you to me too.

Yes, apart from changing the tense of the verb, you also have to think about changing other things, like pronouns and adverbs of time and place.

'We went yesterday.'  > She said they had been the day before. 'I’ll come tomorrow.' >  He said he’d come the next day.

I see, but what if you’re reporting something on the same day, like 'We went yesterday'?

Well, then you would leave the time reference as 'yesterday'. You have to use your common sense. For example, if someone is saying something which is true now or always, you wouldn’t change the tense.

'Dogs can’t eat chocolate.' > She said that dogs can’t eat chocolate. 'My hair grows really slowly.' >  He told me that his hair grows really slowly.

What about reporting questions?

We often use ask + if/whether , then change the tenses as with statements. In reported questions we don’t use question forms after the reporting verb.

'Do you have any experience working with people?' They asked if I had any experience working with people. 'What acting have you done?' They asked me what acting I had done .

Is there anything else I need to know about reported speech?

One thing that sometimes causes problems is imperative sentences.

You mean like 'Sit down, please' or 'Don’t go!'?

Exactly. Sentences that start with a verb in direct speech need a to + infinitive in reported speech.

She told him to be good. (Direct speech: 'Be good!') He told them not to forget. (Direct speech: 'Please don’t forget.')

OK. Can I also say 'He asked me to sit down'?

Yes. You could say 'He told me to …' or 'He asked me to …' depending on how it was said.

OK, I see. Are there any more reporting verbs?

Yes, there are lots of other reporting verbs like promise , remind , warn , advise , recommend , encourage which you can choose, depending on the situation. But say , tell and ask are the most common.

Great. I understand! My teacher said reported speech was difficult.

And I told you not to worry!

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Reported Speech in English Grammar

Direct speech, changing the tense (backshift), no change of tenses, question sentences, demands/requests, expressions with who/what/how + infinitive, typical changes of time and place.

• Lingolia Plus English

Introduction

In English grammar, we use reported speech to say what another person has said. We can use their exact words with quotation marks , this is known as direct speech , or we can use indirect speech . In indirect speech , we change the tense and pronouns to show that some time has passed. Indirect speech is often introduced by a reporting verb or phrase such as ones below.

Learn the rules for writing indirect speech in English with Lingolia’s simple explanation. In the exercises, you can test your grammar skills.

When turning direct speech into indirect speech, we need to pay attention to the following points:

• changing the pronouns Example: He said, “ I saw a famous TV presenter.” He said (that) he had seen a famous TV presenter.
• changing the information about time and place (see the table at the end of this page) Example: He said, “I saw a famous TV presenter here yesterday .” He said (that) he had seen a famous TV presenter there the day before .
• changing the tense (backshift) Example: He said, “She was eating an ice-cream at the table where you are sitting .” He said (that) she had been eating an ice-cream at the table where I was sitting .

If the introductory clause is in the simple past (e.g. He said ), the tense has to be set back by one degree (see the table). The term for this in English is backshift .

The verbs could, should, would, might, must, needn’t, ought to, used to normally do not change.

If the introductory clause is in the simple present , however (e.g. He says ), then the tense remains unchanged, because the introductory clause already indicates that the statement is being immediately repeated (and not at a later point in time).

In some cases, however, we have to change the verb form.

When turning questions into indirect speech, we have to pay attention to the following points:

• As in a declarative sentence, we have to change the pronouns, the time and place information, and set the tense back ( backshift ).
• Instead of that , we use a question word. If there is no question word, we use whether / if instead. Example: She asked him, “ How often do you work?” → She asked him how often he worked. He asked me, “Do you know any famous people?” → He asked me if/whether I knew any famous people.
• We put the subject before the verb in question sentences. (The subject goes after the auxiliary verb in normal questions.) Example: I asked him, “ Have you met any famous people before?” → I asked him if/whether he had met any famous people before.
• We don’t use the auxiliary verb do for questions in indirect speech. Therefore, we sometimes have to conjugate the main verb (for third person singular or in the simple past ). Example: I asked him, “What do you want to tell me?” → I asked him what he wanted to tell me.
• We put the verb directly after who or what in subject questions. Example: I asked him, “ Who is sitting here?” → I asked him who was sitting there.

We don’t just use indirect questions to report what another person has asked. We also use them to ask questions in a very polite manner.

When turning demands and requests into indirect speech, we only need to change the pronouns and the time and place information. We don’t have to pay attention to the tenses – we simply use an infinitive .

If it is a negative demand, then in indirect speech we use not + infinitive .

To express what someone should or can do in reported speech, we leave out the subject and the modal verb and instead we use the construction who/what/where/how + infinitive.

Say or Tell?

The words say and tell are not interchangeable. say = say something tell = say something to someone

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The Reported Speech

Table of Contents

What is reported speech.

Reported speech is when you tell somebody what you or another person said before. When reporting a speech, some changes are necessary.

For example, the statement:

• Jane said she was waiting for her mom .

is a reported speech, whereas:

• Jane said, “I’m waiting for my mom.”

is a direct speech.

Reported speech is also referred to as indirect speech or indirect discourse .

Before explaining how to report a discourse, let us first distinguish between direct speech and reported speech .

Direct speech vs reported speech

1. We use direct speech to quote a speaker’s exact words. We put their words within quotation marks. We add a reporting verb such as “he said” or “she asked” before or after the quote.

• He said, “I am happy.”

2. Reported speech is a way of reporting what someone said without using quotation marks. We do not necessarily report the speaker”‘s exact words. Some changes are necessary: the time expressions, the tense of the verbs, and the demonstratives.

• He said that he was happy.

More examples:

Different types of reported speech

When you use reported speech, you either report:

• Requests/commands
• Other types

A. Reporting statements

When transforming statements, check whether you have to change:

• place and time expression

1- Pronouns

In reported speech, you often have to change the pronoun depending on who says what.

She says, “My dad likes roast chicken.” => She says that her dad likes roast chicken.

• If the sentence starts in the present, there is no backshift of tenses in reported speech.
• If the sentence starts in the past, there is often a backshift of tenses in reported speech.

No backshift

Do not change the tense if the introductory clause (i.e., the reporting verb) is in the present tense (e. g. He says ). Note, however, that you might have to change the form of the present tense verb (3rd person singular).

• He says, “I write poems.” => He says that he writes English.

You must change the tense if the introductory clause (i.e., the reporting verb) is in the past tense (e. g. He said ).

• He said, “I am happy.”=> He said that he was happy.

Examples of the main changes in verb tense :

3. Modal verbs

The modal verbs could, should, would, might, needn’t, ought to, and used to do not normally change.

• He said: “She might be right.” => He said that she might be right.
• He told her: “You needn’t see a doctor.” => He told her that she needn’t see a doctor.

Other modal verbs such as can, shall, will, must, and ma y change:

4- Place, demonstratives, and time expressions

Place, demonstratives, and time expressions change if the context of the reported statement (i.e. the location and/or the period of time) is different from that of the direct speech.

In the following table, you will find the different changes of place; demonstratives, and time expressions.

B. Reporting Questions

When transforming questions, check whether you have to change:

• The pronouns
• The place and time expressions
• The tenses (backshift)

Also, note that you have to:

• transform the question into an indirect question
• use the question word ( where, when, what, how ) or if / whether

>> EXERCISE ON REPORTING QUESTIONS <<

C. Reporting requests/commands

When transforming requests and commands, check whether you have to change:

• place and time expressions
• She said, “Sit down.” – She asked me to sit down.
• She said, “don’t be lazy” – She asked me not to be lazy

D. Other transformations

• Expressions of advice with must , should, and ought are usually reported using advise / urge . Example: “You must read this book.” He advised/urged me to read that book.
• The expression let’s is usually reported using suggest . In this case, there are two possibilities for reported speech: gerund or statement with should . Example : “Let’s go to the cinema.” 1. He suggested going to the cinema. 2. He suggested that we should go to the cinema.

Main clauses connected with and/but

If two complete main clauses are connected with and or but , put that after the conjunction.

• He said, “I saw her but she didn’t see me.=> He said that he had seen her but that she hadn’t seen him.

If the subject is dropped in the second main clause (the conjunction is followed by a verb), do not use that .

• She said, “I am a nurse and work in a hospital.=> He said that she was a nurse and worked in a hospital.

punctuation rules of the reported speech

Direct speech:

We normally add a comma between the reporting verbs (e.g., she/he said, reported, he replied, etc.) and the reported clause in direct speech. The original speaker”s words are put between inverted commas, either single (“…”) or double (“…”).

• She said, “I wasn’t ready for the competition”.

Note that we insert the comma within the inverted commas if the reported clause comes first:

• “I wasn’t ready for the competition,” she said.

Indirect speech:

In indirect speech, we don’t put a comma between the reporting verb and the reported clause and we omit the inverted quotes.

• She said that she hadn’t been ready for the competition.

In reported questions and exclamations, we remove the question mark and the exclamation mark.

• She asked him why he looked sad?
• She asked him why he looked sad.

Can we omit that in the reported speech?

Yes, we can omit that after reporting verbs such as he said , he replied , she suggested , etc.

• He said that he could do it. – He said he could do it.
• She replied that she was fed up with his misbehavior. – She replied she was fed up with his misbehavior.

List of reporting verbs

Reported speech requires a reporting verb such as “he said”, she “replied”, etc.

Here is a list of some common reporting verbs:

• Cry (meaning shout)
• Demonstrate
• Hypothesize
• Posit the view that
• Question the view that
• Want to know

In reported speech, we put the words of a speaker in a subordinate clause introduced by a reporting verb such as – “ he said ” and “ she asked “- with the required person and tense adjustments.

Related pages

• Reported speech exercise (mixed)
• Reported speech exercise (questions)
• Reported speech exercise (requests and commands)
• Reported speech lesson

Reported Speech

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• An Introduction to Punctuation
• Ph.D., Rhetoric and English, University of Georgia
• M.A., Modern English and American Literature, University of Leicester
• B.A., English, State University of New York

Reported speech is the report of one speaker or writer on the words spoken, written, or thought by someone else. Also called reported discourse .

Traditionally, two broad categories of  reported speech  have been recognized: direct speech  (in which the original speaker's words are quoted word for word) and indirect speech (in which the original speaker's thoughts are conveyed without using the speaker's exact words). However, a number of linguists have challenged this distinction, noting (among other things) that there's significant overlap between the two categories. Deborah Tannen, for instance, has argued that "[w] hat is commonly referred to as reported speech or direct quotation in conversation is  constructed dialogue ."

Observations

• " Reported speech is not just a particular grammatical form or transformation , as some grammar books might suggest. We have to realize that reported speech represents, in fact, a kind of translation , a transposition that necessarily takes into account two different cognitive perspectives: the point of view of the person whose utterance is being reported, and that of a speaker who is actually reporting that utterance." (Teresa Dobrzyńska, "Rendering Metaphor in Reported Speech," in Relative Points of View: Linguistic Representation of Culture , ed. by Magda Stroińska. Berghahn Books, 2001)

Tannen on the Creation of Dialogue

• "I wish to question the conventional American literal conception of ' reported speech ' and claim instead that uttering dialogue in conversation is as much a creative act as is the creation of dialogue in fiction and drama. 
• "The casting of thoughts and speech in dialogue creates particular scenes and characters--and . . . it is the particular that moves readers by establishing and building on a sense of identification between speaker or writer and hearer or reader. As teachers of creative writing exhort neophyte writers, the accurate representation of the particular communicates universality, whereas direct attempts to represent universality often communicate nothing." (Deborah Tannen, Talking Voices: Repetition, Dialogue, and Imagery in Conversational Discourse , 2nd ed. Cambridge University Press, 2007)

Goffman on Reported Speech

• "[Erving] Goffman's work has proven foundational in the investigation of reported speech itself. While Goffman is not in his own work concerned with the analysis of actual instances of interaction (for a critique, see Schlegoff, 1988), it provides a framework for researchers concerned with investigating reported speech in its most basic environment of occurrence: ordinary conversation. . . .
• "Goffman . . . proposed that reported speech is a natural upshot of a more general phenomenon in interaction: shifts of 'footing,' defined as 'the alignment of an individual to a particular utterance . . .' ([ Forms of Talk ,] 1981: 227). Goffman is concerned to break down the roles of speaker and hearer into their constituent parts. . . . [O]ur ability to use reported speech stems from the fact that we can adopt different roles within the 'production format,' and it is one of the many ways in which we constantly change footing as we interact . . .."(Rebecca Clift and Elizabeth Holt, Introduction. Reporting Talk: Reported Speech in Interaction . Cambridge University Press, 2007)

Reported Speech in Legal Contexts

• "​ [R]eported speech occupies a prominent position in our use of language in the context of the law. Much of what is said in this context has to do with rendering people's sayings: we report the words that accompany other people's doings in order to put the latter in the correct perspective. As a consequence, much of our judiciary system, both in the theory and in the practice of law, turns around the ability to prove or disprove the correctness of a verbal account of a situation. The problem is how to summarize that account, from the initial police report to the final imposed sentence, in legally binding terms, so that it can go 'on the record,' that is to say, be reported in its definitive, forever immutable form as part of a 'case' in the books." (Jacob Mey, When Voices Clash: A Study in Literary Pragmatics . Walter de Gruyter, 1998)
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Direct and Indirect Speech: Useful Rules and Examples

Are you having trouble understanding the difference between direct and indirect speech? Direct speech is when you quote someone’s exact words, while indirect speech is when you report what someone said without using their exact words. This can be a tricky concept to grasp, but with a little practice, you’ll be able to use both forms of speech with ease.

Direct and Indirect Speech

When someone speaks, we can report what they said in two ways: direct speech and indirect speech. Direct speech is when we quote the exact words that were spoken, while indirect speech is when we report what was said without using the speaker’s exact words. Here’s an example:

Direct speech: “I love pizza,” said John. Indirect speech: John said that he loved pizza.

Using direct speech can make your writing more engaging and can help to convey the speaker’s tone and emotion. However, indirect speech can be useful when you want to summarize what someone said or when you don’t have the exact words that were spoken.

To change direct speech to indirect speech, you need to follow some rules. Firstly, you need to change the tense of the verb in the reported speech to match the tense of the reporting verb. Secondly, you need to change the pronouns and adverbs in the reported speech to match the new speaker. Here’s an example:

Direct speech: “I will go to the park,” said Sarah. Indirect speech: Sarah said that she would go to the park.

It’s important to note that when you use indirect speech, you need to use reporting verbs such as “said,” “told,” or “asked” to indicate who is speaking. Here’s an example:

Direct speech: “What time is it?” asked Tom. Indirect speech: Tom asked what time it was.

In summary, understanding direct and indirect speech is crucial for effective communication and writing. Direct speech can be used to convey the speaker’s tone and emotion, while indirect speech can be useful when summarizing what someone said. By following the rules for changing direct speech to indirect speech, you can accurately report what was said while maintaining clarity and readability in your writing.

Differences between Direct and Indirect Speech

When it comes to reporting speech, there are two ways to go about it: direct and indirect speech. Direct speech is when you report someone’s exact words, while indirect speech is when you report what someone said without using their exact words. Here are some of the key differences between direct and indirect speech:

Change of Pronouns

In direct speech, the pronouns used are those of the original speaker. However, in indirect speech, the pronouns have to be changed to reflect the perspective of the reporter. For example:

• Direct speech: “I am going to the store,” said John.
• Indirect speech: John said he was going to the store.

In the above example, the pronoun “I” changes to “he” in indirect speech.

Change of Tenses

Another major difference between direct and indirect speech is the change of tenses. In direct speech, the verb tense used is the same as that used by the original speaker. However, in indirect speech, the verb tense may change depending on the context. For example:

• Direct speech: “I am studying for my exams,” said Sarah.
• Indirect speech: Sarah said she was studying for her exams.

