Q: My 6-year-old male client drools has language and cognitive problems but no articulation problems, but he drools a lot. I know of your dropper technique. Should I use the dropper with him or just tell him to swallow every 90 seconds?
As I am sure you know, a technique is just a technique. Therapy is all about finding out if a certain technique works for a certain client. Therefore in regard to this specific technique, if he can swallow on demand, you don’t need the dropper. But if he can’t, you do.
Posted in Oral Motor.
Tagged with Drooling, Oral Motor, Oral-Tactile.
By Pam M
– May 18, 2013
Q: I am very frustrated working in the public school. I am forced to see very low functioning children 2-4 times per week, and even with this much therapy they are not progressing in vocabulary, phonemes, nothing. Am I doing something wrong?
Let me be very blunt here.
Warning! Those of you who don’t know me need to be warned that I do not speak with political correctness. I find it to be an imposition on our freedom of speech and therefore a violation of the constitution. I will not be held responsible for anyone who is offended by the following comments…
Again… Let me be very blunt here.
I believe that we need a change of school culture. We are seeing children with very low cognitive skills too much and students with mild speech problems and average intelligence or better too little. I have a long-term goal to change this back to the common sense procedures that SLPs used to use.
I am teaching today’s SLPs to begin to repeat to their teams the following concept: “A child can speak only as well as he understands.”
In general––
- Kids whose cognition is below the 6-month level should be saying no words and they should be making very few sounds. They should not even be babbling. They should have no “communicative intent” and should not be able to use signs, gestures, or pictures for any meaningful purpose. They should be encouraged to make sound, any sound.
- Kids whose cognition is at the 6-10 month level are at the stage of “illocution.” This is still a pre-language level. They should have no concept of word and thus they should be saying no words. They should only be making some spontaneous sound, and a few babbling-type noises. Their sounds should be becoming regular, consistent, and repetitive however. In other words, they should have a few sounds that they say to the exclusion of everything else. They should be getting good at repeating these sounds and every sound they make should be celebrated.
- Kids who function at 10-14 months of age should be saying one single word only. But because these kids usually have dysarthria too (due to neuromuscular disorder) they probably still have no words. These children may have a word or two that pops out occasionally but never on demand. They should be in situations in which it is likely that they will say the word they have. For example, if the child can say “keys” he should be encouraged to say keys many times per day. Each time he spontaneously produces the word should be celebrated. “Yeah! David is learning how to say keys!”
- Kids who function at the 14-18 month cognitive level should be saying 1-10 words at best. But because these kids usually have dysarthria too (due to neuromuscular disorder) they probably still have no words. They should be using gestures, facial expressions, objects, and pictures, and some vocalizations to begin to communicate their wants and needs. They should not be able to practice words on demand, but words should be popping out here and there. These should be celebrated whenever they occur.
- Kids who function at the 18–24 month level should be saying 10-25 words (probably fewer), and up to 50 words at the very best. But because these kids usually have dysarthria too (due to neuromuscular disorder) they probably still have very few words. They should be using these words consistently for communication purposes. The words probably will be very hard to understand due to the dysarthria. They probably will lock in on an incorrect way to say a word and they will say it that way for many years. For example, perhaps the child’s name is Kristie, and she calls herself “Tee-Tee.” I would not expect this to change for a very long time.
Kids with very low cognition should not been seen multiple times per week. That is called “Babysitting.” They do not change fast enough to warrant that much therapy. Instead, we should be acting as consultants to the team about how to stimulate for a few basic communication routines that are functional for the child at home and at school. It only takes one time per month to do this, at most.
We need school psychologists to step up to the plate again and put cognitive ages on these kids. In lieu of this information, we need to help the parents and team understand the child’s cognition. We can help them understand the developmental level of the child’s play, his ability to understand vocabulary words, his ability to follow directions, and his ability to answer questions (with word, sound, gesture, sign, or picture).
Again: A child can speak only as well as he understands.
Add to that: A child usually says far less that he understands.
One final note: We should not be assigning children with low cognition and neuromuscular disorder with the diagnosis of “apraxia.” A child with low cognition and neuromuscular has “mental retardation” and “dysarthria.” Three-to-five days per week of therapy will not change his IQ and therefore it will not change his verbal output.
Posted in Apraxia and Dysarthria, Articulation.
Tagged with Apraxia, Becoming Verbal, Dysarthria, Evaluation, Goals & IEP's, In Therapy, Language Development, Phonological Development, Preschoolers.
By Pam M
– May 13, 2013
Q: I have heard you complain about research in the area of apraxia. Why do you think it is so poor?
Think about this: APRAXIA occurs in the ABSENCE of neuromuscular disorder while DYSARTHRIA occurs in the PRESENCE of neuromuscular disorder.
Now think about this: ALL the research in speech that has been done on apraxic kids since the beginning of time has been done without any assessment of their muscle tone. Researchers have just been assuming that tone is okay. Researchers are taking all kids with very severe artic/phono problems and calling them apraxic without ANY evaluation of their tone.
Therefore all the apraxia research done from the beginning of time through today should be thrown out and we should start over. Researchers in the area of apraxia should be required to have an assessment of client tone done by an OT/PT to qualify the subjects for their research projects. Those with hypertonicity or hypotonicity should be tossed out.
Posted in Apraxia and Dysarthria, Evidence-Based Practice.
Tagged with Apraxia, Dysarthria, EBP, Evaluation.
By Pam M
– May 8, 2013
Q: What would to do in an evaluation to differentiate between CAS and dysarthia? Specifically would you rule out muscle weakness?
The definitions of apraxia and dysarthria speak for themselves––
- APRAXIA is a motor speech disorder that occurs in the ABSENCE of neuromuscular problems. It is a problem in the perception of movement, and therefore it causes problems in planning movement. The result is severe articulation and phonological deficit.
