Improving Social Interaction Among Primary School Students with Stuttering

The research aimed to examine the effectiveness of a guidance program in enhancing social interaction abilities among elementary school students with stutteringwho have a stutter. The sample consisted of 20 students, divided into two groups. Prior to the intervention, both groups were assessed using a social interaction scale. Subsequently, the experimental group underwent the 17-sessions experimental variableguidance program, which involved awith 17-sessions which guidance program aimed at developing social interaction skills. On the other hand, the control group did not receive any intervention. Following the intervention, the same social interaction scale was administered to both groups. The results indicated statistically significant differences between the levels of social interaction in the experimental group and the control group, favoring the experimental group. Additionally, there were no statistically significant differences between the average ranks of the two measurements (post-follow-up) concerning social interaction among elementary school students who stutter in the experimental group.


INTRODUCTION
Language is a fundamental aspect of human life, serving as a crucial means of communication and interaction within society.It encompasses more than mere symbols, sounds, or gestures, as it enables individuals to express thoughts and desires while reflecting their personality.Language plays a vital role in conveying and acquiring information, connecting individuals within a society (Gee, 2001).
The process of language and speech involves various factors, including organic functions and the influence of psychological, health, social, and educational aspects.Language skills facilitate successful communication, understanding, problem solving, and the acquisition of values and attitudes (Kuball & Peck, 1997).It is an essential attribute for interaction and flexible adjustment to different listeners and social situations.Language development may be affected in individuals with special needs, leading to impairments such as limited linguistic output or structures.Conversational or expressive language is an important means of conveying thoughts and feelings, contributing to social life.
Stuttering, a fluency disorder hampers communication and self-concept, affecting individuals' ability to express themselves and interact with their environment (Nousia et al., 2022).Social interaction, relying on verbal and nonverbal communication, is the foundation of social systems and requires self-confidence and mutual trust.Individuals with social dimensional measurement of the Social Anxiety Scale for Stuttering Children (Teacher's Assessment), indicating the effectiveness of the proposed guidance program.
Besides, Berchiatti et al. (2020) demonstrated the effectiveness of a selective guidance program in reducing social withdrawal behaviors among stuttering children in primary schools.Park et al. (2016) confirmed the effectiveness of virtual reality therapy in reducing withdrawal behaviors among preschool children.Boyle et al. (2016) study highlighted the effectiveness of a guidance program based on social story strategy in developing self-confidence and reducing stuttering among elementary school children.
Collectively, these studies contribute to our understanding of the social implications of stuttering and highlight the importance of addressing psychological and social factors to improve the well-being and communication skills of individuals who stutter.These interventions contribute to enhancing social interaction and improving communication skills in children with stuttering as well.

Ra,onale of the Study
Stuttering not only affects speech but also hinders social life, leading to additional pressure and potential negative coping methods.It limits communication, participation, and interaction with others, resulting in feelings of inadequacy, lack of confidence, social withdrawal, and fear of speaking.Early intervention is crucial to help individuals with stuttering overcome isolation and improve their social interactions (Bara, 2021).
Guidance and therapeutic interventions have shown effectiveness in reducing the severity of stuttering and promoting normal communication (Connery et al., 2021).Studies have highlighted the positive impact of training programs, guidance programs, and interventions based on positive psychology techniques in improving social interaction and reducing social anxiety among individuals with stuttering.However, there is a lack of studies in this area.Therefore, the research problem revolves around studying the effectiveness of a guidance program in improving social interaction among elementary school children with stuttering and assessing the differences in social interaction scores before and after the program.

Aims and Hypotheses
In light of the research questions, the research objectives can be formulated in a procedural manner.This research aims to test the effectiveness of a guidance program in improving social interaction among a sample of stuttering children in the elementary stage.In addition, the following sub-objectives are sought to be achieved: 1) Improve social interaction among a sample of stuttering children in the elementary stage and 2) Verify the effectiveness of a guidance program in improving social interaction among a sample of stuttering children in the elementary stage.
Based on the theoretical framework and previous studies presented, the current research Hypotheses can be formulated as follows: 1) There are no statistically significant differences between the mean ranks of the two groups (experimental and control) on the social interaction scale among a sample of stuttering children in elementary school in favor of the experimental group, 2) There is no statistically significant increase in social interaction among the participants in the experimental group as measured by the post-test application of the social interaction scale, and 3) There are no statistically significant differences between the mean ranks of the post-test and follow-up measurements in improving social interaction among the experimental group of elementary school stuttering children.