In the above example, the present continuous tense “am studying” changes to the past continuous tense “was studying” in indirect speech.

Change of Time and Place References

When reporting indirect speech, the time and place references may also change. For example:

• Direct speech: “I will meet you at the park tomorrow,” said Tom.
• Indirect speech: Tom said he would meet you at the park the next day.

In the above example, “tomorrow” changes to “the next day” in indirect speech.

Overall, it is important to understand the differences between direct and indirect speech to report speech accurately and effectively. By following the rules of direct and indirect speech, you can convey the intended message of the original speaker.

Converting Direct Speech Into Indirect Speech

When you need to report what someone said in your own words, you can use indirect speech. To convert direct speech into indirect speech, you need to follow a few rules.

Step 1: Remove the Quotation Marks

The first step is to remove the quotation marks that enclose the relayed text. This is because indirect speech does not use the exact words of the speaker.

Step 2: Use a Reporting Verb and a Linker

To indicate that you are reporting what someone said, you need to use a reporting verb such as “said,” “asked,” “told,” or “exclaimed.” You also need to use a linker such as “that” or “whether” to connect the reporting verb to the reported speech.

For example:

• Direct speech: “I love ice cream,” said Mary.
• Indirect speech: Mary said that she loved ice cream.

Step 3: Change the Tense of the Verb

When you use indirect speech, you need to change the tense of the verb in the reported speech to match the tense of the reporting verb.

• Indirect speech: John said that he was going to the store.

Step 4: Change the Pronouns

You also need to change the pronouns in the reported speech to match the subject of the reporting verb.

• Direct speech: “Are you busy now?” Tina asked me.
• Indirect speech: Tina asked whether I was busy then.

By following these rules, you can convert direct speech into indirect speech and report what someone said in your own words.

Converting Indirect Speech Into Direct Speech

Converting indirect speech into direct speech involves changing the reported speech to its original form as spoken by the speaker. Here are the steps to follow when converting indirect speech into direct speech:

• Identify the reporting verb: The first step is to identify the reporting verb used in the indirect speech. This will help you determine the tense of the direct speech.
• Change the pronouns: The next step is to change the pronouns in the indirect speech to match the person speaking in the direct speech. For example, if the indirect speech is “She said that she was going to the store,” the direct speech would be “I am going to the store,” if you are the person speaking.
• Change the tense: Change the tense of the verbs in the indirect speech to match the tense of the direct speech. For example, if the indirect speech is “He said that he would visit tomorrow,” the direct speech would be “He says he will visit tomorrow.”
• Remove the reporting verb and conjunction: In direct speech, there is no need for a reporting verb or conjunction. Simply remove them from the indirect speech to get the direct speech.

Here is an example to illustrate the process:

Indirect Speech: John said that he was tired and wanted to go home.

Direct Speech: “I am tired and want to go home,” John said.

By following these steps, you can easily convert indirect speech into direct speech.

Examples of Direct and Indirect Speech

Direct and indirect speech are two ways to report what someone has said. Direct speech reports the exact words spoken by a person, while indirect speech reports the meaning of what was said. Here are some examples of both types of speech:

Direct Speech Examples

Direct speech is used when you want to report the exact words spoken by someone. It is usually enclosed in quotation marks and is often used in dialogue.

• “I am going to the store,” said Sarah.
• “It’s a beautiful day,” exclaimed John.
• “Please turn off the lights,” Mom told me.
• “I will meet you at the library,” said Tom.
• “We are going to the beach tomorrow,” announced Mary.

Indirect Speech Examples

Indirect speech, also known as reported speech, is used to report what someone said without using their exact words. It is often used in news reports, academic writing, and in situations where you want to paraphrase what someone said.

Here are some examples of indirect speech:

• Sarah said that she was going to the store.
• John exclaimed that it was a beautiful day.
• Mom told me to turn off the lights.
• Tom said that he would meet me at the library.
• Mary announced that they were going to the beach tomorrow.

In indirect speech, the verb tense may change to reflect the time of the reported speech. For example, “I am going to the store” becomes “Sarah said that she was going to the store.” Additionally, the pronouns and possessive adjectives may also change to reflect the speaker and the person being spoken about.

Overall, both direct and indirect speech are important tools for reporting what someone has said. By using these techniques, you can accurately convey the meaning of what was said while also adding your own interpretation and analysis.

Frequently Asked Questions

What is direct and indirect speech?

Direct and indirect speech refer to the ways in which we communicate what someone has said. Direct speech involves repeating the exact words spoken, using quotation marks to indicate that you are quoting someone. Indirect speech, on the other hand, involves reporting what someone has said without using their exact words.

How do you convert direct speech to indirect speech?

To convert direct speech to indirect speech, you need to change the tense of the verbs, pronouns, and time expressions. You also need to introduce a reporting verb, such as “said,” “told,” or “asked.” For example, “I love ice cream,” said Mary (direct speech) can be converted to “Mary said that she loved ice cream” (indirect speech).

What is the difference between direct speech and indirect speech?

The main difference between direct speech and indirect speech is that direct speech uses the exact words spoken, while indirect speech reports what someone has said without using their exact words. Direct speech is usually enclosed in quotation marks, while indirect speech is not.

What are some examples of direct and indirect speech?

Some examples of direct speech include “I am going to the store,” said John and “I love pizza,” exclaimed Sarah. Some examples of indirect speech include John said that he was going to the store and Sarah exclaimed that she loved pizza .

What are the rules for converting direct speech to indirect speech?

The rules for converting direct speech to indirect speech include changing the tense of the verbs, pronouns, and time expressions. You also need to introduce a reporting verb and use appropriate reporting verbs such as “said,” “told,” or “asked.”

What is a summary of direct and indirect speech?

Direct and indirect speech are two ways of reporting what someone has said. Direct speech involves repeating the exact words spoken, while indirect speech reports what someone has said without using their exact words. To convert direct speech to indirect speech, you need to change the tense of the verbs, pronouns, and time expressions and introduce a reporting verb.

You might also like:

• List of Adjectives
• Predicate Adjective
• Superlative Adjectives

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MY NAAMEE IS KISHU AND I WANTED TO TELL THERE ARE NO EXERCISES AVAILLABLEE BY YOUR WEBSITE PLEASE ADD THEM SSOON FOR OUR STUDENTS CONVIENCE IM A EIGHT GRADER LOVED YOUR EXPLABATIO

sure cries l miss my friend

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Reported speech: indirect speech

Indirect speech focuses more on the content of what someone said rather than their exact words. In indirect speech , the structure of the reported clause depends on whether the speaker is reporting a statement, a question or a command.

Indirect speech: reporting statements

Indirect reports of statements consist of a reporting clause and a that -clause. We often omit that , especially in informal situations:

The pilot commented that the weather had been extremely bad as the plane came in to land. (The pilot’s words were: ‘The weather was extremely bad as the plane came in to land.’ )

I told my wife I didn’t want a party on my 50th birthday. ( that -clause without that ) (or I told my wife that I didn’t want a party on my 50th birthday .)

Indirect speech: reporting questions

Reporting yes-no questions and alternative questions.

Indirect reports of yes-no questions and questions with or consist of a reporting clause and a reported clause introduced by if or whether . If is more common than whether . The reported clause is in statement form (subject + verb), not question form:

She asked if [S] [V] I was Scottish. (original yes-no question: ‘Are you Scottish?’ )

The waiter asked whether [S] we [V] wanted a table near the window. (original yes-no question: ‘Do you want a table near the window? )

He asked me if [S] [V] I had come by train or by bus. (original alternative question: ‘Did you come by train or by bus?’ )

Questions: yes-no questions ( Are you feeling cold? )

Reporting wh -questions

Indirect reports of wh -questions consist of a reporting clause, and a reported clause beginning with a wh -word ( who, what, when, where, why, how ). We don’t use a question mark:

He asked me what I wanted.

Not: He asked me what I wanted?

The reported clause is in statement form (subject + verb), not question form:

She wanted to know who [S] we [V] had invited to the party.

Not: … who had we invited …

Who , whom and what

In indirect questions with who, whom and what , the wh- word may be the subject or the object of the reported clause:

I asked them who came to meet them at the airport. ( who is the subject of came ; original question: ‘Who came to meet you at the airport?’ )

He wondered what the repairs would cost. ( what is the object of cost ; original question: ‘What will the repairs cost?’ )

She asked us what [S] we [V] were doing . (original question: ‘What are you doing?’ )

Not: She asked us what were we doing?

When , where , why and how

We also use statement word order (subject + verb) with when , where, why and how :

I asked her when [S] it [V] had happened (original question: ‘When did it happen?’ ).

Not: I asked her when had it happened?

I asked her where [S] the bus station [V] was . (original question: ‘Where is the bus station?’ )

Not: I asked her where was the bus station?

The teacher asked them how [S] they [V] wanted to do the activity . (original question: ‘How do you want to do the activity?’ )

Not: The teacher asked them how did they want to do the activity?

Questions: wh- questions

Indirect speech: reporting commands

Indirect reports of commands consist of a reporting clause, and a reported clause beginning with a to -infinitive:

The General ordered the troops to advance . (original command: ‘Advance!’ )

The chairperson told him to sit down and to stop interrupting . (original command: ‘Sit down and stop interrupting!’ )

We also use a to -infinitive clause in indirect reports with other verbs that mean wanting or getting people to do something, for example, advise, encourage, warn :

They advised me to wait till the following day. (original statement: ‘You should wait till the following day.’ )

The guard warned us not to enter the area. (original statement: ‘You must not enter the area.’ )

Verbs followed by a to -infinitive

Indirect speech: present simple reporting verb

We can use the reporting verb in the present simple in indirect speech if the original words are still true or relevant at the time of reporting, or if the report is of something someone often says or repeats:

Sheila says they’re closing the motorway tomorrow for repairs.

Henry tells me he’s thinking of getting married next year.

Rupert says dogs shouldn’t be allowed on the beach. (Rupert probably often repeats this statement.)

Newspaper headlines

We often use the present simple in newspaper headlines. It makes the reported speech more dramatic:

JUDGE TELLS REPORTER TO LEAVE COURTROOM

PRIME MINISTER SAYS FAMILIES ARE TOP PRIORITY IN TAX REFORM

Present simple ( I work )

Reported speech

Reported speech: direct speech

Indirect speech: past continuous reporting verb

In indirect speech, we can use the past continuous form of the reporting verb (usually say or tell ). This happens mostly in conversation, when the speaker wants to focus on the content of the report, usually because it is interesting news or important information, or because it is a new topic in the conversation:

Rory was telling me the big cinema in James Street is going to close down. Is that true?

Alex was saying that book sales have gone up a lot this year thanks to the Internet.

‘Backshift’ refers to the changes we make to the original verbs in indirect speech because time has passed between the moment of speaking and the time of the report.

In these examples, the present ( am ) has become the past ( was ), the future ( will ) has become the future-in-the-past ( would ) and the past ( happened ) has become the past perfect ( had happened ). The tenses have ‘shifted’ or ‘moved back’ in time.

The past perfect does not shift back; it stays the same:

Modal verbs

Some, but not all, modal verbs ‘shift back’ in time and change in indirect speech.

We can use a perfect form with have + - ed form after modal verbs, especially where the report looks back to a hypothetical event in the past:

He said the noise might have been the postman delivering letters. (original statement: ‘The noise might be the postman delivering letters.’ )

He said he would have helped us if we’d needed a volunteer. (original statement: ‘I’ll help you if you need a volunteer’ or ‘I’d help you if you needed a volunteer.’ )

Used to and ought to do not change in indirect speech:

She said she used to live in Oxford. (original statement: ‘I used to live in Oxford.’ )

The guard warned us that we ought to leave immediately. (original statement: ‘You ought to leave immediately.’ )

No backshift

We don’t need to change the tense in indirect speech if what a person said is still true or relevant or has not happened yet. This often happens when someone talks about the future, or when someone uses the present simple, present continuous or present perfect in their original words:

He told me his brother works for an Italian company. (It is still true that his brother works for an Italian company.)

She said she ’s getting married next year. (For the speakers, the time at the moment of speaking is ‘this year’.)

He said he ’s finished painting the door. (He probably said it just a short time ago.)

She promised she ’ll help us. (The promise applies to the future.)

Indirect speech: changes to pronouns

Changes to personal pronouns in indirect reports depend on whether the person reporting the speech and the person(s) who said the original words are the same or different.

Indirect speech: changes to adverbs and demonstratives

We often change demonstratives ( this, that ) and adverbs of time and place ( now, here, today , etc.) because indirect speech happens at a later time than the original speech, and perhaps in a different place.

Typical changes to demonstratives, adverbs and adverbial expressions

Indirect speech: typical errors.

The word order in indirect reports of wh- questions is the same as statement word order (subject + verb), not question word order:

She always asks me where [S] [V] I am going .

Not: She always asks me where am I going .

We don’t use a question mark when reporting wh- questions:

I asked him what he was doing.

Not: I asked him what he was doing?

Word of the Day

If you are on hold when using the phone, you are waiting to speak to someone.

Searching out and tracking down: talking about finding or discovering things

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Reported Speech – Free ESL Lesson Plan

Our new ESL Lesson Plan , “Introduction to Reported Speech,” helps students understand how to describe someone else’s words. Learning how to transform direct speech into reported speech is essential to everyday communication, and students will certainly benefit from this engaging lesson that includes clear descriptions, examples and practice opportunities. Keep reading to find out what to expect and how to teach it virtually or in-person.

When should you teach “Introduction to Reported Speech”?

“Introduction to Reported Speech” is an ESL lesson plan download aimed at students with advanced proficiency levels. To fully grasp the material, students must be very comfortable with changing verbs between various tenses including the perfect, simple and continuous tenses.

You can download the lesson plan here:

How to teach the “Introduction to Reported Speech” lesson

To help students understand this concept, this lesson breaks down the components of transforming direct speech into reported speech: pronouns, tenses, time and the removal of quotation marks. It also spends a substantial portion of slides going over how to  backshift  by “going back a tense” and how to employ possessive adjectives successfully.

The slides are playful and illustrated with many pictures and fun examples to keep your students engaged and motivated.

If you are looking for even more information on how to teach this lesson plan on reported speech, be sure to download a  free Off2Class account . You will gain access to teacher notes that will guide and prepare you. 

Don’t forget about our free lessons!

If you enjoyed this ESL lesson plan download, there are 149 more available here . The lesson plans are designed to save you time . Also, let us know what kind of lessons you are looking for from Off2Class. More than anything, we love hearing from our teachers. So leave your general suggestions, lesson plan ideas, teaching philosophy or anything related in the comments below. Happy teaching! 

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ESL Worksheets for Teachers

Check out our selection of worksheets filed under grammar: reported speech. use the search filters on the left to refine your search..

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Intermediate (B1-B2)

In this lesson, students learn language related to government and human rights by discussing control of technology and information. The control of technology and information is important to lawyers working in diverse fields, ranging from human rights to business.

by Susan Iannuzzi

This worksheet teaches reported speech . The rules for changing the tense of the verb from direct speech are presented and practised. The worksheet is suitable for both classroom practice and self-study. 

Pre-intermediate (A2-B1)

In this lesson, students read an article about pros and cons of Sweden's six-hour work day. The 5-page worksheet includes a grammar activity on reported speech.

The first of a two-part lesson plan that looks at the causes and impact of stress in the workplace. Students read about how stress is affecting small and medium-sized businesses in the UK. The lesson rounds off with a grammar exercise on reported speech in which students complete a stressful negotiation dialogue using the target language structures.

This lesson is based on an article about a woman from New Zealand who became an 'accidental millionaire' when her partner's bank mistakenly increased his overdraft limit by nearly £5 million ($8 million). There is plenty of crime and punishment vocabulary as well as banking terms and expressions (which should be familiar to students who have done the worksheet Banking ). In the grammar section, there is an exercise on the past perfect simple , which is used throughout the article. Use this worksheet with a strong intermediate or upper intermediate class. Important notes are included in the key.