- DYSARTHRIA is a motor speech disorder that occurs in the PRESENCE of neuromuscular problems. It is a problem in the execution of movement. The result is severe articulation and phonological deficit.
Posted in Apraxia and Dysarthria.
Tagged with Apraxia, Down Syndrome, Dysarthria, Evaluation.
By Pam M
– May 2, 2013
Q: I have a 9-year-old male client with Asperger’s who sucks him thumb. I read your book How to Stop Thumbsucking and have had success with other children, but not this one. Advice?
I have never faced this but I think this all boils down to what makes sense for him. It seems that the only things that get through to these clients are the things they can plug into their own logic. If you can figure out what makes ideas get through to him, and if you could steer conversation toward that, then I think you could work out a plan.
For example, if he is rule-bound, perhaps you could teach him a rule: “No children above the age of X suck fingers or thumbs.” Then it would be logical for him to stop because he is beyond that age. Perhaps the rule should be embedded into a series of general 5-10 rules about appropriate behavior in the classroom, at home, etc.
I worked with one very rigid four-year-old who was like this. When he went to his 3-year dental checkup he overheard his dentist say that thumb sucking was not bad. So for the next year the boy insisted that he should be left alone to suck his thumb. But then the dentist reversed this opinion at the boy’s four-year checkup. The doc mentioned that the boy had to stop because it was beginning to ruin his occlusion and the boy quit the next day.
You never know what will cause a child to comprehend and accept a new idea, especially when they have Autism or Asperger’s Syndrome 
Posted in Oral Motor.
Tagged with Autism, Oral Habits, Oral Motor, Oral-Tactile, Thumb Sucking.
By Pam M
– April 29, 2013
Q: My client has low tone and many deviant phonological processes. Is this common? Does this mean he has dysarthria? How should my treatment look different from traditional articulation or phonological therapy?
Yes! If the child has hypotonia then this is dysarthria. Whenever you have muscle tone problems of a global nature, then dysarthria is the diagnosis. Dysarthria is a speech movement problem that is the result of muscle tone disturbance. (See definitions below)
It is common for children with low muscle tone to have speech movement problems, but the specific phonetic and phonological errors will be specific to the child.
In general all kids with severe speech disorders have the same basic problems to various degrees–– final consonant deletion, initial consonant deletion, cluster reduction, cluster deletion, prevocalic voicing, fronting and/or backing, stopping, stridency deletion, syllable deletion, etc. Dysarthric kids usually have vowel distortion, and both apraxic and dysarthric kids usually have an incomplete vowel set. Diphthongs often are shorted into single vowels and the schwa is over-used in both groups. Distortion of phonemes and the supersegmentals is the hallmark of dysarthria.
A client with a motor speech disorder needs to be viewed from all four speech movement subsystems–– Respiration, phonation, resonation, and articulation (jaw, lip, and tongue movement). His are not simple phoneme errors. His phoneme errors are the result of problems in the four movement subsystems.
In terms of therapy, the short and simple answer is that you work on phonemes and phonological processes just like you would for any other client, but you add work specifically to get the child to understand how his body works to inhale, exhale, prolong exhalation, turn his voice on and off, make sound oral and nasal, and move his jaw lips, and tongue in better patterns of mobility and stability. That is why therapists use blow toys, mirrors, tubes, and so forth. In the case of dysarthria, exaggeration is a key piece of treatment. Over-pronunciation is a key to clarity.
Classic Definitions of Dysarthria
“Dysarthria comprises a group of speech disorders resulting from disturbances in muscular control. Because there has been damage to the central or peripheral nervous system resulting in some degree of weakness, slowness, incoordination, or altered muscle tone.”
From: Darley, F. L., & Aronson, A. E., & Brown, J. R. (1975) Motor Speech Disorders
. Philadelphia: W. B. Saunders.
“A generic label for a group of motor speech disorders caused by weakness, paralysis, slowness, incoordination, or sensory loss in the muscle groups responsible for speech”
From: Brookshire, R. H. (1992). Introduction to Neurogenic Communication Disorders
. St. Louis: Mosby.
Posted in Apraxia and Dysarthria, Articulation, Oral Motor.
Tagged with Book Recommendations, Dysarthria, Evaluation, Oral Motor, Tools for Therapy, Toys.
By Pam M
– April 24, 2013
Q: My client can produce only the schwa––“Uh.” He is 3-years-old and pretty smart. But he cannot imitate any consonants or vowels at all. What can I do?
This is what I would be thinking about–––
Teach him to prolong the sound he has––the schwa. And teach him to tolerate your hands on his jaw. Once he can prolong his schwa and tolerate your hands, move his jaw up-and-down while he is vocalizing.
If he can prolong his sound while you are moving his jaw up-and-down, then you will have created a vowel babbling sequence. Research shows that babies babble with vowels before they babble with CVs, and that might be what this kid needs.
The jaw moving up-and-down while vocalizing is called a movement “frame.” Once the frame is developed, then it should be played with, rehearsed, stabilized.
MacNeilage (1998) proposed that “cycles of mandibular oscillation” underlie the basic up-and-down jaw movement patterns of babbling and early speech. This up-and-down pattern is called a “frame” and it was postulated that the frame evolves from chewing.
Therefore chewing activities would be appropriate here too.
The jaw going up-and-down in this frame will make the schwa turn into several different vowels, and you are on your way. You have taught him how to Vowel Babble.
Next, teach him to move the jaw up more firmly. If that happens, consonants will emerge. It is the jaw banging upward within the up-and-down movement frame that causes the anterior consonants to emerge––P, B, M, W, T, D, N, L.
Reference
- MacNeilage, P. F. (1998). The frame/content theory of evolution of speech production. Behavioral and Brain Sciences, 21, p. 499-546.
Posted in Articulation, Oral Motor.