METHODS
The researcher adopted a quasi-experimental method to verify the effectiveness of the guidance program (independent variable) in developing social interaction (dependent variable) among elementary school children who stutter.The research sample was divided into two equal and homogeneous groups.One group was the experimental group exposed to the guidance program, while the other group was the control group that did not receive the program.To assess the sustainability of the program, the program was applied to the experimental group two months after the baseline measurement (follow-up measurement), and the differences in the average scores of the children on the baseline and follow-up measurements of the social interaction scale were determined.
The main sample of the current study consisted of 20 stuttering children with ages ranging from 6 to 7 years.They were purposefully selected and randomly divided into two groups: 10 participants in the experimental group and 10 participants in the control group.The researcher chose the Academic Development Center in Al Qurain city, as it approved and welcomed the application of the study.The center provided a suitable environment with proper lighting, ventilation, and a distance from sources of noise.
Additionally, the center's staff cooperated, and it served as the researcher's workplace, as she works as a speech therapist at the center.The researcher considered several criteria when selecting the sample, including the age range of 6 to 7 years, homogeneity in terms of socioeconomic and sociocultural levels, and ensuring that the participants had not previously received any programs for stuttering reduction or social interaction development.Furthermore, the participants were required to have regular attendance at the center, as the program required consistent attendance to ensure the acquisition of the targeted skills.The researcher conducted interviews with the parents of the participants, explaining the program's concept and obtaining written consent for their children's participation in the program.

The researcher utilized the following research tools, Stuttering test
This test was translated to Arabic language by Nahla Elrefaay, 2001 and aimed to diagnose stuttering in children and the elderly.The test measures the frequency of stuttering, the length of the moment of stuttering, and the movements and sounds that accompany stuttering (Al-Tantawi, 2020).The test dimensions were explained as follows.

Repetition of Stuttering Occurrences
The person who stutters is asked to describe the picture presented to them.Pictures are presented one after another while recording the person's speech using a recorder.1) Wait for the child to comprehend the picture and then start describing.2) Clarifying questions can be used to assist the child.3) As the child starts speaking, the examiner tracks stuttering occurrences by marking each word with a period (.) for fluent words and a forward slash (/) for stuttered words.Make sure each word has a small box next to it.4) Use some or all of the pictures to obtain 150 words.
After filling all 150 boxes, calculate the percentage of stuttered words by counting the stuttered words (/) after excluding the first row of boxes (25 words) and the last row of boxes (25 words).Write this percentage in the designated box on the side of the small boxes (the percentage now becomes a degree in degrees Celsius).Using the Stuttering Occurrence Table for those who do not read, found at the beginning of the answer sheet (Test "J"), convert the percentage into a degree and write it in the designated box (degrees ranging from 0 to 18).

Stuttering Moment Duration
The duration of the longest three stuttering moments is calculated for every 150 words (using the audio recording if necessary).These durations are then averaged and converted to a degree according to the table on the first page of the answer sheet (Test "I").Write the degree in the designated box (degrees ranging from 1 to 7).

Accompanying Movements and Sounds
These are observed during the recording of the 150 words and are detailed in the first table on the answer sheet.The examiner assigns a score based on the scale in the table and records it in the designated box (scores ranging from 0 to 20).The scores from the three test items are summed up and written in the designated box (scores ranging from 0 to 45).Using Table (1), which describes the severity of stuttering for children, convert the total score into a severity rating, either Very Mild, Mild, Moderate, Severe, or Very Severe.

Children's Social Interaction Scale
The scale was developed by El-Sersy, Abdel-Maqsoud, 2016 in Arabic language.This scale aims to measure social interaction in children and consists of 38 statements that assess social interaction.It was individually administered by the researcher by selecting one of three choices that best aligns with the child's condition.Always (earning 3 points), Sometimes (earning 2 points), or Never (earning 1 point).This results in a minimum scale score of 38 and a maximum scale score of 114.

