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School-Age Stuttering
Therapy: Starting with
Success
Owner, Stuttering Therapy Services/Seminars
Nina Reeves, M.S. CCC-SLP BCS-F
www.NinaReeves.com
ASHA Fellow
Nina@NinaReeves.com
Board Certified Specialist-Fluency
Co-Owner, Stuttering Therapy Resources, Inc.
Differences
www.StutteringTherapyResources.com
School-Focused & Private Practice SLP

Disclosures
• Financial
Stuttering Therapy Resources, Inc.
(Royalties, Intellectual Property, and Ownership Interest)
Speaker’s Package

• Non-financial
National Stuttering Association
(Volunteer consulting, advisory boards)

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Let’s Connect!
@StutteringTherapyResources

Place your screenshot here

www.StutteringTherapyResources.
com

StutteringTherapyResources @StutterResource

NINA DIRECT:
nina@ninareeves.com
StutteringTherapyResources
3

This Photo by Unknown Author is licensed under CC BY-SA-NC

Aligning
Expectations
4

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1. The Framework for Success

⊹ Realize…
× Reactions & Feelings are Stuttering still
not directly related to exists
surface stuttering behaviors under the surface

× What does this mean?

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Function
(observable stuttering
Stuttering
behaviors)
is like an
ICEBERG*
Sheehan, J. 1970

Reactions
(thoughts/ Environment
feelings/ (listener reactions/
behaviors)
perceptions/
Impact real-life speaking situations)
(on
communication
and quality of
life) ©Reeves, 2022

*Aligned with the ICF model (see Tichenor & Yaruss, 2019)

WAIT…Nina hasn’t given us that slide she ALWAYS gives us!

Update of Yaruss and Quesal’s (2004) representation of how the World Health Organization’s International Classification of Functioning, Disability and
Health (ICF) can be applied to stuttering. Copyright 2019 Seth E. Tichenor and J. Scott Yaruss.

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2. Essential Messages for All of Us

10

-Nina Reeves, 11/6/2020

Stuttering Verbal
is Diversity™

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People who Stutter Face these Everyday

12

Some Definitions to light our way

Ableism
“Valuing certain types of abilities and bodies over others. It often
includes discrimination and sterotyping.” (Kattari, 2020)

Neurodiversity
Differences are not deficits (coined by Singer, 1999).

13

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Some Definitions to light our way

Microaggressions
“Brief, everyday exchanges that send denigrating messages to certain
individuals because of their group membership.”
--Dr. Derald Wing Sue in Paludi, M.A., Managing Diversity in Today’s
Workplace. Praeger Publishing, 2012

Stigma
“A mark of shame or discredit” (Merriam Webster)
--Externalized/Internalized--

14

Micro-aggressions masking as
“help” q Not calling on student
q Don’t worry, in class
q You did so well! You
everybody stutters q Not having students
didn’t stutter once!
q You can be great in involved in their own
q Try again and use
the chorus instead of IEPs
your “tools”
taking that speaking q Leaving “doesn’t
q I hardly notice you
part present in class” on
stutter; it’s no big
q You just need a little IEP for WAY too long
deal.
confidence
q No need to be
q Don’t be scared, we q OTHERS YOU CAN
nervous, just relax
worked on this in THINK OF?
q If you just…
therapy
q It’s OK…take your
time and try again

15

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Taking this a bit further…

“Microaggressions are insidious, and their effects are toxic. …The
person, group, organization or the entire culture sending these
messages does so unconsciously and is [can be] unaware of their
effect.”

-Dr. Valerie Rein, (2019). Patriarchy Stress Disorder, Lioncrest

Publishing, Austin, TX.

16

Disability-Informed practices are

about changing…
⊹ Mindset ⊹ Model ⊹ Meaningfulness

When we know Our model, by THEN we can align

WHY we are taking what we say and our therapy with
steps away from what we do in enhancing the
”fixing” toward therapy is that student’s ease of
“aligning,” the stuttering is communication
WHATS, WHENS Okay…ALL of it. Not and decrease the
and HOWS of just 10% or “little stigma (internal
therapy are much ones” but all the and external)
easier stutters. impact on their
quality of life.

17

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No matter how we got here...

“You can’t solve a problem with the ways of thinking
that created it.” – Albert Einstein

Ø A SEA-CHANGE must occur…because …

“we can’t script ourselves out of ableism or

microaggressions!”