Tagged with Birth to Three, Intelligibility, Jaw, Phonological Development, Vowels.
By Pam M
– April 19, 2013
Q: I am using your eyedropper method for a non-verbal 5-year-old girl in the trainable cognitive level. She also has a neuromuscular disorder. We do it for 15 minutes and then she gets bored. Do you have advice?
This is not the type of activity that you do for 15 minutes. Weave it in-and-out of other SL activities you are doing. Use the dropper procedure every 90 seconds while she is otherwise engaged. You want to stimulate her to swallow every 90 seconds while she is doing other things.
Posted in Oral Motor.
Tagged with Drooling, Oral Habits, Oral Motor.
By Pam M
– April 14, 2013
Q: Is there an age constraint for starting self-awareness techniques for carryover? My son is 6 years old.
Carryover ideas should start right from the first day of therapy, no matter the client’s age. That means that you are planning for and thinking about and stimulating for carryover from the first day, and you are dropping in ideas here and there.
For example, let’s say your child is learning to keep his tongue in his mouth. He can work on that during a therapy session, and he also can be encouraged to keep his tongue in “while we are driving to the store.” That way you are taking his therapy ideas right into his “real world.”
Posted in Articulation.
Tagged with Carryover, In Therapy.
By Pam M
– April 9, 2013
Q: What type of articulation therapy should be provided for children with Mobius Syndrome?
I have only seen a few children with Mobius Syndrome, and those were seen for diagnosis only.
As I understand it, facial paralysis is the main problem and the paralysis can involve some or all of the facial muscles, particularly the upper lip in most cases.
The breadth and scope of the paralysis will guide speech involvement. One client I saw had paralysis only in the upper lip. Since the upper lip moves very little in speech, her speech was excellent. She could not smile, however, and that was the family’s concern. Clients with more areas of involvement will have more difficulty.
One article I read years ago demonstrated that these kids improve in speech slowly over the years and that we should not give up on artic. (Sorry, no reference, article missing).
I would treat a Mobius client simply as another case of dysarthria– distortion due to muscle tone impairment. I would use exaggeration of speech as my main focus. I also would use quick stretch on the facial muscles to see if I could stimulate their function. And I would use resistance to stimulate more active facial movement.
I also would search the web for more info. I am sure there are SLPs posting info about their therapy with these clients.
Posted in Apraxia and Dysarthria, Articulation, Oral Motor.
Tagged with Dysarthria, Oral Motor, Orofacial Myology.
By Pam M
– April 3, 2013
Q: What is your opinion about push-in vs. pull-out therapy? Is anyone doing research on this?
As far as I know, no one is doing research on in-class versus pull-out therapy for articulation. I cannot address this question as it concerns language.
In my opinion, in-class stimulation is good for the following:
- Building general vocabulary and concepts
- Establishing general communication routines
- Encouraging basic syntactic structures
- Stimulating phonological awareness
- Engaging in articulation carryover activities
- Teaching elocution
- Teaching early-developing phonemes—P, B, M etc.
I do not believe that push-in therapy is appropriate for doing the intimate and private work necessary to correct a lateral lisp, a distorted R, or a frontal lisp. I also do not think it appropriate for teaching tongue placement for some of the more problematic phonemes like K and G and so forth.
When you work in the classroom you give up three essential elements of good articulation therapy: PRIVACY, QUIET, and CONTROL. These things matter greatly when treating the articulation errors mentioned above.
Posted in Articulation.
Tagged with In Therapy, K and G.
By Pam M
– March 31, 2013
Q: My 4-year-old son has a frontal lisp. The school is refusing services and says he will outgrow it. Is this true in all cases?
No one that I know of is researching this area any more and there are big questions like this one that are going un-answered.
There seem to be two types of frontal lisps. The first is an immature speech pattern that will go away with time––by 7-9 years of age. The second is the result of oral-motor dysfunction. My experience is that this second one does not go away with time. It habituates.
Your child is four years of age, and that can make it hard to know which one you are dealing with. Time will tell. But there are other hints we can use to determine if your child’s frontal lisp is the result of simple immaturity of an oral-motor dysfunction––
- Does he have low muscle tone?
- Does he have below average intelligence?
- Does he eat with his tongue coming out too?
- Does he drool or pool saliva?
- Does he have significant food aversions/avoidances (beyond those typical of a child his age)?
- Does he have other motor development problems or delay?
- Does he have orthodontic problems?
- Is he clumsy?
- Does he have problems with hand movements?
- Does he have a hearing impairment?
These are the diagnostic indicators I would use to help me decide if this looks like a child who may outgrow his frontal lisp or if his pattern is one that will habituate. The more of these problems he has the more likely it is that he will NOT outgrow this problem.
Posted in Articulation.
Tagged with Evaluation, Lisps and S, Oral Motor, Phonological Development, Preschoolers.
By Pam M
– March 26, 2013
Q: Do I understand your advice? [...] When working on producing the ‘hissing” sounds, my focus should be on the airflow and not the correct sound production. For example, the client can’t say Ch but is able to get a lot of airflow on her attempt when probed. So I should reward her when she says Ts instead. Is this correct?
My experience and research on normal development demonstrates that children learn MANNER before they learn PLACE features. Thus, stridency “comes in” before the client organizes all the strident sounds by place.
In other words, the DISTINCTIVE FEATURE emerges before children learn to organize all the sounds that have that feature in the correct place.
As such, many children learn to produce a number of strident sounds and they mix them all up for a while before they learn to use the right phoneme in the right place within the right word. For example, a child might produce “fishie” as “Shishie” or “Thishie” or “Fiffie” before he settles on “Fishie.” He has added the frication first, and he has organized the fricated sounds by place second.
