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Why Rag on the EBP?

Q: Why do you keep harping on about the evidence-based practice (EBP)?

I keep “harping on” about the EBP for four main reasons:

  • Because therapists from all over the world continue to submit questions to me about the EBP.
  • Because therapists in my seminars continue to tell me about the problems they are having with the EBP––problems they are having with certain colleagues, administrators, or parents because of it.
  • Because therapists in my seminars continue to tell me that they feel guilty about doing things in therapy for which they have no research––including things they made up themselves, things they learned from other therapists, and things they learn from the clients themselves.
  • Because certain professionals continue to advocate the notion that we only can do in therapy those techniques that been researched––and nothing could be further from the truth.

[Please see more on this blog regarding the EBP.]

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By Pam M – May 16, 2012

Tapping the Tongue to Stimulate the Lingua-alveolars––T, D, N, L

Q: My client backs every lingua-alveolar phoneme. He can do a rudimentary L once in a while, but he substitutes k/t, d/g, and ng/n all the time. What can I do?

You probably are trying to get your client to elevate the tongue-tip to learn T, D, N, and L. This is to assume that the child can be taught to produce these sounds in the adult form. You have to revert back to teaching your client how to produce these sounds the way babies produce them when they first appear. This means that you are teaching the phoneme productions with the most primitive motor pattern instead of the mature motor pattern that is fully formed.

In my observation, the lingua-alveolars emerge in babbling (6-10 months of age), not because the tongue-tip elevates, but because the jaw begins to move up-and-down while the tongue-tip protrudes slightly out the front of the mouth. I call this “jaw babbling.” In other words, babies often babble with D, N, and L by protruding the tongue-tip between the lips and banging the jaw in an up-and-down movement sequence. Try it yourself to feel this movement pattern.

Therefore, when I have a client who cannot produce any lingua-alveolar sounds, I teach the client to stick his tongue out just a little (so that only just the very tip touches the inner surfaces of the anterior lips), and I teach him to move the jaw up-and-down in sequence while babbling. This way the upper surface of the tongue-tip bangs against the upper lip, and the upper central incisors if they are present.

Tapping

Basically you are using the method OTs and PTs call “tapping.” Persistent stimulation in the form of tapping causes increased body part awareness at that part, and it causes muscle tone to increase there (Hagbarth, 1952). Tapping downward on the tongue-tip can cause it to begin to rise.

Practice babbling sequences with D, N, L, and T this way. Also work on simple CV and CVCV words this way (See chart below).

Also, the tongue-tip begins to activate (move more) when babies begin to spit applesauxe and other purees out the mouth by “tongue-spitting.” This is one of the places I almost always use feeding therapy techniques in my articulation work. Feeding therapy methods are an excellent way to stimulate infantile forms of the oral movements that will be needed for speech articulation.

Reference

  • Hagbarth, K. E. (1952) Excitatory and inhibitory skin areas for flexor and extensor motor neurons. Acta Physiol Scand 26, p. 1-58.

Words to Practice With Big Up-Down Jaw Movements

Target Phoneme Target Word CV CV-CV
D Daddy Dae Dae-dae
Doggie Daw Daw-daw
Donut Doh Doh-Doh
L Lollipop Lah Lah-Lah
La-La
(the Telletubby)		 Lah Lah-Lah
Yellow Lah Lah-Lah
N Grandma Nah Nah-Nah
Nanny Nae Nae-Nae
No No No-No
T Ta-ta (bye) Tah Tah-Tah
Toe Tow Tow-Wuh
Cookie Too Too-Tee

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By Pam M – May 12, 2012

Outgrow jaw instability?

Q: My four-year-old client has apraxia and jaw instability. The mom wants to know if jaw stability will improve on its own.

There is no way to know that. Certainly jaw stability improves with time, but it may not improve in this child without help. He is developing oral motor patterns that may stay with him until he receives therapy to change them. He should have jaw stability by now, so the question is, why doesn’t he? Whatever is preventing it from stabilizing presumably will continue to inhibit it.