Upper-intermediate (B2-C1)

This lesson teaches the vocabulary and grammar necessary for taking meeting minutes in English. Students listen to a dialogue of a meeting and read an extract from the minutes. After studying the vocabulary and grammar used in the text, they practise reporting statements and taking minutes.

This lesson is based on an article on the nascent space tourism industry. The text focuses on the different companies that will be operating in this market, including Richard Branson’s Virgin Galactic, as well as the future costs and environmental impact of commercial space flights. In the grammar section of the worksheets, reported statements and questions are studied and practised. At the end of the lesson, students discuss whether they believe space tourism could become mass market.

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Content Validity of the Modified Functional Scale for the Assessment and Rating of Ataxia (f-SARA) Instrument in Spinocerebellar Ataxia

• Open access
• Published: 07 May 2024

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• Michele Potashman 1 ,
• Katja Rudell 2 ,
• Ivanna Pavisic 2 ,
• Naomi Suminski 2 ,
• Rinchen Doma 2 ,
• Maggie Heinrich 2 ,
• Linda Abetz-Webb 3 ,
• Melissa Wolfe Beiner 1 ,
• Sheng-Han Kuo 4 ,
• Liana S. Rosenthal 5 ,
• Theresa Zesiwicz 6 ,
• Terry D. Fife 7 ,
• Bart P. van de Warrenburg 8 ,
• Giovanni Ristori 9 ,
• Matthis Synofzik 10 ,
• Susan Perlman 11 ,
• Jeremy D. Schmahmann 12 &
• Gilbert L’Italien 1  

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The functional Scale for the Assessment and Rating of Ataxia (f-SARA) assesses Gait, Stance, Sitting, and Speech. It was developed as a potentially clinically meaningful measure of spinocerebellar ataxia (SCA) progression for clinical trial use. Here, we evaluated content validity of the f-SARA. Qualitative interviews were conducted among individuals with SCA1 ( n  = 1) and SCA3 ( n  = 6) and healthcare professionals (HCPs) with SCA expertise (USA, n  = 5; Europe, n  = 3). Interviews evaluated symptoms and signs of SCA and relevance of f-SARA concepts for SCA. HCP cognitive debriefing was conducted. Interviews were recorded, transcribed, coded, and analyzed by ATLAS.TI software. Individuals with SCA1 and 3 reported 85 symptoms, signs, and impacts of SCA. All indicated difficulties with walking, stance, balance, speech, fatigue, emotions, and work. All individuals with SCA1 and 3 considered Gait, Stance, and Speech relevant f-SARA concepts; 3 considered Sitting relevant (42.9%). All HCPs considered Gait and Speech relevant; 5 (62.5%) indicated Stance was relevant. Sitting was considered a late-stage disease indicator. Most HCPs suggested inclusion of appendicular items would enhance clinical relevance. Cognitive debriefing supported clarity and comprehension of f-SARA. Maintaining current abilities on f-SARA items for 1 year was considered meaningful for most individuals with SCA1 and 3. All HCPs considered meaningful changes as stability in f-SARA score over 1–2 years, 1–2-point change in total f-SARA score, and deviation from natural history. These results support content validity of f-SARA for assessing SCA disease progression in clinical trials.

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Introduction

Spinocerebellar ataxias (SCAs) are a dominantly inherited heterogeneous group of rare disorders that cause progressive neurodegeneration of the cerebellum and spinal cord [ 1 , 2 , 3 ]. Almost 50 different SCA genotypes have been identified, each with a distinct pathophysiology and clinical profile. Of these, SCA types 1, 2, 3, and 6 have been considered the most common worldwide [ 1 , 3 , 4 , 5 , 6 , 7 ]. The recent identification and characterization of the newly discovered SCA27b variant has suggested that this may account for a substantial proportion of previously unexplained late-onset dominant and sporadic cerebellar ataxias, though its global prevalence remains to be established [ 4 , 5 , 8 , 9 ]. Whereas symptom manifestation and disease trajectory vary across SCA types, all share the cardinal features of cerebellar dysfunction, which includes progressive lack of voluntary motor coordination, gait impairment, loss of balance and associated falls, and speech and swallowing difficulties [ 1 , 10 , 11 , 12 ]. In addition to affecting physical functioning, symptoms impair independent ability to conduct activities of daily living (ADLs), which increases reliance on caregivers and severely impacts patient quality of life [ 13 , 14 , 15 , 16 ]. Patient life expectancy varies widely between SCA types [ 7 , 17 ].

To reliably measure the severity and progression of cerebellar ataxia, notably SCA, the Scale for the Assessment and Rating of Ataxia (SARA) was developed by a panel of expert clinicians to provide semi-quantitative scoring of patient gross and fine motor function [ 18 ]. The SARA evaluates 8 items concerning gait, stance, sitting, speech, and upper and lower limb coordination. It provides a combined total score that indicates disease severity, with higher scores denoting more severe disease. A number of patient registries and clinical studies have used the SARA as an outcome measure to date to assess the impact of pharmacologic and/or non-pharmacologic therapies on SCA symptom progression [ 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ]. Recently, the SARA was modified to serve as a primary endpoint in a randomized clinical trial of individuals with SCA [ 33 ]. Accounting for feedback from discussions with the Food and Drug Administration (FDA), and upon analysis of US natural history data from the Clinical Research Consortium for the Study of Cerebellar Ataxia and a phase 2 study of troriluzole [ 34 ], removal of the 4 appendicular items from the original SARA was implemented. These items were not considered sensitive for measurement of meaningful change in a clinical trial setting conducted over 48 weeks.

The resulting modification of the SARA, the functional SARA (f-SARA), is a 4-item scale that assesses Gait, Stance, Sitting, and Speech. Each of the 4 items is rated on an ordinal scale from 0 to 4, where 0 indicates normal or unimpaired function, and higher responses indicate progressive impairment. The total f-SARA score is the sum of the 4 individual items (16 points).

When developing or adapting a clinical outcome assessment (COA), it is important to collect patient perspectives on their lived experience of the disease of interest, as well as clinical perspectives on the temporal progression of the disease, to support the content validity of the measure [ 35 , 36 ]. In addition, cognitive debriefing and discussions centered around what constitutes meaningful changes in the context of the disease are important steps in establishing the content validity of a new or modified COA. These discussions ensure that the measure has the potential to assess meaningful changes in patient-experienced symptoms reliably [ 35 , 36 ].

The f-SARA was developed to support the primary endpoint in a phase 3 study evaluating the efficacy of troriluzole on ataxia symptoms in individuals with SCA (NCT03701399; trial registration date: October 8, 2018), but the content validity of the items that comprise the f-SARA (i.e., comprehensiveness, relevance, comprehension, and understandability) remains to be determined. To address this need, we conducted qualitative interviews with individuals with SCA and healthcare professionals (HCPs) with expertise in treating SCA to assess the content validity of the f-SARA and to explore what constitutes clinically meaningful changes in SCA symptoms.

Patients and Methods

Study design.

Qualitative interviews were conducted with individuals diagnosed with SCA in the United States and with HCPs who treat SCA in the United States and Europe. Interviews were designed according to the FDA Patient Focused Drug Development Guidance [ 37 , 38 , 39 ] to assess individuals with SCA and HCPs’ perspectives of the f-SARA in terms of comprehensiveness, content validity, item relevance, and ability to measure meaningful changes. Interviews consisted of concept elicitation and cognitive debriefing phases.

Participants

HCPs who met the eligibility criteria and were considered experts in assessing and treating individuals with SCA were identified (eligibility criteria shown in Supplementary Table 1 ). There were 2 cohorts of HCPs included in the interviews. The first from the United States with prior experience of using the f-SARA instrument through participation in the phase 3 study evaluating troriluzole efficacy (NCT03701399) (f-SARA previously exposed; HCPs 1–5), and the second from Europe with no prior clinical experience with the f-SARA instrument (f-SARA newly exposed; HCPs 6–8). All HCPs had extensive experience with COAs in SCA including the SARA.

Eligible individuals aged 18–75 years with any SCA type were recruited via clinician referral or self-referral from a patient advocacy organization (National Ataxia Foundation) (participant eligibility criteria shown in Supplementary Table 2 ).

Interview Process

Discussion guides were developed for semi-structured interviews with individuals with SCA and HCPs, respectively (Supplementary Table 3 ). Interview questions were focused primarily on symptoms and impacts associated with SCA. Interviews were conducted in English via video call and were semi-structured lasting approximately 120–180 min over either 1 or 2 sessions. Interviews also included discussions assessing 2 other SCA COAs, which will be reported elsewhere.

During the interview, demographic and health information was initially collected from individuals with SCA, and pertinent demographic information was ascertained for the HCPs. Participants then underwent a concept elicitation session to explore the lived and observed experiences, and daily functioning abilities of individuals with SCA. The open concept elicitation phase was followed by a set of probes designed to query the symptoms HCPs regarded as most common. Probed concepts were identified from Schmahmann et al. [ 40 ], Potashman et al. [ 41 ], and clinician input. Relevant concepts were then inserted into the interview discussion guide as probes to capture the patient experience of SCA (Fig.  1 ). A sample of the interview guide is presented in Supplementary Table 3 . Based on data from Schmahmann et al. [ 40 ] and Potashman et al. [ 41 ], survey responses from 145 individuals with SCA were qualitatively coded using ATLAS.Ti v22 software. This codebook was then used to analyze the frequency and relevance of concepts identified in the semi-structured interviews. Examination for saturation was assessed at the time of semi-structured interview data analysis.

Study design and development of the conceptual framework

Abbreviations: f-SARA modified functional Scale for the Assessment and Rating of Ataxia, HCP healthcare professional, SCA spinocerebellar ataxia

Finally, cognitive debriefing was employed to evaluate the understandability, relevance, and comprehensiveness of the f-SARA in relation to SCA. Relevance and comprehensiveness of the f-SARA was assessed by mapping concepts discussed by HCPs and individuals with SCA against the items included in the f-SARA to identify factors that were considered important from a disease severity perspective. Meaningful changes as measured through the lens of the instrument, as well as the relevance of specific symptoms and impacts in the context of SCA, were also explored in the interviews.

Sample Size Calculation

In clinical outcomes research studies, a general concept elicitation and cognitive debriefing study is conducted until saturation is reached. Saturation analyses are performed to confirm that there are no further additional concepts identified. Typically, saturation may be reached within 10–15 interviews [ 42 ]. The low prevalence of rare diseases often only allows for small patient sample sizes. Consequently, the data generated from this study were a supplement to previous qualitative work carried out by Schmahmann et al. [ 40 ] and Potashman et al. [ 41 ]. The data generated here, in combination with the results from the open-ended survey [ 40 , 41 ], may be considered acceptable to verify the validity and relevance of the f-SARA in a small (< 10 patients) sample of patients with SCA.

Data Analysis

A descriptive content analysis was used to analyze interviews with HCPs and individuals with SCA, specifically to identify themes or concepts that were elicited from the interviews after they were transcribed. Interviews were conducted via a web-based platform, audio recorded and then transcribed. Transcripts were anonymized and coded using ATLAS.Ti v22 software. A codebook and qualitative analysis plan were developed and used to code each transcript. Briefly, coding dictionaries were developed, using an iterative process after completion of approximately 3 interviews. One codebook was used for analyzing HCP interview transcripts and one for analyzing the interview transcripts from individuals with SCA. The coding process was guided by established qualitative research methods [ 43 ]. Multiple coders reviewed the transcripts to minimize bias. Cognitive debriefing analyses were conducted in accordance with standard procedures to evaluate participants’ understanding of the measures [ 44 ].

Ethical Considerations

The study (BHV-4157-SCA-VAL) was approved by a centralized independent Institutional Review Board (IRB; Salus Institutional Review Board, Austin, TX, USA). IRB approval was not required for HCP interviews conducted in the United States or Europe. All eligible individuals with SCA and the HCPs provided informed consent to participate in the interviews and could withdraw at any time. HCPs received consultancy fees for participating in the interviews.

Participant Demographics and Characteristics

Eight HCPs (all neurologists) from the United States (f-SARA previously exposed; n  = 5, corresponding to HCPs 1–5) and Europe (f-SARA newly exposed; n  = 3, corresponding to HCPs 6–8) with expertise in SCA were recruited from centers of excellence in treating ataxias and related cerebellar disorders. Interviews with US HCPs were conducted between July and September 2022, and those with European HCPs were conducted between June and August 2023. Of 8 participating HCPs, most were male ( n  = 5; 62.5%) (Table  1 ). The number of individuals with all genotypes of SCA that HCPs reported they had treated in clinical practice over the course of their career ranged from “80” to “thousands.”

Individuals with SCA

Overall, 7 individuals with SCA from the United States participated in the interviews (SCA1, n  = 1; SCA3 n  = 6), which were conducted between October and December 2022. Most participants were male ( n  = 4; 57.1%) (Table  2 ), and all (100%) had genetically confirmed SCA diagnoses.

SCA Symptoms, Progression, and Impact on Daily Function

Perspectives from hcps.

To ascertain how SCA progresses and the most important symptoms impacting the function of individuals with SCA, HCPs were asked to describe the symptoms of SCA; how they would define mild, moderate, and severe stages of disease; and what they would consider the most concerning limitation in each of these stages. Overall, SCA was described as a multi-domain progressive disease impacting motor function, speech, vision, and cognition, which affects every aspect of daily life (Supplementary Table 4 ).

HCP5 described the impact of SCA on individuals’ daily lives: “It affects every aspect of their daily lives. It affects their ability to communicate. It affects their ability to ambulate and to walk. It affects fine finger coordination, like fine motor skills. So, that’s definitely a problem for them. Also, people with spinocerebellar ataxia have problems, often with cognitive issues.”

HCPs defined disease severity as an increasing presence of symptoms, which impacts individuals’ autonomy and ability to live independently. Mild disease was characterized by few symptoms and little to no impact on ADLs. Individuals with severe disease were considered to be extremely impaired and limited in ADLs (e.g., needing to use a wheelchair and requiring assistance with most or all activities). Three HCPs (37.5%) characterized disease severity by the use of a walker or wheelchair for mobility. Additional symptoms such as speech, vision, and balance were reported by 4 HCPs (50.0%) as factors that characterize disease severity.

When asked to provide the 5 most impactful symptoms/issues affecting the daily life of individuals with SCA, HCPs spontaneously reported the following concepts: difficulty with walking, speech, fine motor accuracy, and balance, and social/work impact (Table  3 ). Spontaneously reported concepts included 3 of the 4 f-SARA items: Gait, Stance, and Speech.

HCP6 described the top 5 SCA symptoms that impact individuals’ daily functioning: “ Walking, in particular walking stairs, walking on uneven underground surfaces; standing without swaying, standing stable, that’s number 2. Number 3 is writing, and closing, and using a key. That’s impairment number 3. And number 4 is swallowing deficits, coughing, and choking when drinking or eating. And number 5 is speaking unclearly with a slurred voice and having to repeat statements.”