Guidance Program (Prepared by the researcher in Arabic language) Reliability of the Stuttering Scale
Reliability of a scale refers to its ability to produce consistent results when administered multiple times under the same conditions.In other words, it indicates the stability of the scale's results and their minimal variation when administered to the sample multiple times over specific time intervals.The test-retest method was applied, where the test was administered to the study sample, and then re-administered after one month.The correlation coefficient between the scores of the two administrations was calculated using Pearson's correlation coefficient.The results showed statistically significant correlations at a significance level of 0.01 or less.The correlation coefficient for the frequency dimension of stuttering was 0.79, for the duration dimension of stuttering was 0.86, for accompanying movements and sounds was 0.9, and the overall total was 0.92.Based on these results, the Stuttering Scale demonstrates high reliability and can be applied effectively.

Reliability of the Children's Social Interaction Scale
The researcher assessed the reliability of the Children's Social Interaction Scale using Cronbach's alpha coefficient.The results showed that the value of Cronbach's alpha coefficient was 0.811, indicating high reliability.The scale's reliability was also confirmed using the splithalf method, where the test items were divided into two halves (odd-numbered items and evennumbered items).The correlation coefficient between the scores of the odd-numbered and evennumbered items was calculated, and then the correlation coefficient was corrected using Spearman-Brown formula.The Spearman coefficient was 0.871, and the Guttman coefficient was 0.862.Thus, the researcher confirmed the validity and reliability of the scale in its final form, making it suitable for application in the primary study sample.This provides the researcher with complete confidence in the accuracy and suitability of the scale to collect the necessary data to answer the research questions.

General Objective of the Program
The overall objective of the program is to improve social interaction among stuttering children and test the effectiveness and sustainability of the program among stuttering children aged 6-7 years.

Operational Objectives of the Program
Derived from the general objective of the program are a set of operational sub-objectives that the program aims to develop among the stuttering children in the current research.These operational objectives are achieved through constructive work within the sessions and through the implementation of home activities assigned to the stuttering children with the assistance of their parents.The following are the most important objectives.Provide mothers with information about the guidance program and the feasibility of their participation in the training.Develop cognitive, emotional, and skills behavior among children through remembering, analyzing, understanding, synthesizing, applying, evaluating, imitating, experimenting, mastering, practicing, responding, and receiving.

The Importance of the guidance Program
The importance of the guidance program lies in its reliance on guiding children and training them to improve the social interaction of stutterers.Assisting mothers in understanding their children's condition and providing them with psychological support.Helping mothers acquire knowledge on how to interact with their children and emphasizing the role of the family in assisting their stuttering children.The program can be utilized as a scientific model for guiding and training stuttering children.The need for stuttering children to have guidance and training programs to improve social interaction.