Posted in Apraxia and Dysarthria, Oral Motor.

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By Pam M – May 9, 2012

Lateral Lisp, Missing Teeth, and Malocclusion

Q: My client has no incisors and an underbite, and she distorts both S and Z. These errors sound like a lateral lisp, however when I use your straw testing method, there is no airflow coming out the sides, only the front. My colleague tells me that this is a lateral lisp. But how can it be if the air doesn’t come out the sides?

Your colleague is wrong: If the airstream is not coming out the sides (as tested with the straw) then it is not a lateral lisp. A lateral lisp comes out the sides. Period. Thus the term “lateral” lisp. Your client’s phonemes sound lateral, however, due to the missing teeth and the malocclusion. Let me explain.

Incisors

The incisors form a “dental barrier” or “wall” against which the midline airstream of the sibilants strikes. The airstream hits the back of the wall, rebounds, tumbles around, and then exits the mouth. This striking, tumbling, and exiting together all create the strident (fricated) sound.

Missing Front Teeth

When the front teeth are missing, especially when so many are missing, the airstream broadens. The air usually will come out where ever the teeth are missing. This interferes with the sharp sound that should occur, and it gives a broad and sloppy sound to all the sibilants––S, Z, Sh, Zh, Ch, and J. All of these phonemes can end up sounding lateral, but they are not. They are midline according to your straw test.

Malocclusion

A malocclusion causes further distortion of the strident sounds. The anterior dental barrier has to be like a straight wall of teeth against which the airstream strikes before it escapes out the front of the mouth. When there is malocclusion, the front teeth do not meet together correctly. With an underbite, you have a wide anterior-posterior gap. Thus you have additional distortion of the airstream.

Analysis

Your client does not have a lateral lisp. Your client has distortion of the sibilants due to malocclusion and missing incisors. Your client has an articulation problem due to the structural defect. These structural problems cause the sibilants to sound sloppy and distorted.

Treatment

Charlie Van Riper said that when there is a structural deficit, one has two basic options for your path of remediation:

  1. Wait for the structure to be fixed with orthodontia or surgery, and then work on the phonemes.
  2. Teach the client to compensate for his structural problems by teaching an individual or idiosyncratic oral position. This is the sound he will use until the dental problems are fixed, if they ever will. The compensated sound usually is not a “perfect” sound. It is only “good enough” and “as good as it can get.” This concept has to be taught to the client and his parents so that they don’t think you have failed. There is only so much we can do with a structural problem, and the resultant phonemes are only as good as the structure allows.

Thus, your choices are to wait for the client’s teeth to come in before you worry about how well she says these sounds, or you work on the sounds by teaching her to compensate for her structural deficit.

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By Pam M – May 5, 2012

Frequency of Therapy

Q: How often do you see your clients?

I always set once per week as my “must have” level. That is unless they are only on consult, follow-up, or the later stages of carryover.

Over 35 years, I have found that once per week is sufficient for most kids, both the easy kids and the low functioning ones.

Easy kids can do perfectly well with once per week, and low functioning clients do not move fast enough to warrant more than once per week of my individual time. The pervasive belief today is that more is better. But I have not found that to be true. Especially if there are other people in his environment at home and school who are stimulating him in various ways.

With my very severe kids I explain to parents that their kids are going to need therapy throughout their entire school career, and I tell them––

It’s not MORE therapy NOW that makes the difference. What makes a difference is GOOD therapy over the LONG HAUL.

This is my basic “rule” and of course there always are exceptions.

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By Pam M – May 2, 2012

Getting the Mouth to Open

Q: I have a preschool client who talks with his mouth closed. He can imitate me when I model an open mouth posture, but he always closes it when he says a word. I know that he is struggling with motor planning, but I just don’t know where to go from here. Any advice?