18

3. Starting Points that Make a

Difference

19

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Enhancing & Updating Our Own Knowledge

Finish this sentence - Neurology

“The only consistent System

thing
about stuttering is that it
is…” Variability

Demystifying Stuttering (Scott Yaruss)

through SCIENCE and FACT
20

⊹ Experiential Understanding
ü What #stuttervoices are you following on SM? “If you have met ONE
person who stutters,
ü What podcasts of those who stutter are you then you have met
ONE person who
listening to? stutters!”
ü When have you been to an NSA, SAY, FRIENDS, -NSA Zeitgeist

(or other) support organization event?

ü What YouTubes (please vett them) Ted Talks,
documentaries about the lived experiences of those
who stutter have you watched?

21

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Stop Focusing on Fluency

Do you write “% of What is the % How is the child

fluency” in your “achieving” that
goals? chosen? %tage?
• WHY? • WHY? • Manage?
• Is this promoting • Who says? Spontaneous?
masking? Avoidance?

22

What can we do/How can we shift?

*Stop Focusing on *Be Aware of Messages *Meet students where
Fluency! they are
-Ours
*Enhance our own -Child’s *Be an ally and create
knowledge (updated) allies - - not FIXERS
-Caregivers
*Help everyone -Educators *Discuss societal
understand the “big stigmas, as applicable &
-Others
picture” work to handle them
(we just did a whole section
on this!)

23

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Let’s Take a moment

•Interactive
Goal-Forming

25

Meet your Ask Your Students What Their Are!

students
where
THEY ARE!

Therapeutic Alliance: ©Nina Reeves,

Therapy not AT the child, but WITH the child in press for STR
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Writing Goals
JUST SOME SAMPLES

27

Thoughts on Goals
Not every child needs every goal!
Not all goals presented at the same time
No “SET” order to goals
Each “subset” of goals works together
ABCs
NO “levels of fluency” are to be included… (pop quiz: “why?”)

28

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IS THERE A PRESENCE OF
BELIEFS AND/OR OF COPING
PERSONAL REACTIONS (THOUGHTS,
FACTORS/REACTIONS FEELINGS, BEHAVIORS)
THAT ARE LESS HELPFUL IN
THE LONG TERM?

29

Example concepts: Personal Factors/Reaction

Reducing anxiety, shame, avoidance and/or struggle via age appropriate:

• Knowledge of speech anatomy/physiology
• Knowledge of speech and stuttering
• Identification of and exploring stuttering
• Desensitization activities (to decrease fear of stuttering and listener reactions as well
as to increase communicative confidence)
• Cognitive/Affective exploration, and management through self-disclosure, openness,
and increased acceptance
• Self-awareness of avoidance and avoidance reduction over time
NOT a
exhaus n
tive list
! ©Nina Reeves 2019

30

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SAMPLE Goals: Personal Factors/Reactions

Within __ instructional weeks, the
student will demonstrate age- Within __ instructional weeks, the
student will demonstrate age-
appropriate knowledge of the speaking appropriate knowledge of the speaking
process and stuttering by using his process and stuttering by using his
speech journal to document at least speech journal to document at least
_____ key facts about each of these _____ key facts about each of these
areas: speech anatomy/physiology, areas: speech anatomy/physiology,
disorder of stuttering, and successful
disorder of stuttering, and successful people who stutter.
people who stutter.

31

Student’s ability to navigate

stuttering in various
settings and within the
Environment
context of the knowledge
level, perceptions, and
reactions of others

32

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N OT
an e
xh a
list! ustive
Example concepts: Environment

• Educating others about speech and stuttering, and communication

• Increasing self-advocacy
• Developing and maintaining appropriate support systems
• Handling listener reactions
• Handling bullying and inquiries
• Reducing negative response potential through education, awareness
and acceptance

©Nina Reeves 2019

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SAMPLE Goals: Environment

Within 36 instructional Within 36 instructional Within 36 instructional
weeks, the student will weeks, the student will weeks, the student will
demonstrate age- demonstrate ability to inform his caregivers about
appropriate knowledge
of the speaking process
respond appropriately to the process of stuttering
and stuttering by inquiries about therapy by reviewing at
teaching clinician- and speech/stuttering as well least __% of speech therapy
self-selected key facts as to bullying behaviors sessions, using journal
to at least ___ and negative listener
entries as a guide.
significant others in his reactions by creating at
environment as least __ problem solving Documentation will include
documented in journal scenarios as documented signed journal entries,
entries, clinician data, by journal entries, self- clinician data, and/or
and parent/teacher
reports.
reports and caregiver reports.
observations/reports of
significant others.