Techniques Used in the Program
Reinforcement, it can be defined as a behavioral process that involves strengthening behavior.The idea behind reinforcement is that a child tends to repeat behaviors that lead to positive outcomes or relieve them from negative consequences.Reinforcement can be categorized into two main types: positive reinforcement and negative reinforcement.Positive reinforcement refers to any action that leads to an increase in a specific behavior or its repetition and results in positive outcomes for the child.Negative reinforcement, on the other hand, involves the removal of an aversive stimulus, which strengthens the behavior.Reinforcement is considered one of the most important techniques and strategies used in behavior modification with children because it strengthens behavior and should be used in most objectives to achieve the best possible results.
Home Activities, these are a set of behavioral activities and patterns that are assigned after each session based on the session's goals.The counselor is responsible for implementing these activities at home.They are designed in a sequential manner to be implemented in stages.Home activities represent the tasks and responsibilities assigned to the guidance group member outside the sessions.They work towards achieving the guidance objectives in their respective types and transfer the positive impact they have learned, trained, and practiced to their family and social duties.
Dialogue and Discussion, this technique involves a collaborative group that selects a specific problem, determines its dimensions, analyzes its aspects, proposes solutions, and selects the solution to achieve effective and successful outcomes.
Role Play, role-play is one of the techniques that have a positive impact on children in general.It allows the child to freely assume any role, whether it is a realistic character like a student or an imaginary character like a parent.Through role-play, the progress of the child can be assessed based on the roles they perform.
Feedback, feedback involves providing information that allows improvement in motor or cognitive responses based on previous information or responses.
Modeling, modeling, or learning by example, is one of the behavioral techniques that can be used in conjunction with other techniques such as shaping, sequencing, and prompting.It involves modeling the desired response for the child, requiring the child's attention to the model used, and then imitating what is being done, such as imitating breathing techniques during inhalation and exhalation.
Rhythmic Speech, this method is based on the premise that the degree of stuttering decreases when the stutterer speaks rhythmically.A metronome is used to facilitate the pronunciation of each section with a specific rhythm.The metronome divides the passages into equal time intervals, and the speech segments are delivered according to the metronome's timing.This method divides the reading material into simple words that are read in harmony with the metronome, resulting in gradual progress in speech.
Relaxation, this method leads to relaxation of the body muscles and gradually reduces the effect of emotional activity, resulting in a sense of comfort and relief from physical and mental fatigue.At the same time, it helps with mental calmness and ease of fluent speech during relaxation.Then, the treatment is conducted through exercises in deep thinking and speaking with deep breathing.
Shadowing Therapy, shadowing therapy refers to the stutterer repeating the spoken words immediately after the therapist while focusing on the therapist's speech and paying attention to it.This repetition should occur with a very short time delay, so that the stutterer's speech acts as a shadow of the therapist's speech.

Contents of the training program sessions
The guidance program consists of 17 sessions, divided into two stages, each comprising several sessions as illustrates in Table 2.

Procedures
After preparing the theoretical framework and reviewing previous studies, the researcher explored language measures and selected the appropriate Arabic Language Assessment (prepared by Abu Huseibah) for the study sample, as well as diagnostic tools for stuttering, including Nahla El-Rafaie's scale.The researcher also reviewed social interaction measures and chose Asmaa El-Sersy's Social Interaction Scale, along with referencing other programs for guidance in formulating the study's tools.
The researcher developed the program based on the chosen tools and presented it to the supervisors, who evaluated it through the expertise of specialized professors in the field.After obtaining approval for the field application of the study, the researcher visited the chosen academy, where the conditions for sample selection were met, and the participants' scores were recorded.The academy's administration approved the field application, and the researcher observed their willingness to benefit as much as possible from the provided program.The cooperation of the staff was noticed, as they assisted in selecting the study sample and provided a suitable space for implementing the program sessions.
The researcher conducted a pilot study on the study's tools to ensure their validity and suitability for the study sample, considering their characteristics and diverse abilities, as well as the alignment of the tools with the study's objectives and the selection of the primary study sample of children.After confirming the validity of the tools and the program for implementation, the researcher conducted pre-test measurements to assess the level of equivalence between the experimental and control groups.
Upon completing the program sessions, the researcher conducted post-test measurements using the study's tools on both the control and experimental groups to test the research hypotheses and achieve the study's objectives.After one month of the post-test application, the researcher conducted follow-up measurements using the study's tools to ensure the continued effectiveness of the program's impact.After completing the program implementation and conducting post-test and follow-up measurements using the study's tools, the researcher performed statistical analysis of the collected data to test the research hypotheses.
Finally, the researcher analyzed and presented the results according to the research hypotheses, interpreting them in light of the theoretical framework and previous studies.The researcher also provided recommendations and suggestions based on the findings.

Data analysis
To achieve the study objectives and analyze the collected data, several appropriate statistical methods were used using the Statistical Package for the Social Sciences (SPSS).The data was coded and entered into the computer, and the following statistical methods were employed: 1) Checking the internal consistency of the scale by calculating the Pearson correlation coefficient between each domain and the total score of the scale, 2) Ensuring the scale's stability by calculating Cronbach's alpha coefficient, 3) Utilizing means and standard deviations for descriptive analysis of the sample responses, 4) Applying non-parametric statistical methods, such as the Mann-Whitney test, to compare independent groups (scores of the control group and experimental group), and 5) Employing the Wilcoxon test to compare related samples (pre-test, post-test, and follow-up scores) within the same group.