This client can open his mouth, meaning that the mechanics are good. He also can imitate the posture, meaning that he has control over this movement. His problem is that he has a motor memory for word productions that includes a closed mouth position. He has a habit, if you will, of speaking words with the mouth closed. If this is true, your client simply needs to learn to say words with his mouth opening and closing. You can do this in many ways. Here are two basic methods. I would do both of them.

1. Use An Inhibition Technique To Prevent The Mouth From Closing During Word Productions

Have the client hold a tube in his mouth while he sings songs or say words. Use a tube about one-inch in diameter. I like to use plastic plumbing tubes I buy at hardware stores. They come in all different sizes and can be washed and sanitized between clients. The tube will inhibit his mouth from closing, i.e., it will prop his mouth open. The sounds and words will not sound correct obviously because the tube will distort the consonants and vowels. But it is a start. Tell him, “Make a big mouth.” “Make a big mouth and sing.” “Make a big mouth when you say the word.”

2. Use Resistance To Teach Sequential Opening-And-Closing During Syllable Productions

Put your fingers under the client’s chin and push gently upward. Tell him, “Push my fingers down.” Push up slightly so the client learns to push the jaw down (open the mouth) on command. Then remove your fingers and tell him to close his mouth. Then have him open-close in sequences, pushing upward each time he opens the mouth. Then have him babble “bababa…” or “mamama…” in the same way, with your hand under his chin so he can push against it while opening for the vowel. Then do the same with simple CV-CV words like “mama” or “bye-bye.” The jaw goes up for the consonant and down for the vowel.

Don’t use very much force. You are teaching control, not building strength. Building “jaw strength” is something people who do not understand oral motor techniques will say. But this client has enough strength already, obviously, because he already can move in the required direction. What he does not have is awareness and control of the movement during speech. A slight amount of weight added to the movement builds awareness and control. This is a proprioceptive technique––a technique designed to influence muscle function directly.

This second method causes you to teach the jaw to go up with the C, and down with the V. Moving the jaw up-down during speech is one of the most basic oral movement patterns there is. A simple movement pattern like this also is called a metaphonological skill. Oller (1978) said––

“The first metaphonological characteristic is vibration of the vocal cords in ‘normal voice’ or phonation… The second metaphonological characteristic of speech involves opening the mouth while phonating… [Another] metaphonological characteristic of speech…concerns the relative timing of openings and closures of the vocal tract. The transition from closing to opening must occur within a specifiable time frame in order for the resulting syllable to be speech-like” (p. 527-528).

Reference

  • Oller, D. K. (1978) “Infant vocalizations and the development of speech.” Allied Health and Behavioral Sciences Journal, 1 (4) Pp. 523-549.

Posted in Articulation, Oral Motor.

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By Pam M – April 29, 2012

Oral Habits and Dentition

Q: Why does an oral habit like thumb sucking effect the oral structures in some children but not others? I have seen kids who suck their thumbs who have no dental problems, and I have seen kids who suck their thumbs who have terrible open bites.

As I understand things, any oral habit can affect oral structures depending upon the following three factors––

Frequency –– How often the client engages in the habit.

Once per day? Ten times per day?

Duration –– How long the client engages in the habit each time he does.

5 minutes? 5 hours? All night long?

Pressure –– How much pressure is exerted against the teeth and bones.

Is the object/finger just sitting there, or does the client push it hard, or suck it hard?

These are the reasons an oral habit can have a severe detrimental consequence on oral structures in one child but not another. I learned this from an orofacial myofunctional therapist 20 years ago. I do not know if there is research to support this basic notion.

For more information about oral habits, oral rest posture, swallowing, and speech, please visit the website of the International Association of Orofacial Myology.

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By Pam M – April 25, 2012

Substituting N for L

Q: My 5-year-old client substitutes N for L. I cannot seem to help him make the sound oral and not nasal.