Whatever occurs in normal development is what I tend to do in therapy. So when I work with kids who have no strident/fricated sounds I help them first to become aware of the ‘”hissing” element, and I help them produce a variety of these sounds for weeks or months before I worry about whether they are putting the right phonemes in the right words.
As another example, if I am encouraging nasality, I will teach M, N, and Ng all at the same time, and I will let the child mix them up for a while. He may say “no” as “ngo” for a while as a result, but he is rewarded for using a [+Nasal] sound. Later he will be rewarded for using the correct nasal sound.
I do this because it reflects normal development and it gives the client more positive feedback earlier in therapy. Also, some very sever kids –– apraxia and dysarthria and low cognition –– may only be able to do it this way for a long time. Whereas a typical child may go through this “missed up phase” in a few weeks, our clients sometimes get stuck there for years.
Rewarding the acquisition of the feature and not the phoneme allows the client more elbowroom to learn phonemes and phonological processes.
By the way, this way of doing therapy is one I tested for my Masters Thesis. Hodson and Paden did not reference it in their little book Targeting Intelligible Speech, and I do not know why. I think because I had gotten into the whole “oral-motor” thing by then and they wanted to distance themselves from me, but you would have to ask them. Anyway… My research demonstrated that this was a valid way of approaching therapy for kids with multiple phoneme errors. Teach the distinctive feature first.
References
- Hodson, B. W., & Paden, E. P. (1983, 1991) Targeting Intelligible Speech
. San Diego: College-Hill.
- Rosenwinkel, P. (1976) Phonologically-based therapy for children with multiple misarticulations. Master’s Thesis. Urbana: University of Illinois. [This is Pam Marshalla’s Thesis under her maiden name.]
Posted in Articulation.
Tagged with Book Recommendations, Intelligibility, Phonological Development, Phonology, Preschoolers.
By Pam M
– March 20, 2013
Q: My friend’s daughter has a tongue thrust (the tongue pushes forward after the swallow). The orthodontist gave her one technique–– holding gum on the roof of her mouth while she swallows. Do you have any other ideas for tongue thrust techniques for a very typically developing 2nd grader?
First a few words about the general nature of this question: Asking someone for ideas about teaching a correct swallow is like asking someone for techniques to fix an articulation error. There are many interwoven ideas that work together, it is not always a quick fix, and a professional should do the work. A professional who does swallowing therapy should do this work. Thrusting the tongue after the swallow may only be the tip of the iceberg for this child. She may have a forward tongue carriage all the time, she may be avoiding certain foods, she may be munching instead of chewing, she may not transfer food from side-to-side correctly, etc…. the list goes on and on. Her swallow should be evaluated and a treatment program should ensue.
But let’s assume that it is true that all she does wrong is thrust after the swallow Then all she needs to do is learn NOT to do that.
Get her in front of a mirror and show her what she is doing that is different than most. She doesn’t need the gum if she is only thrusting at the end, but it makes for an amusing activity. The piece of gum needs to be very small, and you have to make sure that the presence of the gum is not throwing everything else off–– lip position, jaw position, etc. I would prefer to use something much smaller: Like a piece of knotted dental floss situated between the upper central incisors so that the knot sits right behind the teeth at the alveolar ridge. Another tiny tool to use would be a dental pick.
Basically the child needs to learn to go from oral rest position to a correct swallow, and then go back to oral rest position again. If you understand the correct mature swallow, then you are teaching her that. Use the knotted dental floss or dental pick to teach her to keep the tongue-tip in the right position.
Posted in Oral Motor.
Tagged with Feeding, Orofacial Myology, Swallowing, Tongue, Tools for Therapy.
By Pam M
– March 12, 2013
Q: I am working with a child 2;6 who substitutes /n/ or /m/ for many other consonants. We have worked with words she says often, and she can make the correct sounds in words with a model, but talking on her own she just sounds like she is whining.
Two-year-olds can be so variable, and what looks like something very severe can turn out to be nothing. She simply may be jargoning, and her jargon happens to sound like whining. Time and more treatment may be all she needs. HOWEVER–– With excessive nasality like this, she may need to be seen for VPI evaluation. Do you know if this ever has been initiated for her?
Referring for VPI evaluation can be very problematic with toddlers because you don’t want to alarm the parents unnecessarily. They probably have never heard of a VPI and to introduce it now may send them into a panic. But yet you need to know what is going on.
I probably would see her for a while (3-6 months) and do whatever I could to stimulate a wide variety of phonemes without bringing up the possible VPI issue. I would stimulate all Cs and Vs. Don’t worry about trying to change the ones she is using wrong. Just encourage her awareness and production of all the C’s and V’s. You could work in simple cycles––one week on P, one week on T, one week on S, and so forth.
See how she moves along. See what changes and emerges. Research has shown that toddlers have tremendous variability in phoneme productions until three years of age, so the therapy does not have to be so much about correction as it does general stimulation of phonemes. Let her mix up the phonemes and make mistakes, but just shoot for more variety. Enjoy and celebrate every new word and sound.
I also would have her playing regularly with a kazoo. As you probably know, the kazoo only works when oral sound is produced through it. So use it to encourage general oral sound and to reduce the amount of time she is making nasal sound.
And see how she comes along and how she changes. If she starts gaining new sounds, and they are not nasal, then you know that this is not a structural problem, and she just needs more therapy.
But if she continues to produce only nasal Cs, and if there is nasality on the Vs, and she cannot make sound through the kazoo because she cannot direct airflow only through the mouth, then I would teach the parents about the VP mechanism and express my concern in terms they can understand, and I would refer her to an ENT for evaluation.
You probably will have to refer to the primary physician. So write a great short letter explaining your concerns. Make sure you tell the physician that the child should be moving along faster than she is, and use the phrase “to rule out any velopharyngeal structural anomalies.”
Posted in Articulation.
