How can we help students use fluency enhancing strategies beyond the speech therapy room? Transferring greater fluency to a variety of settings can be a big challenge. If family and friends are reminded of this, they can partner with children, not blame them, when carryover of new speech skills requires problem-solving and patience.
A common tool for carryover is called the “hierarchy”. A hierarchy is simply a sequence of activities that become gradually more difficult. For example, a hierarchy may include first the use of choral speech, then immediate imitation, then delayed imitation, then elicited speech and finally, spontaneous speech. Factors that contribute to fluency breakdown can be similar across students, but I doubt there is a one-size-fits-all hierarchy. So, I view a hierarchy as a process, a sequence of talking tasks that changes week to week depending upon a student’s goal, attempts to change and lessons learned from each attempt. The process considers: When and with whom is the child courageous enough to attempt a small speech change? How can the experience help to design a subsequent attempt at change? In what ways can listeners be educated about and appreciated for supporting the child’s hard work?
Research on fluency offers some guidance. We know that “many variables – such as language, motor, cognitive, emotional, and genetic factors – interact in complex ways” in the development and appearance of disfluency.,  Gosh, this feels overwhelming. So let’s focus on language for now, because we also know that “The importance of the interactions of… language and speech motor processes, is supported by a wealth of data including behavioral findings that increases in utterance length and/or syntactic complexity are associated with the increased occurrence of disfluency.”  We know that language demand affects fluency. Where can family and friends find activities to do with children that control for language difficulty?
I should let you know that there are many commercially packaged therapy programs for stuttering therapy.  Most of them probably include a step-by-step program that includes a hierarchy of speech/language activities. One exception is Easy Talker , which does such an excellent job of presenting an overview of fluency therapy that I give it to my middle school students for free. I’ve spent a small fortune on products published specifically for speech therapy. However, the most fun and cost effective activities were those I created using books, games, and videos found in the clearance sections of book stores and discount outlets.
One day I found some simple story books called “Reading Rod Readers” for only one dollar each. They were orphans of a packaged, patented reading program published by ETA Cuisenaire.  The illustrations were colorful, the literacy goals explicit and the price was right so I scooped up about 15 of them. They became part of take-home lessons for my younger students. I mention this as one example of children’s literature that controls for linguistic difficulty and therefore offers families an opportunity for carryover practice. Such books provide language content at prescribed levels of difficulty. The Reading Rod Readers that I discovered have short language exercises at the end of each story to review vocabulary, grammar, comprehension, and writing skills. Such graduated reading programs, including the English Language Arts workbooks children are already using in school, may provide opportunities for fluency practice.
Some resources for language arts standards across age levels include:
· The American Speech Language Hearing Association 
· Resources for Understanding the Common Core State Standards
· Massachusetts Early Learning Guidelines for Infants and Toddlers
· Massachusetts Curriculum Frameworks for English Language Arts and Literacy
· World Class Instructional Design and Assessment WIDA
· Partnership for Assessment of Readiness for College and Careers
Let’s look at some research on language and fluency.
A recent study examined the oral motor coordination of children who stutter while saying sentences of different length and complexity. Here are some of the study’s conclusions. Note that the abbreviation CWS means ‘children who stutter’ and CTD refers to children who are developing in a typical way.
· “For syntactically simple sentences, CWS had significantly more variable articulatory coordination than CTD
· “…reduced coordinative stability within the speech motor system is likely a significant component of developmental stuttering…
· “…even during perceptually fluent speech production, the speech motor systems of some CWS are functioning with a reduced level of coordinative stability
· “Perhaps responses to sentence length and syntactic complexity differ between children who will persist in stuttering and children who will recover.”
Another recent study reviewed 170 different reports on the language skills of children who stutter. Through a rigorous selection process, 22 studies were chosen that adhered to specific research standards. Note that these findings are described by the abbreviation CWS for ‘children who stutter’ and CWNS for ‘children who do not stutter.’