Results
Demographic data of the study sample, table 3 indicated that the chi-square values are not statistically significant for all variables.These results indicated that there are no statistically significant differences between the experimental and control groups in these variables (age, family socioeconomic status, stuttering severity), indicating the equivalence of the two groups in these variables.

Results of Hypotheses Tests
The researcher provides a description of the research sample, including the means and standard deviations of the experimental group's scores in the pre-test and post-test of the social interaction scale and the control group's scores in the post-test of the social interaction scale.The researcher also discusses the study's findings to verify the hypotheses' results.The first hypothesis stated that there are no statistically significant differences between the means of the two groups (experimental and control) on the social interaction scale among a sample of stuttering children in the primary stage, in favor of the experimental group.
To verify the validity of this hypothesis, the researcher used the Mann-Whitney test for independent samples as an alternative to a t-test for independent samples.This was due to the small sample size, which did not meet the assumption of distribution normality, a prerequisite for using a t-test.The following table presents the results of the statistical analysis for this hypothesis.
From Table 4, it can be observed that the average scores of the experimental group on the social interaction scale were M = 2.20 with a SD = .19,compared to the average scores of the control group on the social interaction scale, which were M = 1.63 with a SD = .19.Therefore, Table 5 indicates the presence of a significant difference at a level of .01 or less between the scores of the experimental and control groups in social interaction after implementing the guidance program.This supports the acceptance of the alternative hypothesis stating, "There are statistically significant differences between the mean ranks of the two groups (experimental and control) on the social interaction scale among a sample of elementary school stuttering children in favor of the experimental group".
The second hypothesis states that "There is no statistically significant increase in social interaction among the participants in the experimental group as measured by the post-test application of the social interaction scale".To test the validity of this hypothesis, the researcher employed the Wilcoxon Signed Ranks Test as an alternative to the paired samples t-test.The following table presents the results of the statistical analysis for this hypothesis.
As shown in Table 5, the mean score of the experimental group on the pre-test measure of social interaction was M = 1.85 with a SD = .27,compared to a M = 2.20 with a SD = .19on the post-test measure.Therefore, Table 6 indicates statistically significant differences in the performance of the experimental group on the pre-test and post-test measures of social interaction among a sample of elementary school children who stutter, with a significance value lower than the level of significance (p = .01).Based on these findings, the alternative hypothesis stating that "there is a statistically significant increase in social interaction among the participants in the experimental group as measured by the post-test application of the social interaction scale" can be accepted.
The third hypothesis stated, "There are no statistically significant differences between the mean ranks of the post-test and follow-up measurements in improving social interaction among the experimental group of elementary school stuttering children.To test the validity of this hypothesis, the researcher used the Wilcoxon Signed Ranks Test as an alternative to the Paired Samples T-Test, and Tables 5 presented the results of the statistical analysis for this hypothesis.
From Table 5, it is evident that the mean scores of the individuals in the experimental group on the post-test measurement of the social interaction scale were M = 2.20 with a SD = .18.Similarly, the mean scores of the individuals in the experimental group on the follow-up measurement of the social interaction scale were M = 2.19 with a SD = .18.Therefore, it is evident from Table 5 that there is no statistically significant difference in the performance of the experimental group on the post-test and follow-up measurements of social interaction among stuttering children in the elementary stage.The significance value was less than the significance level (p = .01).Based on the above, it can be concluded that the hypothesis stating the absence of statistically significant differences between the means of the two measurements (post-test and follow-up) in improving social interaction among stuttering children in the experimental group in the elementary stage can be accepted.