Perspectives from Individuals with SCA

To establish the most important SCA disease-related experiences from the perspective of individuals with SCA1 and 3, individuals were asked to report their signs, symptoms, and impacts on daily life. Probing questions were then asked regarding a set of specific concepts recommended by HCPs as prominent, if they were not spontaneously mentioned. A total of 85 sign, symptom, and impact concepts were reported during the interviews ( n  = 66 spontaneously reported concepts by ≥ 1 individual, and n  = 18 concepts confirmed with probes) (Supplementary Table 5 ). All individuals with SCA spontaneously reported difficulties with walking and balance. Other signs/symptoms/ADL impacts frequently spontaneously reported (≥ 50.0% of individuals) were falls ( n  = 6/7), tired/fatigued ( n  = 5/7), difficulty working ( n  = 5/7), challenges with social life ( n  = 5/7), difficulty being understood ( n  = 4/7), emotional dysfunction ( n  = 4/7), difficulty driving ( n  = 4/7), and vision impairments ( n  = 4/7). When adding in the probed items, the additional concepts of difficulties dressing ( n  = 5/7), difficulties swallowing/choking ( n  = 5/7), difficulties climbing stairs ( n  = 5/7), difficulties exercising ( n  = 4/7), difficulties with housework ( n  = 4/7), unable to do usual activities ( n  = 4/7), difficulties sitting for long periods ( n  = 4/7), issues with bladder function ( n  = 4/7), and requiring assistance to use the toilet ( n  = 4/7) were reported by ≥ 50.0% of individuals.

In addition, over the course of the interviews, all 7 individuals with SCA shared feelings of anxiety, fear of falling, difficulty dealing with the condition alone, nervousness during work calls, trauma from falls, embarrassment during coughing spells, laziness, and not having initiative.

Individual 7 commented regarding important and meaningful issues related to SCA: “And that’s what really bothers me day in and day out. Thinking that I may not have anybody to take care of me. And I won’t be able to even speak to communicate.”

Individual 3 commented regarding important and meaningful issues related to SCA: “You give out the perception that you’re drunk a lot, which causes people to treat you differently, and causes people to look at you differently.”

It was not possible to determine whether saturation was achieved for the entire sample due to the small sample size. However, at least 1 spontaneously reported item from each f-SARA concept was elicited during the first three-quarters of the interviews (i.e., prior to interview of Individual 6). Additionally, on consideration of both the spontaneously reported and probed items, several signs, symptoms, and impacts were reported by all 7 individuals with SCA including difficulties with walking (including abnormal gait), stance, balance, speech (e.g., slurred speech and speech production difficulties), and working; feeling tired or fatigued; and emotional dysfunction (Fig.  2 ).

Overarching concepts identified in interviews with individuals with SCA

Abbreviation: SCA spinocerebellar ataxia

Following this, individuals with SCA were asked to report the symptoms they considered to be most bothersome and what impact they believed these symptoms had on their daily lives (Supplementary Table 6 ). The most bothersome symptoms were neuropathy ( n  = 4/7) and gait and/or balance ( n  = 3/7). Other symptoms reported as most bothersome included vision ( n  = 2) and communication/speech problems ( n  = 2). Impacts to work life ( n  = 1), social life ( n  = 1), and sleep ( n  = 1), and the prospect of a neurological decline in the future ( n  = 1) were also reported as meaningful.

Individual 5 commented regarding the most bothersome SCA symptoms: “Well, the neuropathy is the most bothersome because I cannot sleep.”

Individuals with SCA were then asked probing questions on the detailed aspects of the specific symptom domains that most affected their lives and were most bothersome (Supplementary Table 7 ). Among those who experienced gait and walking difficulties, “general difficulties walking” was considered the most bothersome ( n  = 5/7) and particularly important ( n  = 4/7) symptom. A proportion of individuals reported the “sometimes requiring a walking aid” as the most bothersome ( n  = 2/3) and important ( n  = 3/3) symptom. Three of the 6 individuals included “trouble keeping balance” as the most bothersome ( n  = 3/6), with 2 indicating it as the most important ( n  = 2/7) symptom. Of those individuals experiencing issues with sitting, most indicated general difficulties with sitting to be the most bothersome ( n  = 3/4) symptom, and half reported this to be of particular importance ( n  = 2/4). Two individuals reported “requiring back support to sit,” though neither indicated this to be the most bothersome symptom; 1 individual ( n  = 1/2) reported this to be the most important. For speech, more than half of the individuals with SCA reported that their speech being “occasionally difficult to understand” was the most bothersome ( n  = 4/7) and most important symptom ( n  = 4/7). Of those reporting difficulties with swallowing, most indicated that choking was the most bothersome ( n  = 3/5) symptom, and 2 considered this to be the most important ( n  = 2/5). For energy, 2 individuals considered fatigue as the most bothersome symptom ( n  = 2/7); most reported that fatigue was particularly important ( n  = 5/7).

Relevance of f-SARA Concepts

All HCPs ( n  = 8) spontaneously described the f-SARA concepts of Gait, Stance, and Speech items as relevant for tracking disease progression, and included these concepts in overall disease staging of mild, moderate, or severe SCA. Furthermore, they confirmed that these items reflected meaningful aspects of the lives of individuals with SCA. Sitting, the fourth f-SARA item, was not spontaneously mentioned by any of the HCPs and responses regarding the relevance of Sitting were varied when HCPs were asked probing questions. In addition, HCPs suggested a few concepts to include that could improve the clinical relevance of the f-SARA, namely fine motor accuracy/dexterity ( n  = 6; 75.0%), vision problems ( n  = 4; 50.0%), and swallowing ( n  = 3; 37.5%). HCPs further suggested that inclusion of relevant items evaluating the impact of symptoms on ADLs would promote a more detailed assessment of disease severity.

HCP5 on their overall impression of the f-SARA: “Well, the f-SARA is a good, quick tool to evaluate ataxia symptoms and neurological function in a spinocerebellar ataxia patient.”

HCP6 on their overall impression of the f-SARA: “So, what I do like is that the 4 domains which are there, they are indeed of key importance for ataxia: gait, stance, sitting, speech. Those are 4 domains, not only from [a] neurological perspective, but indeed from a patient’s daily life perspective. Those are 4 domains of high impact for the patient. So, that’s a positive point.”

HCP4 on their overall impression of the f-SARA: “I think that [fine motor dexterity] would be a better addition to the f-SARA than Sitting. Because in my observation, very few people had substantial sway when they’re sitting.”

Three of the 4 concepts in the f-SARA, Gait, Stance, and Speech, were considered relevant by all 7 individuals with SCA. Sitting was reported as meaningful by 3 individuals. When asked to rank the relevance of concepts covered by the f-SARA using a 5-point rating scale (from 0 = “not at all” relevant to 4 = “extremely” relevant), 6 of 7 individuals reported that most items were relevant (each concept ≥ 1 [a little relevant]) in the context of their experience of SCA. Individuals with SCA ranked difficulties with gait and walking ( n  = 7) as extremely relevant (median score of 4), followed by difficulty with standing/balance ( n  = 6; median score of 3); the median score for both speech ( n  = 6) and sitting ( n  = 7) was 2. In addition to rating the relevance of f-SARA concepts, individuals with SCA were asked to rank the 3 most important concepts from the f-SARA. Most individuals reported Gait ( n  = 6) as the most important, followed by Stance ( n  = 3), Speech ( n  = 2), and Sitting ( n  = 1). Those who considered Gait to be the most important concept generally reported that difficulties with mobility impacted their sense of independence. Individuals who reported balance as the most important concept indicated frequently falling affected their ability to enjoy hobbies. For those who regarded difficulties with Speech as the important concept, it was highlighted that progressively losing the ability to communicate with others would negatively impact quality of life. The individual who reported Sitting as the most important noted that it was currently difficult to sit because of the pain.

Individual 6 commented on the most important f-SARA concept: “I would say the difficulty walking and the gait would be most important. Gait and walking around is essential to seeing the world and being part of the world around you. And if you can’t move and you can’t walk, you can’t be out in the world.”

Individual 3 commented on the most important f-SARA concept: “Difficulties with gait and walking is definitely number 1. It’s like effort every single step you take not to fall, which is frustrating because your knees buckle.”

Capturing Meaningful Change and Stability Using the f-SARA: Perspectives from HCPs

Meaningful change in f-sara scores.

To assess whether the f-SARA captures changes perceived as clinically meaningful, HCPs were asked to describe what changes in the f-SARA score would be most meaningful when prescribing a therapy to individuals with SCA.

Considering meaningful improvement of f-SARA items, all HCPs ( n  = 8/8) reported that a 1-point improvement in Gait would reflect a meaningful change (Supplementary Table 9 ). For Stance, the majority of HCPs ( n  = 6/8) reported that a 1-point improvement would be meaningful. The additional HCPs considered meaningful change to be a 2-point improvement ( n  = 1) or reducing the need for aids/supports ( n  = 1). Most HCPs ( n  = 6/8) considered a 1-point improvement on the Speech item as meaningful; however, 1 HCP clarified their response by stating that a 1-point change on Speech would be a meaningful improvement when the item score changed from 3 to 2 or 1. The 2 additional HCPs considered that meaningful improvement on the Speech item would be a 1- to 2-point change. Of interest, 1 HCP indicated that a 1-point improvement on any of the Gait, Stance, or Sitting items would be of particular importance. Defining meaningful change for the Sitting item was considered challenging by the majority of HCPs ( n  = 6/8) because the ability to sit does not typically deteriorate linearly, and an individual’s ability to sit may vary day to day.

HCP8 commented on meaningful improvement in f-SARA items: “If you are able to change from in need of support to going down to no need of support, that is a relevant change.”

HCP5 commented on meaningful improvement in f-SARA items: “I would say a 1-point improvement on the Gait would be the most meaningful.”

For meaningful worsening on the Gait item, most HCPs ( n  = 7/8) considered a 1-point decline to be meaningful; however, 1 HCP reported that it was difficult to quantify. Among the Stance, Sitting, and Speech items, all HCPs previously exposed to the f-SARA ( n  = 5/5) considered a 1-point decline to be meaningful. Of note, 4 HCPs previously exposed to the f-SARA ( n  = 4/5) spontaneously reported that the 0- to 4-point scoring scale of the f-SARA may be unlikely to detect small (< 1-point) changes that would be meaningful to individuals with SCA. HCPs newly exposed to f-SARA did not quantify meaningful decline on the Stance, Sitting, and Speech items, stating that it was anchored to f-SARA natural history changes that they did not have experience with yet.

HCP6 commented on meaningful worsening in f-SARA items: “In the Gait item, a 1-point change is a huge thing.”

HCP1 commented on meaningful changes in f-SARA items: “Well, I think a change certainly for Gait, Stance, and Sitting, a full point for any of these areas would obviously be clinically meaningful. So, I think the scoring levels definitely reflect clinically meaningful changes in an exam that would be hard to overlook.”

For the total f-SARA score, all 8 HCPs regarded minimum meaningful improvements or worsening as a 1- to 2-point change; however, intra-individual meaningful changes on total f-SARA score differed between previously-exposed and newly-exposed HCPs. Previously-exposed HCPs considered meaningful improvement or worsening as a 1- to 2-point change in total f-SARA score, whereas newly-exposed HCPs reported that meaningful change would be anchored to natural history changes. Most HCPs ( n  = 5/8) specified that a minimum of a 1-point change in the f-SARA total score would be regarded as meaningful improvement; however, responses ranged from 1 to 4 points. One HCP noted that a worsening of the f-SARA total score by 1 to 2 points was aligned with the natural history of disease progression over 1 year. Of the HCPs who indicated that a 2-point change in f-SARA total score would be meaningful ( n  = 3/8), 1 qualified their statement by reporting that a 1-point change may not represent a real effect, and another stated that a 1-point change on > 1 domain would be meaningful. Additionally, 1 HCP indicated that meaningful improvements in the f-SARA total score may be relative to the baseline of each individual (e.g., worsening of 1 point by going from 13 to 14 may not be meaningful, but an improvement from 6 to 5 points may be meaningful). A minimum of a 1-point worsening in total f-SARA score was reported by most HCPs ( n  = 6/8) as meaningful, with responses ranging from 1 to 4 points.

HCP6 commented on meaningful worsening in f-SARA total score: “I would think a worsening of 2 points over 2 years.”

HCP2 commented on meaningful improvement in f-SARA total score: “I think 1 point [change] will be meaningful, but 2 points change probably much more so, with the total score.”

Meaningful Stability in f-SARA Scores

Stability in f-SARA score for individuals with SCA was considered meaningful by all HCPs, though meaningful time frames varied depending on individual patient disease courses. Stability across a 1- to 2-year time frame was regarded as clinically meaningful by most HCPs ( n  = 6/8). However, 1 HCP indicated that the time frame for meaningful stability should be considered in the context of f-SARA performance versus disease natural history. Another HCP considered that stability over a 1-year period may not be meaningful in a disease with slow progression, and the meaningfulness of differences between patients studied in a clinical trial should be used as reference. Considering the definition of stability, most HCPs ( n  = 6/7; 1 HCP was not asked) reported that a 0-point change on the f-SARA total score would indicate disease stability for individuals with SCA. However, 1 HCP reported that a 1-point fluctuation between annual visits can occur and did not agree that a 0-point change indicated true stability.

HCP1 commented on stability in the f-SARA score in individuals with SCA: “If my exam shows exactly the same scoring, level 2 ability for walking from visit to visit over the course of a year, for instance, I would say that’s meaningful,”

HCPs 1–5 ( n  = 5) reported that no change in f-SARA individual item scores over a 1- to 2-year time frame would be regarded as clinically meaningful. However, HCPs 6–8 ( n  = 3) reported that no changes in individual item scores had varying importance, which was dependent on the specific item, patient baseline level of impairment, and deviation from the natural history of SCA.

HCP6 commented on the meaningfulness of no change in the f-SARA score: “I would consider no change a meaningful outcome if and only if via the natural history they would otherwise have worsened in this time frame.”

HCP7 commented on the meaningfulness of no change in the f-SARA score: “Of course, 1 year is enough [for no change to be meaningful]. But if you extend your observation period, the stability may be also more and more meaningful, of course.”

Capturing Meaningful Change and Stability Using the f-SARA: Perspectives from Individuals with SCA

Individuals with SCA were asked to describe what would constitute meaningful improvement and worsening related to each of the 4 f-SARA items based on their current level of disease severity (Supplementary Table 8 ).

Six of 7 individuals reported that maintaining their walking ability for a period of 1 year would be meaningful. Individuals who considered themselves as having mild difficulties focused on the ability to walk without stumbling or falling when describing meaningful change ( n  = 3/3). Those who considered themselves as having moderate difficulties or those who used walking aids, focused on switching to no aid use or less complex walking aids ( n  = 3/4). These descriptions of improvements are consistent with 0–1-point changes on the f-SARA Gait item. Most individuals with SCA ( n  = 4/5) defined meaningful worsening as the loss of independence, which would limit conduct of ADLs.

Individual 5 commented on meaningful improvement in the f-SARA Gait item: “If I had stability and stay where I was, I’d be happy”.

Individual 4 commented on meaningful worsening in the f-SARA Gait item: “It would probably mean that I would have to lose the ability to live independently.”

All individuals with SCA ( n  = 7) reported that no worsening in Stance symptoms for 1 year would be meaningful. Individuals generally reported that meaningful improvement would allow them to stand freely, without assistance or falling ( n  = 7/7). Most individuals ( n  = 6/7) considered meaningful worsening to be the loss of the ability to stand and the need for a wheelchair.

Individual 1 commented on whether stabilization of current ability in the f-SARA Stance item over a 1-year period is meaningful: “Yeah, because it goes along with standing, walking, and everything else.”

All 7 individuals with SCA agreed that maintaining their current sitting ability for 1 year would be meaningful to them. Meaningful improvement was difficult to ascertain because most individuals did not have difficulty sitting. However, the ability to stand from a sitting position or to sit from a standing position without falling into a chair or without assistance was seen as a meaningful improvement for 3 individuals ( n  = 3/7). Two individuals with SCA3 ( n  = 2/7) considered meaningful improvement as maintaining their current ability to sit. Individuals with SCA described meaningful worsening as the loss of ability to participate in leisure activities ( n  = 2/7) and the need for assistance or support while sitting by ( n  = 2/7).