Tagged with Birth to Three, Evaluation, Nasality, Phonological Development, Resonance, Tools for Therapy.
By Pam M
– March 7, 2013
Q: My 4-year-old client has learned L with his tongue-tip down. Should I let him continue this pattern, or should I teach him to make a tip-up L?
In my opinion, you always want the tongue-tip to be elevated when it is supposed to be on T, D, N, and L. You want your client to be developing oral movement patterns that will help him succeed all the way through to mature speech. So you are teaching him things today with your eye on his whole life––not just what is good enough for today. Whatever patterns you accept may lock in for a lifetime.
HOWEVER — It is normal to produce L with the tip down at his age so he may outgrow it. But I would get that tongue-tip more active now. His need for therapy for other phonemes suggests that he needs help with the overall process of speech movement learning. You already are in the process of teaching him correct oral movements in many other ways and you might as well set the tongue-tip on the right course too.
Posted in Articulation, Oral Motor.
Tagged with Oral Motor, Phonological Development, Tongue.
By Pam M
– March 2, 2013
Q: I am an SLP and cannot figure out how to remediate my own 20-month-old daughter’s speech problem. She is very expressive, has unlimited vocabulary, is speaking in 4-word sentences, and has above average articulation. She recently developed a cold which is now gone but as a result she is now producing L in place of N in all word positions. She is saying “Lo for “no” and “Bel” for “Ben.” She had this correct before. How should I correct and should I take her to an ENT?
I have to be very honest here and say that I think you are overly concerned about a very minor problem. Your child is only 20 months old! Less than two years! Her speech and language skills already are far beyond most kids — some quite normal kids have not even begun to speak at this age.
Research has shown that toddlers in this age range speak fewer than 50 words, they produce unintelligible jargon, the two-word combinations they produce are just emerging, and phonological errors abound. In a summary of the literature, Vihman (2000a and b) explained that phonological development does not settle into adult-like patterns until children are three years of age. Therefore your daughter has at least a year and a half of development before this should be any kind of concern. That is her age times two!
If she were my child, I would leave this completely alone for one full year. Give her time to work it out. She does not need therapy to fix this. She also doesn’t need an ENT visit to prove that toddlers make articulation errors. (If you think her ears are still clogged up, take her to your physician. If necessary he/she will refer to the ENT.)
The most I would do in terms of remediation is play with minimal pair words: Bell and Ben, for example. Most children her age do not understand the humor of minimal pairs, but I bet your child can. Make a picture of a bell and a picture of Ben, and have fun comparing and contrasting the two. I would make this be auditory work, and I personally would not correct her error. We do not want fluency to become an issue over pressure to speak perfectly, do we?
If I may be so presumptuous, my guess is that this advice to back off might help you in other aspects of her development, too. One does not have to teach normal children to be normal. Leave them alone and they turn out normal You have already proven that a mom who has excellent speech and language stimulation skills can turn out a child with superior skills in these areas. Now let it go. Be her mom first and her teacher or therapist a distant second.
References
Posted in Articulation.
Tagged with Birth to Three, Evaluation, Language Development, Phonological Development.
By Pam M
– February 27, 2013
Q: My two-year-old client uses words inconsistently. For example, he only uses “more” when he wants food, and he only says “mama” once or twice a day.
Two-year-olds are notoriously inconsistent about everything they do. They go to bed right away one night, and scream bloody murder about it for two hours the next. You ask them if they want a cookie, they say cookie and take it one minute, and the next they won’t even look up at you. Welcome to the toddler’s world.
Two-year-olds are “on their own agenda.” This is how they should be This is a sign that they have reached the two-year-level. They are interested only in what they are interested in, and they don’t do what we want them to very well. They don’t really care what we want them to do, either. They are discovering, for the first time in their lives, that they can make their own choices, and they do so at every turn.
In terms of using “more” only for food, research shows that children use first words with a global and not a specific meaning. You are teaching him that “more” means “more,” but he may not see it that way. Perhaps the child thinks the word “more” means “eat” or “I want to eat that.” Therefore he would use “more” only for food. That would be expected in a very young child. If he continues to show that kind of rigidity of word meaning over time, however, you may have to look into whether this client has a language learning problem of some type. Time will tell.
Posted in Other.
Tagged with Becoming Verbal, Birth to Three, Evaluation, Language Development, Phonological Development, Preschoolers.
By Pam M
– February 23, 2013
Q: What do you recommend to begin doing reading on tongue thrust?
In terms of textbooks, I would recommend either of the following. The chapters about what to do in therapy for tongue thrust are basically the same in both of these books:
- Hanson, M. L., & Barrett, R. H. (1988) Fundamentals of orofacial myology. Springfield: Charles C. Thomas.
- Hanson, M. L., & Mason, R. M. (2003) Orofacial Myology: International Perspectives. Springfield: Charles C. Thomas.
Posted in Oral Motor.
Tagged with Book Recommendations, Feeding, Oral Motor, Orofacial Myology, Tongue.
By Pam M
– February 18, 2013
Q: How do you transcribe a frontal lisp?
There are many ways to designate a frontal lisp–
- Some therapists do like to write it as Th/S (using IPA symbols, of course.)
- Some place a right-facing arrow under the phoneme, to indicate that the tongue is protruding forward.
- Some draw a circle between a downward-facing caret and an upward-facing caret, indicating the tongue is between the upper and lower teeth.
- Some simply write D for distorted, but I think that is the lamest of all because it doesn’t tell you anything about how it is distorted.
- The IPA diacritic is a three-sided box indicating the teeth. The open end faces down. Your basic phonetics text should have this last one.
Posted in Articulation.
Tagged with Evaluation, Goals & IEP's, Lisps and S.
By Pam M
– February 13, 2013
Q: How do you teach Sh and Ch when a client has a lateral lisp?
Start with Sh––
- Have the client smile and produce an exaggerated Long E–– Eeeee.