These are the types of things I would try…

Use a Vowel

  • Have her open her mouth wide and say “Ah.”
  • Then have her prolong “Ah” for 5 seconds or more.
  • Then have her continue to say “Ah” while she lifts and lowers her tongue-tip up to the alveolar ridge about 5 times.
  • Tell her, “Don’t try to say L. Just lift up the tip of your tongue, and then lower it again five times.”
  • It will sound like this: “Ahhhh-L-Ahhhhh-L-Ahhhhh…..

Use a Tube

  • Take a tube that can stretch from her nose to her ear.
  • Have her listen to the lack of sound coming through her nose when she says “Ah.”
  • Then have her say “M” and have her listen to the nasal sound.
  • Then teach her that she is letting L come out her nose.
  • Have her hold the tube from nose-to-ear to hear this as she tries to say L.

Pinch the Nose Closed

  • Have her hold her nose to inhibit the air from coming through.
  • As she drives the sound to the nasal passageways, it will be blocked at the pinched nostrils.
  • She will notice the pressure build-up that occurs in the nasal cavities.
  • Tell her not to do that.

Use a See-Scape

  • Place the nasal bulb of the See-Scape into one nostril.
  • Have the client say N. The movable piece will go up.
  • Have her say a sound that she says with good oral airflow, like S, and have her observe that the piece does not move. Repeat this with several other oral sounds.
  • Now have her try the same with L.

Use Tissue Paper and a Tube

  • Hold a tube at the nose, and have it stretch to several tiny pieces of tissue paper on the table.
  • Have her sniff out the nose to make the tissues fly.
  • Have her produce M and N to observe how the tissues fly.
  • Now repeat with non-nasal sounds, like S, T, and K. She will notice that the tissues do not fly
  • Transfer the same activity to the glides––W, L, Y, R.

Use the Fingers to Feel Vibration

  • Have the client place her fingertips on the sides of the nose.
  • Teach her how to feel the nasal vibration that occurs with M, N, and Ng.
  • Have her feel the lack of nasal vibration that occurs with oral sounds.
  • Extend the experience to all the glides––W, L, Y, R.
  • Focus on L.

 

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By Pam M – April 20, 2012

Apraxia and Dysarthria and Real Oral Motor Therapy

Q: Would you agree with the following statement:  Children with apraxia will respond to structured production of increasingly difficult syllable shapes, while children with dysarthria need supplementing with oral motor exercises to address muscle weakness.

Before I answer your question, let me say a few things about “muscle weakness” and dysarthria because many SLPs––including professors of articulation and phonology––do not seem to understand this area very well. The muscle weakness seen in dysarthria can have many different causes, and the treatment will be no good unless the cause is taken into consideration. One cannot simply do “oral motor exercises” to address “muscle weakness”. It is much more involved than that.

Differential Diagnosis

It all boils down to the differential diagnosis of the muscle tone disturbance. For example, muscle weakness can be caused by muscle tightness (spasticity). Increasing muscle “strength” will not help the client move better in that case. In fact it may only make his spasticity worse. The therapy needs to include activities to reduce the spasticity while improving overall tone. The therapy will be more about increasing flexibility and range in the tight areas, and learning to move with the right points of mobility and stability. The therapy will be more about inhibiting unhelpful movements while facilitating appropriate movements. It will be much less about building “strength” per se.

In Speech

Let’s carry this example into speech: A client with dysarthria may have limited tongue movements, and his tongue may seem “weak”. But very tight muscles in the shoulders, neck, and jaw could be causing the limited tongue movements. Activities to improve strength in the tongue probably will have a limited effect on speech movement because that is not the problem. The problem is that proximal tension (shoulders, neck, jaw) is inhibiting distal mobility (tongue). The therapy needs to include activities to relax or inhibit the tension, and it needs to include activities to increase tongue mobility. The therapy is one of improving the oral movement patterns, not of increasing strength. The tongue’s actual “strength” has very little to do with it.

[By the way, a number of techniques to inhibit muscular tension related to dysarthria were demonstrated in The King’s Speech. The therapist included rolling, rocking, shaking, and other techniques to release tension in the diaphragm, chest, neck, and jaw.]