Individual 4 commented on meaningful worsening in the f-SARA Sitting item: “Well, it would mean that I couldn’t watch TV, or sit on my trike, or ride the recumbent in the gym without needing support.”

Five of 7 individuals with SCA stated that stability in their speech over 1 year would be meaningful. Overall, for those who considered themselves to have mild ( n  = 3/7) or moderate ( n  = 3/7) speech impairment, meaningful improvement was reported as being understood by others, not having to repeat oneself, speaking faster, articulating clearly, and requiring less energy during conversations. These descriptions of improvements are consistent with 0–1-point changes on the f-SARA Speech item. Five individuals with SCA ( n  = 5/7) described meaningful worsening as slurring words, having to repeat oneself more often, and not being understood by other people.

Individual 2 commented on meaningful worsening in the f-SARA Speech item: “It would be if I was significantly slurring more, and people were asking me – if they wanted me to repeat myself again.”

Individual 4 commented on meaningful worsening in the f-SARA Speech item: “One, I’d have to stop working. And then 2, probably more important, my kids would probably not want to talk to me. And then who talks to me?”

f-SARA Cognitive Debriefing

A full cognitive debriefing of all the components of the f-SARA was conducted with the HCPs (those previously exposed to the f-SARA [ n  = 5] and those newly exposed to the f-SARA [ n  = 3]) to confirm the content validity of the f-SARA. For each item (Gait, Stance, Sitting, and Speech), HCPs were asked about the f-SARA instructions (e.g., general ease of understanding and their interpretation of instructions), the f-SARA items (e.g., their interpretation and clarity of the items), and the f-SARA item response options (e.g., their interpretation and clarity of each item’s response options).

Nearly all HCPs understood the general instructions for each item and found the instructions easy to follow, with a couple of exceptions noted (e.g., 1 HCP found the Sitting item instructions difficult to follow, and 1 did not find the general instructions on the Gait and Speech items easy to follow). All HCPs correctly interpreted each item, their response definitions, and scoring instructions (Table  4 and Supplementary Table 10 ). The clarity of the response definitions was deemed good by most HCPs. The choice of response section on the 5-point ordinal scale was also described as easy by all HCPs for the Gait and Stance items; however, it was indicated as potentially difficult to clinically distinguish between certain response options for the Sitting and Speech items. In addition, some HCPs (all with previous exposure to the f-SARA [ n  = 5]) commented that the scoring may not be sensitive enough to capture small but meaningful changes in patient function.

HCP3 commented on f-SARA response options: “A 0–4 scale is easier than the SARA, for sure. It means each question has the same weight, which in that regard makes it an improvement over the SARA.”

HCP5 commented on f-SARA response options: “The problem with it [the f-SARA] is that it is probably not appropriate for monitoring just very small, fine quantitative changes in a patient’s clinical function.”

HCP8 commented on f-SARA response options: “I think for example, in the Gait, the original SARA contains 8 items, which is perhaps too granular. So, reducing the number of items to score makes sense. And these items here do reflect the correspondence, perhaps more between a score and a functional milestone with, for example, needing support. So, the Gait item for me as a concept makes sense, reducing granularity, matching functional milestones.”

The development and validation of a well-defined SCA-specific COA that reliably measures meaningful changes in the symptoms and daily functioning of individuals with SCA is important for the measurement of potential treatment benefits in the clinical trial setting. This study provides a comprehensive overview of the complexity and heterogeneity of the impact of symptoms in a sample of patients with SCA1 and 3 from the perspectives of the individuals with SCA and the HCPs who treat them. The findings support the content validity and clinical meaningfulness of the f-SARA for use by HCPs who treat individuals with SCA in a clinical trial setting.

Among the f-SARA concepts evaluated during the interviews, 3 of 4 concepts were reported to be relevant for SCA by all 7 individuals with SCA and all 8 HCPs. These 3 concepts were Gait, Stance, and Speech. Sitting was considered relevant by approximately half of the individuals with SCA but was reported as less important than other items in early disease. These results are consistent with data previously reported from surveys with individuals with SCA and their caregivers, who identified the f-SARA concepts that are most important to them: Gait (97.9–98.7%), Stance (73.4–79.3%), Speech (65.5–73.4%), and Sitting (6.9–8.9%) [ 40 , 41 ]. The descriptions of mild, moderate, and severe SCA provided by HCPs and individuals with SCA were similar to the rating options for each f-SARA item, particularly those assessing Gait and Speech, suggesting that the items included on the f-SARA adequately reflect the temporal progression of SCA. All HCPs understood the general instructions, severity definitions, and rating/scoring instructions for the f-SARA. They agreed that the f-SARA was easy to administer, and that the items were clear and easy to score; however, there were some suggestions for improvement on the Sitting and Speech items.

Overall, HCPs and individuals with SCA reported that the f-SARA had the potential to detect clinically meaningful changes in symptoms of SCA, including stabilization. While individuals with SCA were not asked to provide a numerical value that would constitute a meaningful change in f-SARA score, most indicated that maintaining their current abilities for Gait and Speech for 1 year would be meaningful. There was disagreement between HCPs on what would represent meaningful change. HCPs with previous f-SARA exposure considered that a 1- to 2-point change on the f-SARA total score and a 1-point change on the item score was meaningful. Conversely, the f-SARA newly-exposed HCPs frequently referenced the need for natural history data to accurately define what constitutes meaningful change on both the total and item level f-SARA scores and had difficulty providing numerical values. However, whether previous exposure to the f-SARA or familiarity with natural history studies drove the differences between HCP cohorts remains unknown. Nonetheless, all HCPs, regardless of previous f-SARA exposure, agreed that f-SARA total score changes of 1–2 points would be considered meaningful for individuals with SCA.

While the Gait, Stance, and Speech concepts assessed in the f-SARA were determined to be relevant by HCPs and individuals with SCA, the Sitting concept was considered less relevant to SCA disease progression. Of those individuals with SCA participating in the interviews, most presented with mild-to-moderate SCA and had retained their ability to sit unsupported, which may have influenced their views on the relevance of the Sitting concept. Despite this, when considering the range of ADLs important to individuals with SCA, sitting may be a core ability that promotes retention of some independence. Similar to the individuals with SCA, some HCPs indicated that Sitting was less relevant across the spectrum of disease than other symptoms, particularly as stability in the sitting position is not impacted until later stage disease [ 45 ]. Interestingly, clinical studies have demonstrated that sitting abilities differ between SCA types, and individuals with SCA2 show significantly greater difficulties with sitting than those with other types of SCA [ 46 ]. While the concept of Sitting on the f-SARA was considered less relevant for individuals with SCA1 and 3 included in this study, it may be more applicable to those with other genotypes, particularly SCA2. Additional concepts such as manual dexterity (highlighted as particularly important by HCPs), vision impairments, cognition, mood, and work activities, which were relevant to individuals with SCA in this study, are not included on the f-SARA. The assessment of manual dexterity is included in the original SARA and reflects the interest to assess this concept in both clinical practice and trial settings [ 19 , 47 ]. In addition, the Patient-Reported Outcome Measures (PROM)-Ataxia [ 40 ] and Brief Ataxia Rating Scale (BARS) measures [ 48 ] address more concepts than the f-SARA and may also be considered for evaluation of SCA disease progression. Further studies evaluating both the SARA and the f-SARA in tandem may provide insights into the relevance and validity of the instruments for disease progression. Despite this, the current study has identified the potential benefits of the f-SARA for evaluating disease progression in individuals with SCA over the course of a 12-month clinical trial, and for the assessment of therapies that might alter disease progression.

Natural history data are now available for the f-SARA, reported as a 1-point change over 1.5 years in individuals with early-stage SCA1, 2, 3, and 6 [ 49 ]. Further, Moulaire et al. [ 49 ] report that use of the f-SARA to detect clinically meaningful change in a 12-month interventional trial is a valid approach provided studies use larger sample sizes compared with those using the original SARA. A sample size of approximately 280 individuals with varying SCA subtypes (SCA1, 2, 3, and 6) was regarded as appropriate for a trial using the f-SARA, because this would account for the reduced sensitivity associated with the inclusion of only 4 items on the instrument, rather than the original 8 items in the SARA [ 49 ].

The development of a valid COA for use in the clinical trial setting that can reliably detect improvement of SCA symptoms caused by therapeutic intervention is of particular importance as the ataxia field moves towards phase 3 studies of multiple therapies [ 50 ]. There has been much debate in the field on the usefulness and relevance of the original SARA as the primary outcome measure in interventional trials. Indeed, a study investigating the clinical meaningfulness of the SARA from the perspective of individuals with mild-to-moderate SCA3 found that 25% of the total SARA score was overestimated by HCPs and did not reflect clinically meaningful impairments for individuals (with notable exception of the Gait item) [ 51 ]. Additionally, the Maas and van de Warrenburg study [ 51 ] indicated that modified versions of the SARA, which include reappraisals of scoring weights at the item level, are likely required to identify meaningful treatment effects [ 51 ]. While the f-SARA satisfies these criteria, further studies investigating whether the item 0–4 ordinal response scale detects treatment-dependent small but clinically meaningful changes are warranted.

Our findings confirm the content validity of the f-SARA and provide new evidence to support its use for evaluation of disease severity and progression in individuals with SCA in the clinical trial setting. Further studies are required to determine the sensitivity of the f-SARA to detect treatment effects, and to establish how the f-SARA may be used in conjunction with other COA instruments (i.e., those that measure manual dexterity or ADLs) to optimize future study design and data collection. We note the recommendation from some HCPs that the clinical relevance of the f-SARA could be refined and improved by including manual dexterity items such as finger–nose and finger chase. We emphasize, however, that this essentially reverts to the original SARA scale and does not incorporate insights from the analysis of US natural history data and the troriluzole phase 2 study, which suggest that appendicular items are less sensitive to change and/or are more variable over 1 year. Furthermore, the challenge with use of the original SARA instrument in a clinical trial enriched to capture changes in axial items is the absence of dynamics in appendicular scores in this population [ 52 , 53 ].

Limitations of this study include the small sample size, convenience sampling, and limited inclusion of individuals with varying SCA subtypes. Sample bias may have been introduced because all individuals with SCA1 and 3 in the study were from the United States, and some were self-referred from a patient advocacy organization. The small sample size prevented data saturation being reached for some concepts in the interviews alone with individuals with SCA. Despite this, most concepts reached a form of data saturation through consideration of the qualitative patient survey data [ 40 , 41 ]. Additionally, when the f-SARA was developed and the corresponding content validity interviews were designed, SCA3 was considered to be one of the most common genotypes of SCA in the United States and globally. We note that SCA27b may account for a substantial proportion of previously unexplained late-onset dominant and sporadic cerebellar ataxias [ 4 , 5 , 8 , 9 ], and the relevance of the f-SARA in patients with this genotype has yet to be assessed. Most individuals ( n  = 6/7) in the current study had mild-to-moderate SCA3, which may limit the generalizability of the results to individuals with other SCA subtypes, particularly those with non-CAG repeat SCA subtypes. In addition, individuals with mild-to-moderate SCA3 may not have experienced the full spectrum of symptoms associated with SCA (i.e., those symptoms that manifest in later disease stages such as substantial difficulties with sitting), which could also have introduced bias during the concept elicitation phase. Further, while the interviews conducted with HCPs were designed to assess the broad spectrum of SCA, HCPs may have unconsciously provided responses related to SCA subtypes 1, 2, and 3 because of greater exposure to individuals with these more common subtypes.

Conclusions

The f-SARA was developed based on recommendations from a regulatory body to capture unequivocal and compelling changes that might be functionally meaningful and reflect treatment effect in individuals with SCA. Our findings reveal that the f-SARA was well understood by HCPs and perceived to be relatively easy to implement. HCPs and individuals with SCA1 and 3 reported that the Gait, Stance, and Speech concepts included in f-SARA would detect clinically meaningful changes in SCA symptoms. Assessment of the concept of Sitting in early disease requires further consideration.

Data Availability

The datasets generated during and analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

The authors are grateful to the individuals with SCA who participated in the interviews and the National Ataxia Foundation for supporting the identification of participants with SCA. The authors thank Audra Gold and Kavita Jarodia of Parexel for their input on the study. Medical writing support was provided by Laura Graham, PhD, of Parexel and was funded by Biohaven Pharmaceuticals, Inc.

This study was supported by Biohaven Pharmaceuticals, Inc.

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Michele Potashman, Melissa Wolfe Beiner & Gilbert L’Italien

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Katja Rudell, Ivanna Pavisic, Naomi Suminski, Rinchen Doma & Maggie Heinrich

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Linda Abetz-Webb

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Sheng-Han Kuo

Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA

Liana S. Rosenthal

Department of Neurology, Ataxia Research Center, University of South Florida, Tampa, FL, USA

Theresa Zesiwicz

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Terry D. Fife

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Bart P. van de Warrenburg

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Contributions

Michele Potashman, Melissa Wolfe Beiner, and Gilbert L’Italien contributed to study conception and design. Material preparation and data collection was performed by Katja Rudell, Naomi Suminski, Rinchen Doma, Maggie Heinrich, Ivanna Pavisic, and Linda Abetz-Webb. All authors contributed to data analysis and interpretation. All authors commented on the manuscript during development and approved the final version.

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Correspondence to Michele Potashman .

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Ethical approval.

The study (BHV-4157-SCA-VAL) was approved by a centralized independent Institutional Review Board (IRB; Salus Institutional Review Board, Austin, TX, USA). IRB approval was not required for HCP interviews conducted in the United States or Europe. HCPs received consultancy fees for participating in the interviews.

Human Ethics and Consent to Participate

All eligible individuals with SCA and the HCPs provided informed consent to participate in the interviews and could withdraw at any time. The study was conducted in accordance with the 1964 Declaration of Helsinki.

Competing Interests

Michele Potashman, Melissa Wolfe Beiner, and Gilbert L’Italien are employed by, and own shares in, Biohaven Pharmaceuticals, Inc. Katja Rudell, Naomi Suminski, Rinchen Doma, and Maggie Heinrich are employees of Parexel and were commissioned by Biohaven Pharmaceuticals, Inc. to conduct the study. Ivanna Pavisic was an employee of Parexel until July 2023 and was commissioned by Biohaven Pharmaceuticals, Inc. to conduct the study. Sheng-Han Kuo, Theresa Zesiwicz, Bart van de Warrenburg, Liana S. Rosenthal, Terry D. Fife, Giovanni Ristori, Matthis Synofzik, and Susan Perlman received consultancy fees from Biohaven Pharmaceuticals, Inc. for participating in the interviews. Linda Abetz-Webb received consultancy fees from Parexel for this study. Sheng-Han Kuo has received consultancy fees from Biohaven Pharmaceuticals, Inc., Praxis Precision Medicines, and Sage Therapeutics. Theresa Zesiwicz has received personal compensation for serving on the advisory boards of Boston Scientific, Reata Pharmaceuticals, and Steminent Biotherapeutics; and received personal compensation as senior editor for Neurodegenerative Disease Management and as a consultant for Steminent Biotherapeutics. Royalties: royalty payments as co-inventor of varenicline for treating imbalance and nonataxic imbalance. Grants: research grant support as Principal Investigator for studies from AbbVie, Biogen, Biohaven Pharmaceuticals, Inc., Boston Scientific, Bukwang Pharmaceuticals Co, Inc., Cala Health, Inc., Cavion, Friedreich’s Ataxia Research Alliance; Houston Methodist Research Institute, National Institutes of Health, REtrotope Inc, and Takeda Development Center Americas, Inc. Bart P. van de Warrenburg has served on advisory boards and/or as consultant for Servier, Vico Therapeutics, Biohaven Pharmaceuticals, Inc., and uniQure. Royalties: BSL—Springer Nature. Grants: Radboud University Medical Center, ZonMw, Gossweiler Foundation, Hersenstichting, NWO, and Christina Foundation. Jeremy D. Schmahmann has served on the editorial board for The Cerebellum, Editorial Board, 1999. Consultancy: Biohaven Pharmaceuticals, Inc. Site Principal Investigator: Biohaven Pharmaceuticals, Inc. clinical trials in ataxia and multiple system atrophy. Research support, commercial entities: Biohaven Pharmaceuticals, Inc. support of clinical trials. Research support, academic entities: National Ataxia Foundation. Research support, foundations, and societies: National Ataxia Foundation, 2019, Principal Investigator license fee payments. Technology or inventions: Brief Ataxia Rating Scale (BARS) and Brief Ataxia Rating Scale revised (BARS2). Copyright held by The General Hospital Corporation. Cerebellar Cognitive Affective/Schmahmann syndrome Scale. Copyright held by The General Hospital Corporation. Patient-Reported Outcome Measure of Ataxia. Copyright held by The General Hospital Corporation. Cerebellar Neuropsychiatric Rating Scale. Copyright held by The General Hospital Corporation.