- Then tell him to hold his tongue in the E position and pant. He will be making a gross Sh at that point.
- Now have him keep panting in that way and round the lips. He will be saying Sh.
Then go to Ch––
- Have the client prolong Sh–– Shhhhhhhhhhh.
- While prolonging Sh, have him lift and lower the tongue-tip. He will be saying Shhhhh-t-Shhhhh-t-Shhhhh-t… Tell him NOT to make a T, but to simply lift the tip to “Close the gate and stop the Sh.”
- Have him do this sequence faster and faster. The faster he goes, the more it will sound like Ch.
Posted in Articulation.
Tagged with Lisps and S, Sh Zh Ch and J, Tongue.
By Pam M
– February 8, 2013
SLPs often overlook the diagnosis of mild dysarthria. This therapist’s letter perfectly describes such a client. My answer below summarizes the problems and offers links to treatment.
Q: I was hoping you could provide some guidance for me with a student I am evaluating. She is 11 years old and has been in speech for R, L, S, Th for several years. I met her for the first time this week when I began her re-evaluation. The SLP who has worked with her previously was concerned about possible language impairment and felt there was something “odd” about her speech…
She can produce all sounds in all positions at the word level. She occasionally has errors with R, L, and Th in phrases, sentences, and conversational speech. She is about 98% intelligible to the unfamiliar listener. She hates coming to speech. Her language standard scores were around 90-95, and commensurate with IQ. Her social skills were slightly immature, but not of concern.
My concern is that her speech is “odd.” It almost sounds as if she has an accent of some type. She puts stress on the wrong syllables at times, and her voicing was slightly off occasionally (i.e, “to” sounded close to “do”). She appeared to be over-articulating everything. Her oral mechanism showed some groping behaviors and decreased control. Her tongue deviated to the left slightly when protruded. She occasionally deleted medial consonant (“bottle caps” became “bo-uh caps,” “medicine” became (me-cine”). Her diadokokinetic rate slowed as she went on and her productions were imprecise. She had no vowel errors and her consonant errors were fairly consistent. She had much more trouble with multi-syllabic words like “statistical analysis” and “alternative opinion.” She was able to perform nonspeech tasks such as wave goodbye or pretend to lick a sucker easily and smoothly.
My question is can there be very mild cases of apraxia and if so what do we do for that child? She seems to have responded well to conventional articulation therapy, and I didn’t think that was typical of apraxia. I would appreciate any tips you have!
Answer: You are looking at mild dysarthria, not apraxia. I am certain of this. Most SLPs miss this diagnosis.
Mild dysarthria is characterized by general imprecision, high level consonant errors, occasional CCR, occasional syllable deletion, occasional phoneme deletion, occasional prevocalic voicing, slight disturbance of prosodic features, and mild OM dysfunction. Usually there also is slight distortion of vowels and diphthongs, and substitution of schwa for vowels. I would listen more carefully to those vowels and diphthongs. The vowels probably are passible but not perfect, not fully resonant, not what the elocutionists called “round and orotund.”
See this blog’s past posts for more info on dysarthria. Some of these QAs are about very severe dysarthria, others about mild. But the therapy is essentially the same for both. She may be over-articulating everything to help her be as intelligible as she can be. It may be a strategy to help her sound better. Without the over-articulation she may sound absolutely terrible, as she probably does when she is very tired or when she is not paying good attention to her speech.
Speech at this level switches from phonemes to voice, resonance, and prosody. For treatment strategies see the other QAs about dysarthria in this blog.
Posted in Apraxia and Dysarthria.
Tagged with Apraxia, Dysarthria, Evaluation.
By Pam M
– February 3, 2013
Q: My client has no fricatives/affricates. I have been working of F for about three months, and he is just not getting it.
This is how I work: If I cannot get one particular phoneme when a client has none in the class, I revert back to stimulating the class or distinctive feature.
Instead of teaching one particular phoneme in the class or with the feature, stimulate for them all. That way the client learns to recognize the similarities between them. The similarities between Th, F, V, S, Z, Sh, ZH, Ch, and J is the frication.
Don’t worry about which phoneme he is using. Only concern yourself with the fact that he is adding frication to his phonological repertoire. Therefore, if you are stimulating him to make S, and he makes Sh instead, don’t worry about it. Reward him for adding the frication.
Think about it this way: The only difference between voiceless Th, F, S, Sh, Ch, and H is place of articulation. Also, the only difference between voiced Th, V, Z, Zh, and J is place of articulation. All of these sounds are fricatives, and each has a unique place. Teach the manner/class/feature first, and the place second. I believe that this reflects the way phonology develops naturally.
There are many ways to approach this. Here are two ideas -–
1. Teach one sound and concept per phoneme in the same time period. This is a basic Van Riper method. Give each sound its own “personality”:
- Th (voiceless) – Th-th-th Angry goose sound
- Th (voiced) – Thhhhh Motor boat sound
- F – F-f-f-f-f Hissing cat sound
- V – Vvvvvv Vacuum cleaner sound
- S – Ssssss Snake sound
- Z – Zzzzz Bee sound
- Sh – Shhhhh Quiet sound
- Zh – Zhhhhh Airplane sound
- Ch – Ch-Ch-Ch Choo-choo train sound
- J – J-J-J-J Jumping sound
- H – H-h-h-h Panting dog sound
2. Teach one word per phoneme in the same time period. In general I like to use final position for the voiceless phonemes, and initial position for the voiced phonemes:
- Th (voiceless) – Bath
- Th (voiced) – That
- F – Off
- V – Vee (letter V)
- S – Bus
- Z – Zoo
- Sh – Wish
- Zh – Zsa-Zsa (a woman’s name)
- Ch – Ah-Choo!
- J – Joe
- H – Hot
Posted in Articulation.