The Differences Between Apraxia and Dysarthria

This is what has helped me to understand the difference between apraxia and dysarthria: Ultimately apraxia is a problem in the perception of movement, while dysarthria is a problem in the execution of movement. A client who does not perceive his own movements well (apraxia) will not know how to plan out subsequent movements. He will lack the initiative to move and/or will move inconsistently and thus perform poorly. A client who cannot execute his movements well (dysarthria) also will perform poorly. The impact on speech can be very similar, especially in children, and both types of clients may need to work on many of the same skills. The focus will be different. The focus in apraxia will be on perception while the focus in dysarthria will be on execution.

The Similarities Between Apraxia and Dysarthria

In many ways therapy for children with apraxia and dysarthria looks exactly the same:

  • Both need to improve tactile and proprioceptive awareness of their oral structures, and the movements of those structures.
  • Both need to improve dissociation, direction, and grading of their own controlled speech movements.
  • Both need help in maturing their speech movements along several continuums: gross-to-fine, proximal-to-distal, medial-to-lateral-to-rotational, and so forth.
  • Both need to learn how to move the oral mechanism in specific ways for specific phonemes (consonants and vowels).
  • Both need to learn how to sequence vowels into diphthongs.
  • Both need to learn how to sequence phonemes into syllables.
  • Both need to learn how to sequence syllables into words, and maintaining syllables in words.
  • Both often need work on breath support for speech so their words, phrases, and sentences can be stronger and longer, and so prosody improves.
  • Both often need work on producing voice, and differentiating between voiced and voice-less phonemes.
  • Both often need work on resonance.
  • Both often need help organizing phonemes by place of articulation.
  • Both almost always need auditory training and phonological awareness activities to assist in their speech movement learning.

The Final Analysis

I think it is safe to say that once a wide variety of phonemes are emerging–

  • Kids with apraxia need more work on phonemes and syllable sequencing
  • Kids with dysarthria need more work elocution, enunciation, and precision of sound production.

What I Wish

I wish we could drop both of these terms, and simply call these children speech movement impaired. That way we could perhaps stop obsessing about “apraxia” and “dysarthria”, and we could begin to discuss the real underlying sensory-motor issues. We could begin to talk openly and honestly about the diagnosis and treatment of speech movement problems. For example:

  • What does it mean to have a muscle tone disturbance, and how does high or low tone effect speech movement learning? How does spasticity interfere with speech movement learning? How does it interfere with jaw, lip, tongue, or velar movement? How does it interfere with respiration, phonation, and resonation? How does one influence muscle tone?
  • What is a vestibular deficit? How does vestibular stimulation affect muscle tone and arousal for learning speech movements?
  • What does it mean that a client has tactile defensiveness, oral-tactile hyper- or hyposensitivity? How do these problems interfere with speech movement learning? How do tactile awareness and discrimination activities improve speech movement learning?
  • What does it mean if a client has retention of primitive reflexes? How does this interfere with speech movement learning? What should we do about them? How can reflexes be used to stimulate speech movement learning?
  • How does one teach dissociation of speech movement? Why does one do this? What does the term “grading” of oral movement mean? How can we teach it?
  • What is the process of inhibition and facilitation of movement? How can we use it to facilitate better jaw, lip, or tongue movement for speech sound production?

The Problem We Have Today

As I see it, the problem we have today is that the “anti oral-motor people” have moved the discussion away from real sensory-motor issues and into the arenas of “motor learning theory” and “non-speech oral motor exercises.” Put simply, they have knocked the discussion off track. They are complaining about horns, whistles, muscle strength, and the number of repetitions of a certain movement is necessary to improve speech. These are not the issues. The issues listed above (and many more) are the real oral motor issues that therapists have been discussing for more than 30 years.