34

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Interruptions in the
forward flow of
Function speech
Feeling of “stuckness”

35

ex N O T
ha a
u n
lis stiv
t! e

Example concepts: Function

• Addressing frequency and significance of stuttering

• Navigating/decreasing physical tension/struggle in
communication
• Enhancing speech fluency/flow
• Decreasing avoidance/escape behaviors
©Nina Reeves 2019

36

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Sample Goals: Function

Within __ instructional weeks, and
Over a period of ___ consecutive within ___ clinician data probes, the
instructional days, the student will student will demonstrate the ability to
demonstrate the ability to use a modify physical tension during a
moment of stuttering by exhibiting
fluency enhancing technique of his independent use of self-chosen
choosing in ___ classroom stuttering management techniques in
situations as reported by the ___ of ____ attempts along a hierarchy
student and/or teacher and of linguistic complexity during
documented by checklists and structured therapy activities.
Documentation shall include clinician
targeted observations. data and/or self reports.

©Nina Reeves 2019

37

(Activity
Impact Limitation/Participation
Restriction)

38

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N Example concepts: Impact

ex h O T a n
aus
list tive • Increase student’s ability to communicate effectively in a variety of
!

settings
• Increase participation in activities that involve verbal interactions
across settings
• Decrease overall impact of stuttering on student’s perceived quality
of life
• Increase student’s functional communication skills
• Increase student’s comfort, spontaneity, naturalness, and
satisfaction in real-life (functional) communication
©Nina Reeves 2019

39

SAMPLE Goals: Impact

Over ___ consecutive days in a
Over ___ consecutive days in a classroom classroom setting and over ___
setting and over __ clinician data probes, clinician data probes, the student will
the student will demonstrate the ability independently handle self-identified
verbal time pressure situations by
to participate in classroom discussions by effectively communicating his message
volunteering to answer questions in class in ___ of ___ speaking opportunities.
at least ___ times per day as measured This will be documented by student
by teacher observations/charting and self-reports and teacher reports.
student journal entries.

©Nina Reeves 2019

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Intervention: Environment
(Others’ Understanding of & Reactions to Stuttering)

Ahh…the environment! ☺
Without a doubt, if we miss THIS piece of the puzzle, no
matter what we do in therapy, the child has a decreased
opportunity for long-term progress
Dr. Phil! “contaminate or contribute”
What do they NEED? Let’s Ask THEM…
CHILD can be the “teacher/advocate”

41

YES! Discuss THIS

Update of Yaruss and Quesal’s (2004) representation of how the World Health Organization’s International Classification of Functioning, Disability and
Health (ICF) can be applied to stuttering. Copyright 2019 Seth E. Tichenor and J. Scott Yaruss.

43

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Top 8 things NOT to say to a person who

stutters…
That everyone says to people who stutter

“Stop Think about what

Slow Down, you want to say,
Start Over, Just…Relax,

Take a Deep Breath, Everybody Stutters,

Use your tools!”

44

“If you have met ONE caregiver of a child who stutters, then you
have met ONE caregiver of child who stutters!”

Help Caregivers Identify their…

Perceptions
Knowledge levels
Belief systems
Expectations
Messages

45

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How to involve stakeholders

Explore Stuttering • Discuss: thoughts and
feelings drive behavior
Build knowledge • No right or wrong, just
Watch videos “tune-in”
Discuss Iceberg • Explore interaction of
Discuss child’s iceberg caregiver and child

46

Peers and Siblings

Increase knowledge & Classroom presentations
understanding Resources:
1-1 Child as own Stuttering
advocate Bullying & Teasing
Include in therapy It IS our role!
How to help

47

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Specific to
Teachers
They oversee MUCH of the child’s
day-to-day communication
environment
Find out what they know
Find out what they are doing/saying

48

Collaborating with Teachers

Don’t assume they know more about stuttering than the
average person on the street
Have child be the “expert”
Small changes make a big difference
What about timed reading tests and presentatons
Making plans for classroom participation that don’t diminish
the child’s abilities

49

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Some Language For Caregivers AND

Students
“How are you “How is that for “How did that
feeling about that?” you?” impact you?