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Potashman, M., Rudell, K., Pavisic, I. et al. Content Validity of the Modified Functional Scale for the Assessment and Rating of Ataxia (f-SARA) Instrument in Spinocerebellar Ataxia. Cerebellum (2024). https://doi.org/10.1007/s12311-024-01700-2

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Research Article

Observer-rated outcomes of communication-centered treatment for adults who stutter: A social validation study

Contributed equally to this work with: Courtney T. Byrd, Geoffrey A. Coalson

Roles Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Visualization, Writing – original draft, Writing – review & editing

Affiliation Arthur M. Blank Center for Stuttering Education and Research (AMBCSER), The University of Texas at Austin, Austin, Texas, United States of America

Roles Data curation, Formal analysis, Investigation, Methodology, Software, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Roles Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Validation, Writing – review & editing

Affiliation AMBCSER, Atlanta Satellite, Atlanta, Georgia, United States of America

• Courtney T. Byrd, 
• Geoffrey A. Coalson, 
• Danielle Werle

• Published: May 16, 2024
• https://doi.org/10.1371/journal.pone.0303024
• Reader Comments

Previous studies have reported that adults who stutter demonstrate significant gains in communication competence, per self-ratings and clinician-ratings, upon completion of a communication-centered treatment, or CCT. The purpose of this social validation study was to determine whether communication competence ratings reported by untrained observers are consistent with client and clinician judgments of communication competence gains following CCT. Eighty-one untrained observers completed an online survey that required each to view one of two videos depicting an adult who stutters during a mock interview recorded prior to CCT or after CCT. Observers were then asked to rate the communication competence of the interviewee on a 100-point visual analog scale and provide additional demographic information. Communication competence of the adult who stutters who had completed CCT was rated significantly higher in their post-treatment video. Upon controlling for two demographic factors found to be associated with observer ratings (years of education, years the observers had known an adult who stutters), significantly higher ratings of communication competence for the post-treatment video were maintained. These preliminary findings provide social validity for CCT by demonstrating that the gains in communication competence reported in previous studies through clinician and client observations are also reported by untrained observers who are not familiar with CCT.

Citation: Byrd CT, Coalson GA, Werle D (2024) Observer-rated outcomes of communication-centered treatment for adults who stutter: A social validation study. PLoS ONE 19(5): e0303024. https://doi.org/10.1371/journal.pone.0303024

Editor: Ronald B. Gillam, Utah State University, UNITED STATES

Received: July 17, 2023; Accepted: April 2, 2024; Published: May 16, 2024

Copyright: © 2024 Byrd et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: In additional to the data presented in the manuscript, all additional csv files will be available at the Texas Data Repository ( https://doi.org/10.48321/D1M343 ).

Funding: This project was supported by the Arthur M. Blank Family Foundation legacy grant, and endowed support provided through the Michael and Tami Lang Stuttering Institute, the Dr. Jennifer and Emanuel Bodner Developmental Stuttering Laboratory, and the Dealey Family Foundation Stuttering Clinic. CL is the recipient of each endowment. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have no competing interests.

Introduction

Public perception that adults who stutter are poor communicators is pervasive. Decades of research illustrate the widespread belief that competent communication–a skill that is considered essential for academic success (e.g., [ 1 ]), workplace advancement (e.g., [ 2 – 5 ]), and interpersonal relationships (see [ 6 , 7 ])–cannot be adequately attained in the presence of stuttered speech. Based on this assumption, treatment options for adults who stutter have historically focused, in part or whole, on learning to speak fluently, and/or modifying moments of stuttered speech (see systematic review by Brignell et al. [ 8 ]). Although clinical trials are available that indicate post-treatment fluency gains are achievable for some adults (e.g., [ 9 – 11 ]), these reviews also note considerable individual variability. Only recently have clinical researchers demonstrated that targeting fluency during treatment is not necessary to improve the communication competency or quality of life of persons who stutter [e.g., 12–14]. These findings align with contemporary views of stuttering, which are anti-ableist in nature, and do not view stuttering as a condition that needs to be fixed (e.g., [ 12 – 14 ]).

Byrd and colleagues [ 15 – 17 ], for example, explored the impact of participation in a communication-centered treatment (CCT) designed to improve communication competence with no attempt to change speech fluency. Participants were rated to be significantly stronger communicators post-treatment by clinicians who were unfamiliar with the participants and blinded to pre-/post-treatment status of video samples [ 15 , 16 ]. Participants themselves also reported significantly stronger communication competencies after treatment and across a variety of speaking contexts (dyad, small group, large group, public presentation) and listeners (strangers, acquaintances, friends; Coalson et al. [ 17 ]). Neither clinician- nor self-ratings of communication competency were predicted by pre-treatment stuttering frequency [ 15 , 16 ] or changes in stuttering pre- to post-treatment [ 17 ].

Although CCT appears to provide meaningful outcomes from the perspective of clinicians and participants who have received this treatment, ratings from the general public (i.e., observers unfamiliar to CCT) are needed to provide social validation (e.g., [ 18 , 19 ]). Schloss and colleagues [ 20 ] examined the social validity of clinician-reported outcomes of a treatment designed to increase assertiveness during communication exchanges of three adults who stutter. Ten graduate students naïve to the treatment randomly viewed one of two videos, either pre-treatment or post-treatment, and rated the speaker’s assertiveness during the interview. Based on higher assertiveness ratings from the naïve observers for post-treatment video samples, researchers concluded that the potential treatment effects could be extended to the general public. A second social validation study by Schloss and colleagues [ 21 , n = 11 naïve observers, n = 3 adults who stutter] replicated the previous outcomes with respect to observed assertiveness of the same three adults who stutter post-treatment. Interestingly, outcomes across these two studies also found that post-treatment changes in assertiveness demonstrated an inconsistent relationship with post-treatment stuttering, suggesting that changes in communication can be achieved independent of changes in fluency.

Taken together, the available clinical data for treatments that are communication rather than fluency centered provide preliminary but compelling evidence that fluency and communication are not inextricably linked. Specific to the data available regarding CCT, both the participants and the clinicians in the prior studies had shared knowledge of the nature of stuttering, the focus of CCT, and the desired clinical outcomes. That is, there was a relatively shared criteria for subjective evaluation in a controlled clinical setting. One could argue that these criteria may diverge from the appraisal used by unfamiliar, untrained laypersons. In addition, clinicians who participated in the previous CCT studies were blind to the pre- versus post-treatment status of videos, and videos were randomized, but they were evaluating a large number of consecutive videos depicting participants who stutter–a scenario rarely encountered in everyday life which may have potentially compromised their ratings. A social validation study, similar to Schloss et al. [ 20 , 21 ], would address these potential rating biases and provide confirmation whether observations made by clinicians, and prior participants, are similarly observed by the general public.

Therefore, to extend previous findings to a more socially valid context, the present study examined whether post-treatment gains in communication competency observed by clinicians and self-reported by participants in previous studies are also identifiable to untrained observers. To do so, we recruited a large cohort of untrained observers to rate the communication competency of an unfamiliar adult who stutters based on a video sample recorded either before treatment or after treatment. To explore implicit factors known or suspected to influence social evaluation, and evaluation of people who stutter (e.g., [ 22 , 23 ]) in particular, we also considered to what extent demographic and observer-related factors may account for perceived communication competency ratings for each video sample.

Treatment for adults who stutter

Three systematic reviews [ 9 – 11 ] have found that positive treatment outcomes are associated with a remarkable variety of treatments and a variety of related clinical factors (see Johnson et al. [ 11 ] for comparison of client-based, intervention-based, and interpersonal-based factors in stuttering treatment outcomes). To date, the majority of treatment approaches for adults who stutter primarily or exclusively target fluency-centered speech techniques intended to either eliminate or minimize moments of stuttered speech (i.e., fluency shaping [ 24 , 25 ]; stuttering modification [ 26 ]). Studies have demonstrated that fluency gains following fluency centered treatment are observed, even 3- to 12- months post-treatment (e.g., [ 27 – 29 ]). Yet, from the few randomized control trials (RCTs) that exist for adults who stutter, it is evident that fluency-centered treatment (a) has an inconsistent impact on the psychological consequences of stuttering [ 28 , 29 ]), (b) is prone to high rates of relapse (71% [ 30 ]), and (c) may compromise the speaker’s innate ability to communicate (e.g., unnatural, effortful, and/or incongruent with their identity [ 31 ]). Additionally, listeners often rate speech techniques employed during treatment to achieve fluency as equally or less desirable than stuttered speech [ 32 – 34 ].

Furthermore, several recent studies indicate that stuttering severity does not predict communication attitudes in persons who stutter regardless of age (e.g., children [ 35 ]; adults [ 36 ]). These data suggest that the assumption that fluency must be targeted to facilitate positive perspectives of self and/or communication in persons who stutter may be misleading. In fact, Byrd and colleagues [ 15 – 17 , 37 , 38 ] provide evidence that significant positive changes in communication attitudes, and communication competence, can be reliably obtained through participation in a treatment that focuses on improving overall communication and explicitly excludes clinical goals that attempt to eliminate, or modify stuttered speech.

Preliminary CCT outcomes with children who stutter

Byrd et al. [ 37 , n = 23, ages 7- to 14-years old] examined changes in cognitive and affective wellbeing before and after treatment reported by 23 children and adolescents who stutter and their parents. Specifically, adolescents reported greater quality of life (as measured by the Overall Assessment of Speaker’s Experience with Stuttering [ 39 ]) following treatment, and parents reported significant improvement in their child’s ability to establish peer relationships (as measured by the PROMIS-Pediatric Short Form Peer Relationships Scale [ 40 ]). A follow-up study by Byrd et al. [ 38 ] replicated these findings in an additional 23 child and adolescent participants (ages 7- to 14-years old). That is, participants and their parents reported significant post-treatment gains in quality of life and peer relationships. Taken together, these findings suggest that treatment that excludes any attempt to modify speech fluency, and instead targets communication competencies, may result in significant gains that meet or exceed those previously reported for fluency-focused or stuttering modification treatment approaches.

Byrd et al. [ 15 ] extended analyses of their communication centered, whole person approach, by examining communication competencies in 37 children and adolescents who stutter (ages 4- to 17-years old) pre- versus post-treatment. An unfamiliar clinician rated pre- and post-treatment presentations (3 to 4 minutes in length), recorded in front of a large group of peers, based on nine different communication competencies: (1) language use, (2) language organization, (3) speech rate, (4) intonation, (5) volume, (6) gestures, (7) body position, (8) eye contact, and (9) facial affect (for detailed description, see Byrd et al. [ 15 , 16 ]). Findings provided preliminary evidence that, in addition to replicating the positive post-treatment changes in cognitive and affective aspects of stuttering reported in prior studies (Byrd et al. [ 37 , 38 ]), clinicians rated communication competency of children who stutter as significantly stronger during presentations recorded after treatment. Of particular relevance to the present study, these changes in communication competence following CCT were not significantly predicted by pre-treatment stuttering frequency.

Preliminary CCT outcomes with adults who stutter

Positive post-treatment gains in communication competence after treatment for children who stutter have been replicated in adults who stutter who have also participated in CCT. Coalson et al. [ 17 ] examined self-reported clinical outcomes from 33 adults who stutter after an 11-week communication-centered treatment (for greater detail, see S1 Appendix ) similar to the one-week treatment program for children described in Byrd et al. [ 15 , 16 , 37 , 38 ]). During the first and last week of treatment, participants completed the Self-Perceived Communication Competence [ 41 ]—a brief scale designed to self-assess communication competence in four specific communicative contexts (dyad, small group, large meeting, presentation) with three interlocutors (stranger, friend, acquaintance). Significant gains in self-rated communication competence were reported post-treatment and, similar to the children and adolescents who stutter in Byrd et al. [ 15 ], post-treatment gains were not predicted by stuttering frequency.

These self-reported outcomes by adults who have completed CCT have also been found through clinician observation. Byrd et al. [ 16 ] examined post-treatment communication competencies in 11 adults who stutter. Each participant completed a mock interview with an unfamiliar interviewer in the week prior to treatment, and in the week after completion of treatment. Randomized video samples of these pre-and post-interviews were rated offline by a certified and licensed speech-language pathologist unfamiliar with the speaker and blind to pre-/post-treatment status of each video. As with the clinician observations for children and adolescents who have participated in CCT [ 15 ], adults who stutter demonstrated observable post-treatment improvements in eight of the nine targeted communication competencies (i.e., language use, language organization, speech rate, intonation, volume, gestures, body position, eye contact, and facial affect), and again, these improvements were not predicted by pre-treatment stuttering frequency. Taken together with Coalson et al. [ 17 ], these preliminary data suggest that expert clinicians, as well as the adults who stutter themselves, observe positive changes in communication competencies after completing CCT that are independent of pre- and/or post-treatment stuttering.

Untrained observers

Although the participant- and clinician-based outcome measures used in Byrd et al. [ 15 – 17 ] are commonplace within clinical trials of adult stuttering treatment (e.g., [ 28 , 42 – 45 ]; however, see [ 46 – 49 ] for third-party ratings of naturalness), it could be argued that the changes reported were evaluated from two parties–the participant and the clinician–whose shared perspectives invite a potential for rater bias. A logical means to address potential rater biases due to familiarity with the condition, and/or its treatment, is to examine clinical outcomes from the perspective of raters who have neither–the untrained observer.

To date, post-treatment communication competence of adults who have completed CCT has yet to be explored from the perspective of the untrained observer. Unlike clinicians or participants, who have shared understanding of communication competence in the context of CCT, untrained observers provide a valuable means to assess the social validity of any communicative outcome measure, by virtue of the inherently variable intrinsic and extrinsic cues that they may use to evaluate a speaker’s communication competence. By assessing the perspective of a large group of untrained observers, we can capture the variance of such internal criteria while also measuring the broader impact of CCT outcomes. Thus, our primary research question is to assess to what extent the gains in communicative competence observed by clinicians, and self-reported by participants, in previous studies are also evident to the general public. Given the potential influence of generalized biases towards stuttering, and persons who stutter, a secondary question is to what degree specific demographic factors may mediate the general public’s perception of CCT outcomes.

Potential observer-based demographic mediators

Among the general public, there is a well-documented negative bias towards persons who stutter (e.g., [ 50 – 53 ]). A number of demographic factors have been found to influence an untrained observer’s evaluation of any speaker (e.g., age, gender, education, occupation, familiarity with language/multilingualism), including those who stutter (see [ 23 , 54 , 55 ]). Such demographic factors as well as additional observer-based factors have a potential influence on naïve observers’ attitudes towards adults who stutter (e.g., familiarity with a person who stutters [ 56 , 57 ]; personal history with a communication disorder [ 58 , 59 ]; visible and/or invisible disability [ 60 ]).