For example, therapists who use and teach “oral-motor techniques” have not been talking about whether blowing a whistle ten times per day for ten weeks will cause /w/, /p/, or /b/ to emerge. Real therapists who do real work have been discussing how one can use tactile, proprioceptive, and vestibular stimulation to influence lip movement. A whistle might be used in the process…or a horn…or a straw…or a gummy worm…or a toothette handle…or a swizzle stick…but whether or not the client can blow the whistle is immaterial.

The real questions are quite basic:

  • What movement is needed?
  • What is interfering with emergence of the movement?
  • How might the movement be facilitated?
  • How might the movement be brought to the client’s awareness?
  • How might we help the client use the movement to make a speech sound?
  • How might we help the client use the movement in speech with better speed and accuracy?
  • How might we help the client use the movement in speech consistently under a variety of circumstances?
  • How might we help him remember to use the movement in speech when we are not around?

If we could stop arguing about what apraxia and dysarthria are, and if we could stop talking about “non-speech oral-motor exercises”, we could elevate the discussion to one that actually would help therapists understand what the therapy is all about when a client has a motor speech disorder.

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By Pam M – April 16, 2012

Labeling Toddlers with Apraxia or Autism

Q: My son is 2 years and 2 months, and he jargons mostly. His therapists can’t seem to figure out if this is apraxia or autism. Why is this?

It can be very difficulty to determine if a child has autism or apraxia when they are under three years of age. This is because so many of the problems overlap. Both disorders cause the child to be non-verbal or minimally so. Both cause much refusal to follow directions and answer questions. Both cause children to have difficulty speaking on demand and imitating sounds and words.

I always tell parents this: Time will tell. It’s not what he’s doing today that matters. It’s how he changes over time, how he shows us he learns. The key to treatment is to find his strongest learning channels and teach to those.

For example, some of these children show a very early interest in the alphabet. To me these children are showing us, “This is how I learn best. This is my strongest learning channel.” Making cards with pictures and printed words may be the best approach to language learning and phoneme acquisition. This technique can be effective whether the child carries the label of apraxia or autism. It depends upon the child.

Many therapists do not care what label the child carries, and they try to avoid assigning a label too early. The label is only necessary for the purpose of payment. What the therapists are concerned about is how your child learns. They are trying to find the best strategies to help your child gain speech and language skills. Since he is only two years old, the therapists will want the freedom to try all kinds of different methods so that they can allow the child to show them how he learns best. If the therapists lock in to only one etiology too early, they may deny the child the very techniques that will help him.

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By Pam M – April 12, 2012

Down Syndrome and Stuttering: Diagnostic Labels

Q: I have a student with Down syndrome who stutters. Her private SLP has diagnosed her as having apraxia, and insists that the fluency problem is part of the apraxia. Can this be right?

Many therapists assign the label of apraxia to children with Down syndrome, but I believe that this is an incorrect diagnosis. Dysarthria should be the assigned disorder. Please note the following definitions:

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.]

Apraxia

“Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone)…” [From: ASHA's Childhood Apraxia of Speech].

Therefore a child with Down syndrome should carry a diagnosis of dysarthria. Down syndrome also is characterized by cognitive deficit.

None of these disorders––apraxia, dysarthria, or cognitive deficit––include stuttering as one of their characteristics.

Therefore, this child should be diagnosed with dysarthria and cognitive deficit related to Down syndrome, and stuttering. Stuttering should be considered a separate problem.

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By Pam M – April 9, 2012

How Long to Fix a Lateral Lisp?

Q: How long should it take to establish midline airstream when a client has a lateral lisp?

This depends upon what you are talking about. Are you trying to figure out how long it should take you to obtain the client’s first midline sibilant, or to finish the entire program?

To be very honest, an SLP with no specific training on how to treat a lateral lisp may NEVER figure out how to get a correct set of midline sibilant sounds out of his/her client. The client may remain in therapy for years with no change.

On the other hand, an SLP with good training, or one who also has figured this out on his/her own, can get a good S, TS, Sh, or Ch out of a client in about five minutes. This depends on the therapist’s skill.