“Do you have some

Let’s get curious “That must have notions about that
about…” been rough…”
for yourself?”

“It seems as though

you have been “I’ve been hearing…”
thinking about it…”

50

For Caregivers AND Students

“Do you think

“What’s that “What’s your “What is the
your measures
going to look like measure of criteria for
will change over
for you?” success?” ‘doing well?’”
time?”

51

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Supporting Caregivers:
Giving time for…
Information must
Acknowledging
be absorbed over
painful feelings
time

Wondering about
Denial as a crisis
future
of confidence
implications

52

HTTPS://WESTUTTER.ORG/WP-CONTENT/UPLOADS/ALLY-2019.PDF

53

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Voices of Those who

Stutter Share…
Listening for the REAL needs

54

What SLPs Should Know…from the perspective of students who stutter

55

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Student Say…

(Let’s have Group Time)

56

Peers/Siblings/Others

Grouping Support
with others organizations
who stutterr and Dealing with
connections bullying

57

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Helping Students Prepare for Listener Reactions

©Nina Reeves, in press for STR

58

Before we jump into “strategies”

Let’s review the FOUNDATIONAL KNOWLEDGE

and SKILLS that are essential for successful
therapy outcomes.

60

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Let’s Consider: Some of the basics

Foundational Knowledge and Skills –
Comprehensive Exploring speech
History and Facts and False
Assessment Exploring Stuttering
Goal Choice and Exploring Acceptance
Therapy Planning And more…

61

Let’s Consider: More of the basics

Learning about Communication
Desensitization
Advocacy
Collaboration with Stakeholders
Carryover
Monitor/Dismissal

62

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BIG Concept
✅Timing is everything!

WHEN to present concepts and

activities depends on…
Age, level of awareness, cognitive
abilities, readiness and other
aspects that only YOU will know as
you get to know the child

63

Where Do the
Strategies Fit In?

64

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Use the ICF to

remind us:
Strategies are only ONE
aspect of stuttering
therapy
65

Focus on
Communication-
Not Fluency
Strategies are to help people who stutter communicate in
easier ways with less tension, avoidance and struggle

66

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Any strategy introduced with

the intent to help children “not
stutter” will likely become an
avoidance, and contribute to
concealment and
masking…leading to increased
negative impact on
communication and
quality of life.
67

Let’s do a brief overview of strategies

◈ It sometimes helps to categorize them into 3

areas that ALL overlap with each other in a
synergistic way
◈General communication skills
◈Fluency enhancing strategies
◈Handling stuttering strategies

68

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Communication Strategies for

School-Age Stuttering Therapy
Communication Fluency Navigating Stuttering
Skills
Enhancing Strategies
Including…
Strategies
Handling Time Pullout
Pressure Light Contact Cancellation
Turn-Taking Easy Onset Preparatory Set
Eye Contact (carefully) Pausing/Phrasing Voluntary Stuttering*
[Pausing/Phrasing]

69

SAMPLE
Strategy Map

©Nina Reeves

71

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Next few slides are for your

reference.
NOT RULES: Concepts to consider…

72

“Techniques:” Consider the Following…

1. Start with foundational knowledge and skills that the
student has not learned or does not remember!
Students need to understand how speech is made. They
also need to know and understand the disorder of
stuttering (to the extent they can given their age, level
of awareness, cognitive abilities and readiness/impact).

73

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“Techniques:” Consider the Following…

2.Map out the array of speech handling
techniques
Not every child needs every strategy (or at
least not all at once), but it is imperative that
they understand the breadth of the
possibilities for navigating communication in
the long term.

74

“Techniques:” Consider the Following…

3. Always integrate “types” of tools, as
needed.
This means stuttering modification, fluency
enhancing, and communication skill
techniques are ALL a part of the process.

75

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Techniques: Consider the Following…

4. Integration takes clinical intuition and

common sense
True integration includes not feeling the need
to do “all stuttering modification,” and then
moving to “all fluency enhancing tools.” It
also means that we don’t need to wait until a
child has mastery of a specific skill before
“weaving in” another technique.