Tagged with Intelligibility, Oral-Tactile, Phonological Development.
By Pam M
– January 28, 2013
Q: I went to your class on R therapy, but I still do not understand how to help a client who can say R in some words but not others. For example, my client can say “board” but not “bird.” Help!
This is what I do with kids who have Rs in some words and not others––
I see if I can manipulate a word they can say in such a way that the “er” is teased away from the rest of the word.
Your client can say “board” but not “bird.” That means that the O in the first word is helping him get to the R. I would try to manipulate “board” to get to the “er.” For example, this is how I might go from “Board” to “Bird”––
- Add a schwa after the word so he says “Boarduh.”
- Now split the word into two distinct syllables so he says “Boar—duh.”
- Now make the pause between the first and second syllable longer so that “Boar” is a separate and distinct unit.
- Then take “Boar” and over-emphasize the O. Exaggerate the vowel by making it longer–– Booooooar.
- Then split this into two syllables–– Booooo—-Er.
- Now you have “Er” separated and can use it to attach to other things.
- To put it into “bird,” use the schwa liberally and split this word into three parts–– “Buh” + “Er” + “Duh.”
- Teach the client to blend these separate parts together back into a single word by prolonging the vowels.
- Finally, take out any extra sounds that inevitably will occur as he tries to blend the sequence of sounds.
This is articulation therapy at its finest!
Posted in Articulation.
Tagged with R Therapy.
By Pam M
– January 23, 2013
Q: I have read your R book and have taken 2 classes from you, but I am still struggling with student with persistent R distortions. She has the most success producing vocalic R (car, ear, air, tire) but not “Er” all by itself.
This is a very common problem that many SLPs have. How does one obtain an isolated “Er” when the child has it in a vocalic position attached to other vowels? I usually help the client like this–
- Take a word she can say with a correct vocalic R–– like CAR.
- Then have her prolong the vowel–– Caaaaaaaaar.
- Then have her prolong the vowel and the R–– Caaaaaaarrrrrrrr.
- Then have her say it again, and as she holds the R, tell her to turn her voice off and then back on. She will say–– Caaaaaaarrrrrrrr––rrrrr.
- Then have her do this many times to obtain a sequence of Ers–– Caaaaaarrrrr-rrr-rrr-rrr-rrr-rrr.
The client simply needs to learn to repeat what she can already do. Tell her, “Keep your tongue in the R place, don’t move it… Say it again… and again… and again. This will isolate it into Er.
Posted in Articulation.
Tagged with R Therapy.
By Pam M
– January 18, 2013
Q: My client has a cross bite and his jaw lateralizes to the right causing overall speech imprecision. I am holding his jaw in place with standard jaw stabilization I learned for feeding therapy, but it’s not working. His jaw slips back out of position as soon as I remove my hand.
That kind of “hands on” jaw stabilization procedure is good for feeding therapy, but is not effective for speech for the very reason you mentioned–– because as soon as you take your hand away, the client reverts to his old pattern. I call that process “assisting” movement, meaning that you are doing the work for the client. You are assisting his movement and he doesn’t have to do any work to make it happen.
A more effective way to provide jaw stability in articulation therapy is to devise a method in which the client activates his own muscles to make the jaw stay at midline. The easiest way to do this is to give the client something on which he can bite with the molars. Use a probe such as a toothette handle, a swizzle stick, a toothpick, a straw, or a coffee stirrer. Place the tool on the molars along the tooth line, and ask the client o bite down on it gently–– Firmly enough to hold it in place but lightly enough so it doesn’t crush.
Now the client will be using his own jaw muscles to hold his jaw in place. If he moves the jaw while speaking, the tool will fall out, and that way he will understand that he moved it, especially if you say, “Oops… It fell out… You moved your jaw and it fell out.” Sometimes I tape a penny on the end of the tool so that it is very heavy on the outer end. When the client loses control it falls out immediately.
Now, engage in the speech activity while the stabilizer is in place, and teach him to hear and see the better performance. (Use a mirror.) Gradually fade the tool and help him maintain performance.
“Hands-on” oral control. An excellent way to control the jaw during feeding therapy (Internet photo)–
“Hands-off” oral control. Placement of the tool between the molars teaches the client to activate his own muscles to control his jaw movements–
Posted in Articulation, Oral Motor.
Tagged with Jaw, Oral Motor, Oral-Tactile, Tools for Therapy.
By Pam M
– January 13, 2013
Q: What do you do for drooling? Do I need to be a swallowing expert to do it?
I see drooling as a three-fold problem––
- The child doesn’t swallow often enough.
- The child doesn’t swallow well enough. (He doesn’t evacuate completely).
- The child isn’t aware when saliva is building up in his mouth, on his lips, etc. (He doesn’t notice it or doesn’t care about it).
So my therapy addresses all three of these issues––
- I teach them to swallow every 1.5 minutes while we engaged in our other speech/language activities. (I use an eyedropper to shoot 2ccs of icy cold water or apple juice into the mouth between closed lips, and I tell them, “Here it comes. Time to swallow.”) Over time I fade the dropper and liquid and teach a dry swallow.
- I make sure they are swallowing correctly. (This is where the knowledge of correct swallow comes in. I do some feeding activities for this.)
- I help them become more aware of saliva and drooling, and I help them care about this. I use mirrors and direct verbal information (e.g., “Oh-oh, you are getting all wet.” “We don’t like that wetness.” “Most people try to stay dry.” “Being dry is nice.” “Mommy likes dryness.”)
For a broader approach please see my little book called How to Stop Drooling.
Posted in Oral Motor.
Tagged with Drooling, Oral-Tactile, Tools for Therapy.
By Pam M
– January 8, 2013
This opinion paper was originally posted as a downloadable PDF on my website’s resources page. I am slowly formatting the articles over there for posting to this blog. This post was authored in November, 2012. Download the original PDF here.