· “…findings suggest that CWNS differ from CWS on several language abilities…CWNS outperformed CWS on seven of the 10 comparisons of language abilities
· “…findings, however, do not necessarily mean that, on average, the language development of CWS is ‘disordered’…but rather…CWS exhibit relatively consistent but subtle differences in language abilities when compared to their normally fluent peers
· “There is some question whether the aforementioned between-group differences in language abilities contribute to actual instances of stuttering…Be that as it may, one could speculate that when planning/formulating sentences, CWS may experience subtle but important difficulties in quickly and efficiently encoding and retrieving lexical items
· “…comprehensive speech-language assessment…may uncover concomitant speech-language concerns that need to be considered in the development of a comprehensive treatment plan for the child…assessment may indicate that CWS’s language abilities are subtly below those of CWNS even though they fall within the broad range of normal limits…coupled with environmental factors that can impede fluency…may constitute a ‘tipping point’ (Gladwell, 2000) where normally fluent speech becomes stuttered speech…”
The relationship between language and fluency is not straightforward. I am not recommending the purchase the Reading Rod Readers or any other specific program. E very student has unique needs. My idea to adapt language arts programs and children’s literature is because of ease of access, portability, affordability, a global interest in literacy, and the findings of recent research that link language demand with speech fluency. Books can be shared with siblings, care givers, extended family and friends as a consistent homework resource. Books transport easily to anywhere the child visits socially or needs to spend time waiting at siblings’ activities, restaurants or stores. Favorite books become family memorabilia shared across generations.  Digital natives may like to browse for apps to supplement the book experience. Families with special interests may enjoy finding books on favorite topics. Those lucky enough to live near a library can ask librarians for age- and grade-level literature. Ask your speech language pathologist what specific goal you and your child could generalize through the use of children’s literature.
 For example, Carrie Clark explains a traditional, hierarchical approach to articulation therapy in her excellent blog series at Podcast 5: Step by Step Guide for Teaching Your Child a New Sound, Speech and Language Kids, http://www.speechandlanguagekids.com/slk5-teach-a-new-sound/
 An example of multiple goals relevant to fluency therapy, including a brief linguistic hierarchy can be found in “Using the CALMS Model as a Thematic Approach to Fluency Therapy” by Elise Kaufman (2005) http://www.mnsu.edu/comdis/isad8/papers/kaufman8.html
 My own graphic of therapy is at https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxqdWRpdGh2YnV0bGVybWFjY2N8Z3g6N2I2NGFiZTQyNGYwMzc3Yg
 Megan K. MacPherson and Anne Smith (2013) Influences of Sentence Length and Syntactic Complexity on the Speech Motor Control of Children Who Stutter, Journal of Speech, Language, and Hearing Research, Vol. 56, 89-102, p. 89.
 Easy Talker: A Fluency Workbook for School-Age Children (13554) ISBN: 9781416404729
Barr guitar, PhD, Julie Reville, c 1997 now distributed by pro-ed
 This company now has a new name and new products: http://www.hand2mind.com/aboutus/press/ETACuisenaire-Rebranded-as-ETA-hand2mind.jsp
 For example, Flash Kids, A Division of Barnes & Noble, NY, NY; and, Spectrum Reading, Greensboro, NC. ; and, the Scholastic Store http://store.scholastic.com/webapp/wcs/stores/servlet/HomeView?storeId=10052&catalogId=10051
 Megan K. MacPherson and Anne Smith (2013), pp. 98-99.
 Ntourou, K., Conture, E.G., Lipsey, M.W (2011) Language Abilities of Children Who Stutter: A Meta-Analytical Review, American Journal of Speech-Language Pathology, Vol. 20, 163-179, quotes are taken from pp. 173-175.
 “Memories of a Bedtime Book Club: personal reflection on reading aloud and some book recommendations, by Dwight Garner, NY Times, April 24, 2013,