76

Techniques: Consider the Following…

5. Techniques are learned and explored at

word/phrase levels and then introduced
and practiced at increasing levels of
linguistic complexity; along with increasing
levels of difficulty in the child’s created
situational hierarchies.

77

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Types of Techniques: These are

INTEGRATED in the process of therapy
Stuttering Modification
*For children who “stutter enough” that they could
(eventually) identify a moment of stuttering as it is
occurring.
*For children who are sensitive to and/or avoid
stuttering
* These techniques are practiced with “fake stuttering”
at first, and then practiced in real instances of stuttering,
as the child increases his ability to identify his own
stuttering moments.

78

Fluency Enhancing
*For children who don’t avoid
stuttering and are not overly sensitive
to stuttered moments
*Also for children who exhibit only
mild stuttering behaviors and little to
no struggle and/or no avoidance
behaviors
79

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Communication Skills
*Not every child will need help in this area.
However, it is important to understand
that enhancing communication skills such
as eye contact, turn taking, initiating
conversations, and handling time pressure
can be helpful to children who stutter

80

Let’s Explore Some

Stuttering!
Repetitions
Word
Syllable
Sound
Prolongations
Blocks Without a doubt, the MOST important
thing you can do to improve your
Play with stuttering:
therapeutic alliance with a person who
Clusters (of stuttering beh)
stutters, is to GET INTO
Secondary behaviors
STUTTERING!
82

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Set up the learning process

by introducing the technique:
● Visual cues and analogies can help
What it is children understand techniques
How it relates to ● SLP models the technique (many, many
communication and times) while talking about what is
stuttering
The steps of happening in their own speech
executing the ● SLP leads the child in a discussion about it
technique to discover with the child (Williams, 1971)
Why it is important
and how it can help rather than teach the technique.
● Technique is learned through a hierarchy
of difficulty, while manipulating variables
to increase success and enhance
carryover
83

***A note about Communication Skills***

Communication skills are an Eye Contact
integral part of the therapy Turn Taking
process for many children who
stutter. Though we do not have Handling Time Pressure
time to go over this in an For more information, these
exhaustive manner, I would like concepts are presented
to highlight the following multiple times in the
literature, including Chapter
concepts here: 9 of our book. (Reardon-
Reeves & Yaruss, 2013).

84

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Handling Time Pressure

(Gregory ‘03 and others)

Discuss Demonstrate/Discover
Gives time for talking, processing, Asking and answering questions (or
thinking, using strategies having a discussion) and then
“Taking charge” of the rate of waiting for 1-2 seconds before
communication exchange continuing

Using Shapiro’s
Concepts
85

Taking Turns -Starkweather, Gregory & Campbell and others

Demonstrate/Discover
Discuss Initiate structured conversations and
allow silence to happen between
Decreases time pressure conversational partner turns
and allows everyone a (May need to cue students to wait, at
first)
chance for contributing to Do some interruptions on purpose and
the conversation apologize
May bring in pragmatic skill of times
and ways to interrupt appropriately
Be CERTAIN to include family members
and peers

86

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Eye Contact
Discuss
(What came first, the chicken or the egg?)
Shows interest in speaker/listener
Illustrates increased comfort in speaking

Demonstrate/Discover
Role play good and poor eye contact in a fun and
interactive way and then ask the child what they
thought of the differences between them
We can make this part of how we do structured
conversations, but no one is to “police” the child’s eye
contact

87

Managing Stuttering:
Strategies to “ease out” DECREASING

of stutters
Struggle

These strategies
Cancellation are not about
fluency, it’s about
Pull-Out decreased in
struggle/tension)
Preparatory Set

88

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Cancellation -Van Riper, 73

Reducing tension in speech after a moment of stuttering has

occurred
How to:
After noticing a moment of stuttering, pause (for
long enough to analyze where stuttering
occurred),
Release tension in speech muscles
Say the stuttered word again utilizing a smooth
form of “easier stuttering “or an easy onset
89

-Van Riper, 73 Pull-Out

Handling stuttering during the moment
Making the involuntary into voluntary (Sheehan)

How to:
During “catching” the moment, tolerate and stay in the
tension,
analyze tension placement
“ease out” of stutter by decreasing speech muscle
tension a little bit at a time as you say the rest of the
word