***
“Marshalla Eye Dropper Technique”
For Drooling Elimination
November 2012, Pam Marshalla, MA, CCC-SLP
Speech-Language Pathologist
Application
This simple process is to be done in conjunction with a good program to facilitate improved oral-motor and feeding skills. It can be employed even if child is on medication or has had surgery to reduce or eliminate drooling. This method is intended to finish off the drooling problem.
Progress
Length of time needed for success depends upon the client’s neuromuscular and cognitive status. Some clients will not stop drooling with this program due to severe neuromuscular or cognitive disability.
Evidence
Please keep in mind that this process has not undergone any controlled study. This outline simply represents the procedures Marshalla developed in therapy. The method is based on four decades of clinical experimentation with a wide variety of clients.
WARNING: DO NOT USE THIS PROGRAM IF THE PATIENT IS IN DANGER OF ASPIRATING ON LIQUID! USE ONLY WITH CLIENTS WHO ARE CLEARED FOR ORAL SWALLOWS OF THIN LIQUIDS!
Materials Needed: Use an eyedropper of some sort, and icy cold water or icy cold apple juice. Pam likes to use the long thin droppers that hair stylists use to touch up the roots of dyed hair. These droppers are plastic, long, thin, and inexpensive.
Basic Procedure: Give the child a tiny sip (2-3ccs) from the dropper every 90 seconds while he is engaged in another quiet activity.
Term: Weave the stimulation in and out of therapy over the course of weeks, months, or years, depending upon the client.
Method
- Tell the child, “Time to suck.”
- Place the dropper just between the lips, against the under side of the upper lip. DO NOT put it all the way into the mouth––keep it outside the teeth. Do not stimulate the tongue—only the upper lip. The tip of the dropper should be positioned against the under side of the upper lip, between the upper and lower incisors.
- Encourage the child to “get it” meaning that he will actively bring up the lower lip. The lips should press together to the point of complete closure. The tiny tip of the dropper should not interfere with full lip closure.
- Once the lips are sealed closed, squeeze the bulb of the dropper so that the liquid shoots into the mouth. This should stimulate a swallow. [See warning above.]
- Over time, squeeze the bulb less, and expect the client to suction by himself more. In other words, hold the dropper to the lips, but don’t squeeze. Expect the client to suction on demand.
- Over time, fade use of the dropper. In other words, tell the client to swallow without the dropper, and expect him to do it. This is called a “dry swallow.” The dry swallow is a swallow of saliva only.
Over Time
- Reduce the amount of bulb squeezing and increase the number of times the child actually suctions by himself.
- Eliminate the squeeze altogether and expect the child to suction the liquid out.
- Eliminate the eyedropper and have the child suction on your command with no liquid offering (Make sure you are using a consistent command throughout).
- Broaden the types of activities during which you are doing this activity.
- Fade your physical and verbal cues.
Aims/Goals
- You are trying to get the client to suction more often so that he does not let saliva pool and drip.
- You are trying to get the client to swallow more often so that he does not let saliva pool and drip.
- You are trying to pair suctioning and swallowing, so that suctioning stimulates swallowing.
- You are trying to stimulate more frequent swallowing.
- You are trying to stimulate more efficient swallowing.
- You are trying to bring the process of suctioning and swallowing to the client’s conscious awareness so that he can produce a dry swallow on demand.
Expectations
- Spontaneous dry swallows should become more frequent.
- Swallowing skill and efficiency should improve.
- Saliva pooling should decrease.
- Drooling should decrease.
Effect
This procedure stimulates SUCTIONING and SWALLOWING. Suctioning is the drawing in, or gathering together, of liquid or food in preparation for swallowing. We suction to clear the mouth before we swallow. Suctioning is done with full lip closure and negative inter-oral air pressure.
Posted in Oral Motor.
Tagged with Drooling, Feeding, Lips, Oral Habits, Oral Motor, Oral-Tactile, Swallowing, Tools for Therapy.
By Pam M
– January 2, 2013
Q: I have a new referral from a dentist for a client with a “gummy smile.” Haven’t seen him yet. What do you think this means?
I would assume that the term “gummy smile” means that the upper lip is retracted and the upper gums are exposed. Assuming that this is the case, the client needs to learn normal oral rest posture. Normal oral rest consists of the lips resting gently together, the teeth resting a few millimeters apart, and the tongue-tip resting on or below the alveolar ridge.
Teaching normal oral rest is an aspect of classic orofacial myofunctional therapy. One of my deepest concerns is that SLP students still are not taught basic concepts like this while still in school. In my never-to-be-humble opinion, all SLPs should have to study the basics of the swallow and oral rest as a part of their articulation training.
Posted in Oral Motor.
Tagged with Lips, Oral Habits, Oral Motor, Orofacial Myology, Orthodontia, Teeth.
By Pam M
– December 31, 2012
Q: I have tried “everything” to teach R to this one client and he has gotten nowhere. Then one day he learns a Spanish trilled /r/, and WHAM! He gets an American R right away. Can you explain this?
Van Riper wrote about this as one method for teaching the retroflex R: “Have the child imitate you as you trill the tongue-tip. Then use this trill to precede the vowel E” (Van Riper, Speech Correction
, 1947, p. 142).
Think of speech as comprised of POSTURES and MOVEMENTS –
- POSTURE: Trilling the tongue sets the tongue in the right posture. The trill sets the tongue wide in the back with its perimeter curled upwards. This is the exact posture for the retroflex R.
- MOVEMENT: Curling the whole tongue back while trilling moves it back in the right direction for R.
Posted in Articulation, Oral Motor.
Tagged with Imitation, R Therapy, Tongue, Trill.
By Pam M
– December 15, 2012
. Boston: Pearson. Pp. 63-104.