Additionally, factors known to mitigate an observer’s overall evaluation of an adult who stutters as a person may override any attempt to measure a targeted trait, such as communication competence, resulting in overly positive evaluations (see Werle & Byrd [ 61 ] for positive feedback bias by professors when evaluating presentations by students who stutter) or overly negative evaluations (see Byrd et al. [ 22 ], for gender bias towards adults who disclose stuttering). Thus, it is plausible that observer ratings of the communication competence of a particular adult who stutters may be driven entirely by their overall perception of all people who stutter. Therefore, in the present study we also aimed to explore and account for observer-based demographic factors that may mediate the ratings of unfamiliar observers.

Rationale for the present study

In sum, the primary aim of the present study was to examine the social validity of post-treatment gains in communication competence of an adult who stutters who completed CCT—an approach to treatment that focuses on communication and makes no direct or indirect attempt to increase fluency or modify stuttered speech. A secondary aim of this study was to assess whether observer-based factors of untrained observers influence perceived communication competence.

Research Question 1 [RQ1]: Do untrained observers, similar to expert clinicians, perceive higher communication competence for an adult who stutters following CCT?

Research Question 2 [RQ2] : Do observer-based demographic factors predict evaluation of the communication competence of an adult who stutters?

The following study was approved by the Institutional Review Board at the University of Texas at Austin (IRB: 2015-05-0044, [ 62 ]). Survey participants indicated consent prior to participation by clicking to advance to the first survey question after reading the cover letter that includes a description of the study, potential benefits and minimal risk of voluntary participation, and compensation for participation ($0.50 per participant, similar to Werle and Byrd [ 61 , 63 , 64 ]). Communication competency stimuli consisted of two separate videos: one depicting a speaker before he had completed CCT (Pre-treatment Video) and one depicting the same speaker after he had received CCT (Post-treatment Video). Written consent was obtained from the adult depicted in the video stimuli prior to his self-selected enrollment in CCT.

Communication-centered treatment (CCT)

A detailed description of the treatment program is provided in Byrd et al. ([ 16 ], see also Coalson et al. [ 17 ] and Byrd [ 65 ]) and summarized in S1 Appendix . The overarching goals are to ensure individuals who stutter communicate competently, advocate for themselves in a manner that maintains agency, and ensure their quality of life does not depend on reducing, or attempting to control, stuttered speech. In brief, adult participants complete 11 weeks of treatment consisting of two 60-minute sessions per week (one group session, one individual session), totaling 22 sessions which include training in Communication, Advocacy, Resilience, and Education (the Blank Center CARE ™ Model). With respect to Communication, participants receive explicit instruction on how to strengthen nine core communication competencies (i.e., language use, language organization, speech rate, intonation, volume, gestures, body position, eye contact, facial affect). All competencies are addressed via a pragmatic as opposed to a fluency framework. For example, as opposed to changing rate, volume, or tone to potentially facilitate fluency, participants learn the importance of changing rate, volume, and intonation with respect to speaking context (e.g., giving a presentation vs. having a one-on-one conversation), and how changes in these competencies can influence both the meaning of their message and listener engagement. Participants also learn that stuttering is an independent construct from communication competence, and that efforts to not stutter may compromise communication.

Training during individual sessions provided an opportunity for participants to review what would be covered in weekly group sessions, to prepare for the activities, and to debrief about topics covered in group sessions from the prior week. During group sessions, participants strengthened their communication competence across a number of distinct, functional yet challenging speaking scenarios, including mock job interviews, small group interactions, impromptu icebreakers, one-on-one interactions with unfamiliar persons, and multiple presentations varied both in purpose (e.g., informative, persuasive, inspirational) and audience composition (e.g., small and large groups, familiar and unfamiliar listeners).

Communication competency stimuli

Two video samples (Pre-treatment Video, Post-treatment Video) from an adult who stutters who participated in Byrd et al. [ 16 ] and Coalson et al. [ 17 ] were selected for stimuli. Table 1 provides a summary of both video stimuli.

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https://doi.org/10.1371/journal.pone.0303024.t001

Each of the two video stimuli depicted a one-on-one, in-person mock interview between (a) the same adult who stutters, who served as the interviewee, and (b) a clinical staff member unfamiliar to the interviewee who served as the interviewer. Interviewers differed between pre- and post-treatment. Each interviewer was unfamiliar with the participant who served as the interviewee, and both were provided identical, commonplace interview questions as prompts (e.g., “What do you consider your strengths and weaknesses?”; “Describe a prior work-related issue and how you addressed it.”).

Selection criteria for video stimuli included (a) significant intra-speaker gains in communication competence as rated by the speech-language pathologist evaluator, and (b) comparable stuttering frequency pre- to post-treatment. The Pre- and Post-treatment Video samples used in the present study were as close to the same percentage and severity possible, though not identical given the natural variability in stuttering frequency and sample length. As detailed in Table 1 , stuttering frequency was 10.6% for the Pre-treatment Video and 8.2% the Post-treatment Video, and stuttering severity for both the Pre- and Post-treatment Videos were rated as moderate per the Stuttering Severity Index– 4 th Edition (SSI-4 [ 67 ]). To confirm there were no perceptible differences in stuttering between the two video samples, a validation survey (administered as part of a separate project, Byrd et al. [ 68 ]) asked a separate cohort of untrained observers not included in this study to rate stuttering severity using a 100-point visual analog scale (0 = no stuttering, 100 = extremely severe stuttering) after rating one of the two video samples. Untrained observers rated stuttering severity to be statistically comparable ( p = .95) between Pre- and Post-treatment Video samples, with nearly identical mean severity ratings ( M = 64.71 and 64.95, respectively). The participant who completed the CCT for which his pre-treatment and his post-treatment interview served as the stimuli for the present study was a 19-year-old Hispanic male who stutters. The participant self-identified as a monolingual English speaker, with no prior or present communication, developmental, psychological, neurological, and/or physical concerns.

Survey administration and observer description

The Pre- and Post-treatment Video samples were embedded in a Qualtrics-based survey distributed to adult untrained observers, with the survey prompting one of the two videos in succession of access to ensure a random yet comparable number of participants observed one of each of the two samples. Potential untrained observers were recruited using the crowdsourcing platform Amazon Mechanical Turk (MTurk) which allows a large and diverse pool of individuals to complete surveys for compensation ($0.50) after requirements for quality were met (e.g., attention/comprehension checks [ 69 ]). This amount was determined based on pilot research for previous studies [ 61 , 63 , 64 ] that assessed engagement and quality of responses. No filters were applied to the recruitment of untrained observers other than location (USA) and respondent approval rate greater than 95% (i.e., rate in which respondents completed surveys were accepted by researchers). Occupations were self-reported by respondents. Unlike previous social validation studies by Schloss et al. [ 20 , 21 ] that recruited college students enrolled in coursework related to communication disorders or special education, the untrained observers in the present study were older ( M = 42.4 years) and relatively few self-reported occupations in allied health ( n = 9 observers [11.11%]; Pre-treatment Video, n = 4, Post-treatment Video, n = 5) or education ( n = 6 observers [7.41%]; Pre-treatment Video, n = 4, Post-treatment Video, n = 2).

Each survey began with an informed consent landing page, followed by the instructions: “You are about to watch a video of an interview. Immediately following the video, you will be asked questions about the interviewee. The interview will be approximately 5 to 7 minutes in length. You will only be able to move forward in the survey after you have watched the video in its entirety.” The untrained observer then watched a single video of the participant—either the Pre-treatment Video or the Post-treatment Video—with the advance button disabled for both the survey portal and the embedded video. Immediately after their viewing of the video, the untrained observers were provided the following instructions accompanied by a 0–100 visual analog rating scale: “Using the scale below, please rate the interviewee’s communication skills. 0 = Communication skills not at all effective, 50 = Communication skills somewhat effective, 100 = Communication skills extremely effective.” The term ‘communication’ was not operationally defined for the observers as allowing the definition of communication to freely vary among observers maintained social validity of data. Upon providing their rating, participants were then asked to describe what factors led to their rating in a free response text box. The subsequent free-text response provided an opportunity to further explore what criteria observers used to rate communication competence without a priori suggestion by the researchers (see S2 Appendix for qualitative analysis of free response data for each video sample).

Following their rating and subsequent free response, observers were asked to provide demographic information (e.g., age, race, ethnicity, gender, education, occupation, primary language). Observers were also prompted to report their personal relationship with stuttering, persons who stutter, or other communication differences (i.e., “Are you a person who stutters? Do you personally know a person who stutters? If so, please describe your relationship and how long you have known this person. Have you had previous speech, language, and/or hearing evaluation or therapy?”) as well as any visible or invisible diagnoses unrelated to communication difficulties (i.e., physical condition, psychological condition, neurological condition, emotional condition, vision/hearing loss, reading condition, other/describe, none). Each survey included three attention check questions and four comprehension check questions to assess the integrity of individual responses. Survey data were collected in July 2021, and all observers were paid in accordance per MTurk standards of distribution.

The survey was initiated by 128 potential observers (67 Pre-treatment Video, 61 Post-treatment Video). Of these 128 potential observers, 36 (19 Pre-treatment Video, 17 Post-treatment Video) did not pass at least one of the seven attention/comprehension check questions during the course of the survey and were excluded from final analysis. Of the remaining 92, four were excluded because they self-identified as a person who stutters (2 Pre-treatment Video, 2 Post-treatment Video). Seven additional observers were excluded (3 Pre-treatment Video, 4 Post-treatment Video) due to free-response items that suggested unclear understanding of the task (e.g., “ She [the interviewer] can ask some more questions .”), questionable attention to the study (e.g., “ Everything is perfect .”), or potentially auto-generated responses (e.g., unusual format of free-responses repeated across items or participants). The final corpus included 81 observers (43 Pre-Treatment Video, 38 Post-Treatment Video). See Table 2 for detailed description of demographics.

https://doi.org/10.1371/journal.pone.0303024.t002

RQ1: Do untrained observers, similar to expert clinicians, perceive higher communication competence for an adult who stutters following CCT?

An independent t -test was conducted to compare untrained observers’ evaluation of communication competency depicted in one of two stimuli—either the Pre-treatment or the Post-treatment Video of an adult who stutters who received CCT. Video time point (Pre-treatment Video, Post-treatment Video) served as the independent variable, and ratings from the 100-point visual analog scale (VAS) of communication competence served as the dependent variable (0 = low competence, 100 = high competence). The independent t -test was two-tailed (α = .05) and effect sizes were calculated and interpreted using Cohen’s d [ 70 ]. Because of the preliminary nature of the data and modest sample size, findings were verified by non-parametric analysis (Mann-Whitney U , α = .05).

RQ2: Do observer-based demographic factors predict evaluation of the communication competence of an adult who stutters?

A linear regression was conducted to assess the influence of viewing communication competency stimuli (Pre-Treatment Video, Post-treatment Video) and nine observer-related variables (i.e., age, race, ethnicity, gender, years of education, non-English primary language, knowing an adult who stutters, number of years the observer has known an adult who stutters, invisible diagnosis; see Table 2 ) upon ratings of the communication competence of an adult who stutters. Categorical variables with responses that were either not reported (i.e., non-binary self-identified gender) or reported infrequently (i.e., non-English primary language with fewer than 4 observers) were transformed to create a single binary variable (i.e., male/female; English/non-English primary language). In addition, to maintain relatively even distribution amongst categories during analysis, race had to be analyzed as a binary variable due to relatively infrequent self-identification as Asian ( n = 13, Pre-treatment Video = 8, Post-treatment Video = 5), Black/African American ( n = 9; Pre-treatment Video = 6, Post-treatment Video = 3) or racial identification that was not included in existing categories ( n = 3; Pre-treatment Video = 2, Post-treatment Video = 1).

To determine which of the nine observer-related factors held meaningful predictive value of observer ratings, and therefore qualify for entry into the linear regression, we applied a version of Hosmer et al.’s [ 71 ] step-by-step method for purposeful selection of covariates modified for OLS linear regression. First, nine univariate analyses were conducted for each variable (chi-square tests for categorical variables, independent t-tests for continuous variables). Variables with p -values greater than 0.25 were excluded. Second, a model with non-excluded variables was fitted, then each predictor re-assessed and deleted if significance exceeded p > .05. Third, the reduced model was compared to the original model using F values to ensure improved fit and to verify that change in beta coefficients between models did not exceed 20% (i.e., deleting-refitting-verifying cycle). Fourth, any variables that were excluded during the initial step were re-entered into the model, one at a time, but retained only if p -values were less than .05. Fifth, any interaction terms of interest between the remaining variables were entered into the model. Interaction terms were assessed using the deleting-refitting-verifying cycle used for main effects and retained only if statistically significant at p < .05 and if model fitness improved. Any main effects and interaction terms remaining after these steps were completed comprised the final model (see Table 3 ). Due to the preliminary nature of the data and modest sample size, bootstrap analysis was conducted to confirm initial findings (95% confidence intervals; 5000 samples). Effect sizes for individual predictors within linear regression were calculated and interpreted using f 2 (.02 = small, .15 = medium, .35 large [ 70 ]).

https://doi.org/10.1371/journal.pone.0303024.t003

RQ1 : Do untrained observers, similar to expert clinicians, perceive higher communication competence for an adult who stutters following CCT?

An independent t -test was conducted to assess how untrained observers rate communication competence of an adult who stutters. As depicted in Fig 1 , findings reveal significantly stronger perceived communication competence for the Post-treatment Video ( M = 70.3, SD = 21.1) than the Pre-treatment Video ( M = 59.0, SD = 20.1), t (79) = 2.46, p = .016, d = .55 [medium effect size]. Findings were confirmed via nonparametric analysis, U (43,38) = 532.50, z = 2.70, p = .007.

https://doi.org/10.1371/journal.pone.0303024.g001

RQ2 : Do observer-based demographic factors predict evaluation of the communication competence of an adult who stutters?

A linear regression was conducted to determine the contribution of nine observer-related factors (i.e., age, race, ethnicity, gender, years of education, non-English primary language, knowing an adult who stutters, number of years observer has known adult who stutters, visible or invisible diagnosis) upon ratings of the communication competence of an adult who stutters. As expected, the Post-treatment Video was a significant predictor of higher ratings of communication competence when entered as the lone predictor variable (β = .27, p = .013), explaining 7.1% of the variance ( R 2 = .071; F (1, 79) = 6.03, p = .016; see Model 1 in Table 3 ). Upon completing Hosmer et al.’s (2013) purposeful selection of covariates, only two factors were identified as potential predictive covariates: (1) years of education, which significantly predicted observer ratings (β = - .33, p < .001) and accounted for an additional 12.2% of the variance ( R 2 = .122), and (2) years the observer has known an adult who stutters, which approached significance (β = .17, p = .087), and accounted for an additional 2.8% of the variance ( R 2 = .028). After statistically accounting for the contribution of these two observer-based factors, the Post-treatment Video remained a significant, positive predictor of improved observer ratings (β = .29, p = .004) with the final model accounting for 22.1% of the variance ( R 2 = .221; F (3, 77) = 7.30, p < .001; f 2 = .36 [large effect size] see Model 2 in Table 3 ).

To verify these outcomes, a bootstrapping analysis was conducted to determine 95% confidence interval (CI) for unstandardized beta coefficients of each factor based on 5000 samples. Bootstrap analysis confirmed a significant, positive coefficient for the Post-treatment Video ( p = .007, [CI: 3.88, 20.72]) while controlling for potential influence of both observer-related factors (years of education: p = .003, [CI: -3.99, -.85]; years observers have known an adult who stutters: p = .049 [CI: .01, .46], see Table 3 ).