Let’s do it together!
90

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Preparatory Set
NOTE: Not all students need this technique!
This is for people who stutter who ANTICIPATE
moments of stuttering (something that is actually not
a good thing)
I am not going to go into depth on this tool, but will
refer you to some reading on it IF and WHEN you
consider it for a student.
Several Resources for further information:
Van Riper ‘73, School Age Stuttering: A Practical
Guide ‘13, Easy Does it for Fluency ‘98, Guitar ’06,
Ramig & Dodge ‘10
91

Preparatory Set - 2
Handling stuttering as a moment begins
NOTE: Not all students need this technique! This is for
people who stutter who anticipate moments of stuttering
How to:
“Feeling” a moment coming (physically)
“Thinking” a moment is coming (anticipation)
Begin the word or phrase with an easy onset or “easy”
voluntary stutter
Continue speaking while moving slowly and easily through the rest of the word or phrase

ONLY person who stutters knows when to use

preparatory sets
Decreases avoidance and increases feeling of taking charge
of communication
Let’s do it together!
92

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An island unto itself

Voluntary Stuttering IS considered part
of stuttering modification in the
literature.
It is important to NOTE that Voluntary
Stuttering has two main reasons for
existing:
1. Fear reduction/desensitization!
2. Deceasing physical tension

93

Voluntary Stuttering-2
Learning how to stutter In essence, people who
differently by stuttering on stutter are
purpose doing what they fear the
Voluntary Stuttering has two most on their own
main reasons for existing: terms
1. Fear How to:
reduction/desensitization, and
Use a purposeful “easy
2. Decreasing physical tension stutter” on a word

94

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Voluntary Stuttering -3
(Van Riper, 72, Johnson, 68, Sheehan, 70)

Take turns putting moments of easy stuttering into

speech during structured activities and then in more
“real life”
speaking situations along a hierarchy of difficulty.
Maintain eye contact during voluntary stutters
Learning to “play” with stuttering and teaching
caregivers and others to stutter
Voluntary stuttering decreases avoidance of stuttering
Let’s do it together!
95

Managing Speech:
Strategies to “ease into”
speech
Light Articulatory Contacts

Easy Onsets of Phonation Enhancing Flow of Speech

Pausing/Phrasing

96

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Light Articulatory Contacts

(e.g., Runyan & Runyan, 93)

Reduces tension while developing a “lighter touch”

of speech mechanism parts
Set it up:
Following discussion of speech machine, and in conjunction with easy onsets,
Discuss and demonstrate tight and loose muscles in general, and then with
speech articulators (Dell, 2000)
Clinician and child use contrasts of muscular tension during talking to feel
what “light” touches are like and how they can help our speech
How to:
As speech production begins, child touches parts of speech machine together
lightly
Continue to speak with slightly reduced rate
Let’s do it together!
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Easy Onsets (e.g., Cooper & Cooper, 03 )

Opportunity to initiate first sounds of a word with and easier, relaxed (decreased
tension) approach to phonation

Indirectly reduces rate and adds smoother transitions between words in phrases
How to:
Easing into first sounds of words and phrases with less speech muscle tension
Gradually move into the rest of the sentence using your regular speech
Learning in a s-l-o-w stretch at first, and progressing to more normal sounding
speech as progress is made

Focus on the FEELing, not the sound

Let’s do it together!
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Pausing/Phrasing (e.g., Nielson & Andrews, Conture ’01)

Phrases are normal groups of words in a message dictated by syntax

Pauses are short breaks between phrases
How to:
Speak normally
At the end of a phrase, take a short pause that is long enough to release
physical tension
Creates normal/natural breath support

Allows decreased physical tension and enhanced formulation time

Indirectly decreases rate of communication (not artificially
decreasing rate of speech)
No “deep breaths” allowed...keep it natural!
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Let’s do it together!

Path to Success with “Strategies”

Know
they Carryover
Prerequisite
Confirm are requires
s are
the Intent systematic
essential NOT
hierarchies
easy!

Why are you doing what you are doing?

Do the child & caregivers understand?

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For selected
resources and
references…
Please email me directly and
reference THIS presentation:
Cullowhee - 4 hour

nina@ninareeves.com

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Tanti Grazie!

Any questions?
You can find me at:
nina@ninareeves.com
@StutteringTherapyResources

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