Discussion
The results indicated that there are statistically significant differences between the mean ranks of the two groups (experimental and control) on the social interaction scale among a sample of elementary school stuttering children in favor of the experimental group".The results also indicated statistically significant differences between the mean ranks of the pre-test and post-test in improving social interaction in a sample of elementary school children who stutter, in favor of the post-test.Moreover, the outcomes reveled that there are no statistically significant differences between the mean ranks of the post-test and follow-up measurements in improving social interaction among the experimental group of elementary school stuttering children.These results underscore the effectiveness of the guidance program in developing social interaction skills among a sample of elementary school stuttering children.
The findings of this study hold significant importance as they shed light on the positive impact of guidance programs on improving social interaction skills in children who stutter.Stuttering can have profound social and emotional consequences for these children, potentially leading to isolation and reduced self-esteem (Rani et al., 2022).The demonstrated effectiveness of guidance interventions suggests a promising avenue for early intervention and support.By enhancing social interaction skills, children who stutter can experience improved quality of life, increased self-confidence, and better integration into social contexts, potentially reducing the stigma associated with stuttering (Nang et al., 2018).These findings underscore the importance of addressing the psychosocial aspects of stuttering and provide valuable insights for educators, therapists, and caregivers.
These results align with a study conducted by El-Qadi (2016), which indicated that the social competence of children with stuttering improved after implementing a cognitivebehavioral guidance program.The study demonstrated the effectiveness of the cognitivebehavioral program, which is one of the modern guidance methods used to enhance social competence and was utilized in the current research.Furthermore, these findings are consistent with a study by Nabil (2020) which found that applying a guidance program led to a reduction in social anxiety among stuttering elementary school students.The study relied on a guidance program based on some positive psychology techniques to reduce social anxiety.Positive psychology techniques are considered effective guidance interventions that benefit both children and adults (Luthans et al., 2008).
Additionally, these results align with the research of Yates et al. ( 2018) which aimed to design a selective guidance program to reduce withdrawal behavior in stuttering elementary school students.The study's results showed the program's effectiveness in reducing withdrawal behavior, which is the opposite of social interaction.The study emphasized the importance of addressing social interaction in guidance programs.These results are also consistent with the findings of Law et al. (2013), who aimed to reduce withdrawal behavior in preschool children and understand its impact on stuttering through virtual reality therapy.The study confirmed the continued effectiveness of the program even after its discontinuation through follow-up measurements.The study relied on virtual reality therapy as a significant guidance intervention in any guidance program.
These results also align with the findings of Obiweluozo et al. (2021), which aimed to design a selective guidance program to reduce withdrawal behavior in elementary school students who stutter.The study's results showed the program's effectiveness in reducing withdrawal behavior, which is the opposite of social interaction.
Despite Yates et al. ( 2018) which addressed the effectiveness of a guidance program based on social story strategy in developing self-confidence and its impact on reducing stuttering in elementary school children, self-confidence is one of the fundamental components of social interaction.A child cannot be socially interactive without being confident, especially since self-confidence includes confidence in social situations (Goel, 2012).Social stories are one of the fundamental guidance components that can be used to increase social interactions, as they provide models and opportunities for children to express themselves, thereby increasing their language skills and social interactions.
Moreover, a connection can be made between the results of this study and the results of the pre-test and post-test comparison for the experimental group, which showed that there is a relationship between language skills and social interaction.The program's success in developing expressive language is reflected in the child's ability to engage in social interaction.Craig et al. (2021) have indicated the close relationship between social interaction and expressive language.
The researcher agrees that social interaction is strongly influenced by the improvement that occurred in expressive language.This allows the child to interact better, as they possess the language that helps them engage in social interactions.Having language skills, both receptive and expressive, supports a child's ability to interact, express themselves, and engage in social interactions.
The researcher also sought the opinions of mothers regarding the program and its role in developing social interaction through friendly meetings that preceded the sessions.Many mothers expressed their satisfaction with the program and its effectiveness.They noticed a

Table 1 .
Scoring system of the stuttering scale for students

Table 2 .
Structured guidance program for students with stuttering: stages and sessions.

Table 3 .
Demographic data of the respondents and the equivalence between the Experimental (N = 10) and Control (N = 10) Groups in Variables (Age, Family Socioeconomic Status, Stuttering Severity)

Table 4 .
Mean, standard deviation, and results of Mann Whitney test for the experimental (N = 10) and control (N = 10) groups on the post-test of the social interaction scale

Table 5 .
Mean, standard deviation, and results of Wilcoxon test of Experimental Group's (N = 10) Pre, Post, and Follow-up test of Social Interaction Scale