Ancillary analyses

The Pre- and Post-treatment Video stimuli included stuttering severity that was rated perceptually similar by untrained observers ( n = 63 Pre-treatment Video, n = 57 Post-treatment Video; p = .95) and categorically similar according to the SSI-4 scale (Pre-treatment Video: moderate; Post-treatment Video: moderate). Nevertheless, the frequency of stuttering decreased from pre- to post-treatment samples as measured by %SS (10.60% to 8.24%, Δ -22.26%) and by Section 1 of the SSI-4 (7 to 6). Further, a slight decrease was observed in physical concomitants (SSI-4-Section 3: 10 to 9), resulting in a lower Total Score on the SSI-4 for the Post-treatment Video, but the same overall severity classification (moderate, 27 to 25; see Table 1 ). To determine whether these decreases in frequency and severity in the post-treatment sample impacted observer-ratings of communication competence, a second analysis was conducted with a different adult who stutters wherein an increase in stuttering (i.e., frequency, duration, and physical concomitants), rather than a decrease, was observed pre- to post-treatment.

A detailed description of pre-/post-treatment outcomes, as well as the regression analysis to control for listener-based factors, is provided in S3 Appendix . In summary, findings from the original analyses of RQ1 and RQ2 were replicated. Similar to results of RQ1 of the original analysis, untrained observers ( n = 96) rated communication competence significantly higher post-treatment ( p = .040, d = .42 [small-to-medium effect size]) for an adult who stutters who demonstrated higher, rather than lower, post-treatment stuttering frequency and severity. Similar to results of RQ2 of the original analysis, post-treatment gains in communication competence were maintained while controlling for potential listener-based factors ( p = .045, f 2 = .24 [medium-large effect size]). These findings, combined with results from the primary analysis, provide counterevidence to the possibility that raters were responding to the interviewee’s stuttering more so than their communication competence.

The primary purpose of this study was to provide social validation of previous clinician- and self-rated gains in communication competence by exploring the perspective of untrained observers. A secondary purpose was to examine whether observer-related demographic factors mediate their perspective. Untrained observers were recruited to view, and then rate, either the Pre- or Post-treatment Video of an adult who stutters who had completed CCT. Similar to clinician- and self-ratings in previous studies, ratings from untrained observers who viewed the Post-treatment Video were higher than the ratings of the untrained observers who viewed the Pre-treatment Video. Two observer-rated factors were identified as significantly associated with communication competency ratings: (1) years of rater education and (2) years the rater had personally known an adult who stutters. Statistically accounting for these factors, the Post-treatment Video ratings remained significantly higher, suggesting that gains in communication competence following CCT are observed by raters unfamiliar with the nature and/or goals of the treatment.

RQ1: Communication competence gains from the perspective of untrained observers

As described above, untrained observers’ post-treatment ratings were significantly higher than the pre-treatment ratings. These findings are consistent with the significant pre-/post-treatment gains in communication competence reported for adults who stutter via self-ratings [ 17 ], and by clinicians [ 16 ]. Findings also corroborate significant gains in communication competence observed by clinicians for young children and adolescents [ 15 ]. Consistency across ratings of communication competence from three different perspectives–self, clinician, and untrained observers–suggest that the gains reported reflect a meaningful change that is observable beyond the clinical environment.

Unlike previous studies by Byrd and colleagues [ 15 , 16 ], wherein a single clinician rated pre-/post-treatment video samples from multiple adults who stutter (i.e., many-to-one), the structure of observation in the present study was reversed. In those previous studies, analyses captured the variance of treatment outcomes across multiple participants, with rater variance held constant by use of a single clinician rater. In the present study, multiple observers rated communication competence of a single adult who stutters who had completed CCT (i.e., one-to-many) based on viewing only one of the two videos, either the pre-treatment or the post-treatment. Thus, we were able to avoid potential order effects. Moreover, this statistical design allowed us to capture the variance of responses amongst observers from the general public. That being said, it is possible that the gains reported from the perspective of viewing only one participant may or may not be observed when evaluating a group of participants before and after treatment. Although the present study’s data provide preliminary support for the social validity of CCT, a natural next step is to assess the variance of treatment outcomes across multiple participants by a single untrained observer, similar to the one-to-many rating design in Byrd et al. [ 15 , 16 ].

As noted, stuttering frequency and severity were comparable between video samples (Pre-treatment Video, SSI-4: moderate [score 27]; Post-treatment Video, SSI-4: moderate [score 25]), lending support to the notion that ratings of communication competence were not likely influenced by changes in stuttering. It might be suggested that ratings of stuttering severity provided by expert clinicians may not reflect judgments of severity by untrained listeners in the general public. However, the previously described non-significant differences in observer-based ratings of stuttering severity (see Table 1 , p = .95) between the Pre- and Post-treatment Video samples suggest this was not the case (as also observed for that adult participant rated in S3 Appendix ).

Alternatively, it is also possible that the stuttering was perceived as less distracting in the Post-treatment Video because it was accompanied by higher communication competence. For example, Werle et al. [ 72 ] reported that untrained observers who viewed a presenter with a stuttering frequency of 15% who demonstrated high communication competence rated their perceptual stuttering as less distracting than observers who viewed the same presenter who exhibited the same 15% stuttering frequency but demonstrated low communication competence.

Further assessment of qualitative feedback from observers in the present study support the findings of Werle et al. [ 72 ], and that of Werle and Byrd [ 61 , 64 ], and indicate that fluency was less of a concern in the presence of stronger communication competence in the Post-treatment Video. For example, observers who viewed the Post-treatment Video noted that they certainly heard the interviewee stuttering, but also commented that its importance was offset by communication skills (e.g., “ The interviewee was very articulate and concise in his language and tone of voice . He used his hands when speaking , which made him appear more animated and that was easier to follow . ” “ Even though the interviewee had a stuttering issue , he was able to explain himself well . He gave good examples when asked for them by the interviewer .”; “ I believe that [he] communicated well . … He looked the interviewer directly in the eyes , smiled , and nodded .” ) . In contrast, observers who viewed the Pre-treatment Video stated that they often focused solely on stuttering (e.g., “ He was not bold and confident about the way he deliver[s] things . He is a stammer[er] ”; “ The interviewee has a speech impediment and it is difficult for him to communicate verbally .”) or stuttering in addition to poor nonverbal communication skills (e.g., “ He seems to stay within his capabilities of communication , but his stutter is distracting . He answers questions directly , but he doesn’t use much eye contact . ” ; “He had a stutter and his body language looked tense but he gave great answers .”)

S2 Appendix provides a full thematic analysis of open-ended text responses provided by untrained observers. In sum, observers who viewed the Post-treatment Video reported more positive comments about stuttering ( n = 14 comments) and fewer negative comments about stuttering ( n = 4 comments) than observers who viewed Pre-treatment Video ( n = 9 positive comments; 36% fewer positive comments; n = 19 negative comments; 79% more negative comments). Thus, even though the Pre- and Post-treatment Videos had similar stuttering frequency, and the same severity rating, qualitative data from the present study indicate that, consistent with Werle et al. [ 72 ], heightened communication competence of the speaker who received CCT appeared to minimize the potential negative influence of stuttering on observer judgment.

RQ2: Observer-based factors associated with ratings of communication competence

Two observer demographic factors–years of education and years the observers had known an adult who stutters–were identified as significant predictors of observer-rated communication competence. Specifically, observers rated communication competence to be stronger as the number of years the observer had personally known an adult who stutters increased, but weaker as the amount of education the observer had completed increased. Although observer-rated evaluations of communication competence remained significant upon controlling for these factors during analyses, the potential implications of these two factors warrant discussion.

Regarding the number of years observers have known a person who stutters, previous research has indicated that people who have developed first-hand relationships with any stigmatized groups are likely to report improved overall judgments of persons within that group (e.g., [ 73 , 74 ]), including persons who stutter (e.g., [ 75 , 76 ]; cf. [ 57 , 77 ]). Thus, results of the present as well as past studies strongly suggest that future studies employing observer evaluations of participants who stutter should continue to include and/or control for the length of time participants know someone who stutters. Measurement or statistical control for this variable would be prudent given its long-standing influence on the general public views of individuals who stutter.

There was a significant negative relationship between years of education and communication ratings, wherein observers with higher levels of education often provided lower ratings of the speaker’s communication competence, regardless of the video viewed. To be clear, the mean number of years of education between groups was nearly identical (Pre-treatment Video; M = 16.4 years of education; Post-treatment Video, M = 16.5 years of education, p = .45). This relationship may be similar to well-documented gender and race discrimination in the workplace within the workplace [ 78 – 80 ]. That is, persons of authority hold lower expectations of stereotyped groups, yet also set higher standards for those group members to prove that their competency is equivalent to non-stereotyped groups. If observers with more formal education in the present study also held higher workplace authority, this may have negatively impacted their perception of communication competence. In short, when asked to evaluate the communication of an interviewee who stutters, individuals with more years of education may have provided ratings based on lower expectations, and higher standards, than individuals with fewer years of education.

Negative association between perceived communication competence and years of education is inconsistent with recent research by Werle and Byrd [ 61 , 64 ]. In these studies, findings were taken to suggest a potential positive response bias when raters with higher years of education (i.e., college professors) evaluate students who stutter. Perhaps this is a unique pattern observed for professors and teachers whose job duties require ongoing evaluation of adult students. It is also possible that the dyadic speaking context lowered the likelihood of positive feedback bias found for professors. That is, professors were potentially more likely to overcorrect their personal biases (observed for Werle and Byrd [ 62 , 65 ]) when presented with a speaker in a context for which they regularly provide evaluation (e.g., oral classroom presentations). In that respect, positive response bias for the mock interviews depicted in the present study may have emerged for observers with a history of employment or training in human resources. Taken together, these two factors–years knowing a person who stutters and years of education–significantly influence ratings of communication competence. However, the significance of ratings based on video status (Pre-treatment versus Post-treatment Videos) remained beyond the influence of these two factors. That overall finding, as well as the large number of observer demographic characteristics included in the analyses, provides confidence that the positive effects of CCT are independent from the unique effects of any demographic factor included in this study.

Limitations and future studies

Although efforts to account for some of the variance were made, we acknowledge that a number of additional factors, known and unknown, beyond the focus of CCT also influence observer judgments. For example, visual nonverbal information (e.g., attire, physical appearance, environments) have a documented effect on evaluator judgments (e.g., [ 81 ]). The same adult completed the recordings for both video samples in the present study. The participant was wearing a dress shirt and necktie during the first interview (Pre-treatment Video) but dressed more casually for the post-treatment interview (Post-treatment Video). One might assume that what the participant was wearing in the Pre-treatment Video may be considered more professional attire, and would influence observer ratings, this video was rated less favorably, suggesting that attire was less critical than overall communication competence.

From a methodological standpoint, video samples that naturally vary in length and content also introduce potential confounds. For example, in the present study, the Post-treatment Video was longer and contained more total words than the Pre-treatment Video, introducing the possibility that observers became fatigued or impatient when viewing and prior to VAS rating. However, the Post-treatment Video Sample received a significantly stronger mean rating than the Pre-treatment Video sample, which tempers this concern. It is also possible that, although both mock interviews were unprompted events, and interviewers were unknown to the participants, the participant benefitted from the previous mock interview experience and felt at greater ease in the identical space provided for both interviews. Additional review of communication competence in a different space, or perhaps investigation of content overlap between interviews, would address this point.

Dyadic interviews lend themselves to a specific, one-on-one style of interaction that favors certain adults who stutter more than others, and post-CCT gains may not necessarily generalize to other contexts such as presentations (however, see Coalson et al. [ 17 ] for post-CCT gains when aggregated across seven speaking contexts reported by adult participants who stutter). Given that possibility, it is important to note the present study is one entry in a series of clinical studies focused on the outcomes of CCT from a variety of perspectives (e.g., self, clinician, observer). A larger cohort of observers is needed to corroborate preliminary results, and examination of clinical outcomes will continue across multiple contexts, from multiple perspectives, and with multiple measures, in future studies.

From a conceptual standpoint, several factors limit the interpretation of these findings. First, the present authors did not employ a control group (e.g., two videos of an adult who stutters during an interview who did not receive CCT) or a control sample (e.g., a video sample of the same adult who stutters in this study, with stuttering digitally removed). For these reasons, our interpretation of the reported social validation data is restricted to the general public’s opinion of communicative change following CCT. As such, present findings do not inform differences relative to non-stuttering individuals or individuals who have not yet received treatment. Further, the current data are limited to samples recorded pre-treatment and immediately post-treatment, with no long-term follow-up data. Future investigations will prioritize these factors to provide greater context for the social validity data reported in the present study.

An additional limitation is sample size. Prior studies examining pre-/post-treatment rating communication competence consistently yielded “large” or “very large” effect sizes (Byrd et al., 2021, d- value range = .75 to 1.18 [6 of 8 competencies]; Byrd et al., 2022: d -value range = .86 to 1.30 [8 of 8 competencies]). Therefore, a priori power analysis was based on large effect size ( d = .80, n = 52). It is true that RQ1 with medium-to-large ( d = .55) effects size yields underpowered results (minimum n = 106). However, the findings of RQ1 are well supported by RQ2. Post-hoc power analysis of the linear regression analysis in RQ2 shows that, while also controlling for two other listener-based variables, the partial R 2 for the single predictor of Pre-/Post-treatment Video stimuli is more than sufficiently powered (power = .99).

Another consideration is that the explicit instructions provided to untrained observers may have also influenced ratings. Before providing numeric ratings of communication competence, survey observers were provided the following prompt: “Using the scale below, please rate the interviewee’s communication skills.” This phrasing may have biased observers to view the interviewee through the lens of communication, which while important, is not the only factor considered during an interview evaluation. Indeed, a majority of the comments provided by the observers referred to some aspect of fluency or communication (121 of the 152 comments, 79.6%), with smaller proportions referring to personality (24 of 152, or 15.8%) or employability (7 or 152, or 4.6%; see S2 Appendix , Table 3 ). A more neutral prompt of “Please rate the person’s performance during the interview.” may have limited the potential bias of the observer.

One final consideration is that observers may have been rating communication relative to “effectiveness”, as stated in the prompt, rather than communication “competence,” as referred to by CCT and supporting research. According to Spitzberg [ 82 , 83 ] and Morreale et al. [ 84 ], communication competence is a superordinate concept that captures whether a speaker demonstrates communicative behaviors that are both effective and appropriate for a given context. Although it is likely that an increase in effectiveness would also result in an increase in competence, differing terminology in survey prompts may yield different observer perceptions and warrants investigation in future studies.

Findings from the present study provide social validation for the gains in communication competence following CCT that have been previously observed through clinician- and self-ratings. A large cohort of untrained observers rated the Post-treatment Video of an adult who completed CCT higher than the untrained observers who observed the Pre-treatment Video of the same adult. Additional research is needed to obtain ratings of multiple participants who have completed CCT to provide further insight into whether the gains reported by clinicians, and individuals who stutter who complete this treatment, translate meaningfully into the general public’s perception of their communication. However, these data, though preliminary, do demonstrate that communication competence and stuttering are distinct constructs that can be targeted and rated, independently, lending further support for anti-ableist approaches that do not aim to increase fluency or modify stuttered speech.

Supporting information

S1 appendix. description of treatment program..

Summary of the Blank Center CARE ™ Model treatment program.

https://doi.org/10.1371/journal.pone.0303024.s001

S2 Appendix. Qualitative study.

Thematic analysis of free-text responses provided by untrained observers.

https://doi.org/10.1371/journal.pone.0303024.s002

S3 Appendix. Replication study.

Data replicating original analyses based on a participant with an inverse stuttering frequency and severity profile.

https://doi.org/10.1371/journal.pone.0303024.s003

Acknowledgments

The authors would like to thank the individuals who stutter who participate in our ongoing clinical trials at the Arthur M. Blank Center for Stuttering Education and Research. We also thank Michael Mahometa for his assistance with statistical analyses.

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