The finishing of the program can take a long time, however. Once a client has produced the first sound correctly, it can take more than a full calendar year to fix the entire system all the way through to complete carryover.

However!! I have seen kids fix up all six lateral sibilants in one week! The rate of change all depends upon the following:

  1. Does the SLP know what s/he is doing?
  2. Does the client have the cognitive skills to understand what is going on?
  3. Does the client have the auditory discriminations skills to do the work?
  4. Does the client have the oral-motor skills to achieve the positions?
  5. Does the SLP know how to train the positions if the client can’t do them?
  6. Does the client have the motivation to change?

If the answer to all of these questions is “Yes”, then therapy should go very fast.

If the answer to any of these questions is “No”, (especially #1 and #5), then this can take a very long time, and some clients will never fix their lateral lisp.

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By Pam M – April 4, 2012

Lateral Lisps in Languages Other than English

Q: I am an SLP from Greece, and I’ve been working with a five-year-old girl with lateral lisp for four months. She still cannot produce a clear “S”. I am interested in buying your book on this subject, but I’d like to know whether these techniques apply only to English. Also, I have heard some SLPs claim that a lateral lisp cannot always be cured.

I have never met a lateral lisp that could not be fixed except in the case of low cognitive skills, autism spectrum disorder, or deafness. I have however met many SLPs who do not know how to treat a lateral lisp. Perhaps those from whom you have heard these negative reports simply do not know how to do it.

I do not know the Greek language, so I do not know how many sibilants you have. American English has six: S (soap), Z (zebra), Sh (shoe), Zh (vision), Ch (chew), and J (jump). I am sure Greek has S, but I do not know the rest of the story. The reason I mention this is because with a lateral lisp, you cannot look only at S. You have to look at how the client is treating all the sibilants. Usually the client uses the same incorrect motor pattern on all of them, and complete success only will be attained when you fix all of them.

I would assume that everything I have outlined in my book on the lisps would apply to all languages. That is because stridency is a universal distinctive feature, and the process to make it is the same in all languages, according to Peter Ladefoged and other linguists.

To create stridency, the tongue elevates its lateral margins and positions them against the sides of the palate. This creates a midline groove. Air travels through this channel and strikes against the front teeth so that frication/stridency is created. My book teaches the basics about how to accomplish this tongue position for the six English sibilants.

For more information see my other blog posts on the lateral lisp. I used to have an on-line course on the lateral lisp, but it is no longer available. We will see if we can do it again soon.

References

  • Ladefoged, P. (2005) Vowels and Consonants: An Introduction to the Sounds of Languages. Australia: Blackwell.
  • Marshalla, P. (2007) Frontal Lisp, Lateral Lisp. Mill Creek: Marshalla Speech and Language.

 

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By Pam M – April 1, 2012

Making Speech Targets Salient – Classic Auditory Training – Tools for Amplifying Speech

This opinion paper was originally posted as a downloadable PDF on my websiteresources page. I am slowly formatting the articles over there for posting to this blog. This post was authored in September 2011. Download the original PDF here.

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Making Speech Targets Salient
Classic Auditory Training
Tools for Amplifying Speech

By Pam Marshalla, MA, CCC-SLP
Speech-Language Pathologist

Making Speech Targets Salient

One of the most important things we do in articulation therapy is to make speech units stand out so the client can focus on them. Our most important tool for making speech units salient is our own speech model. We use our own speech to exaggerate speech in specific ways so that clients can pay attention to the individual sounds/syllables/words we are trying to help them produce better, or to produce for the first time. There are countless ways to help clients pay attention to our modeled utterances. This paper describes many

Techniques

Model

Demonstrate how to say a phoneme, syllable, word, phrase, sentence, and so forth. Modeling the target is the foundation of all speech skill training. Van Riper called it the stimulation method.

Alliteration

Repeat the same sound or word multiple times within the same sentence or phrase. Examples:

  • Young children: Use alliteration while rolling a ball back and forth. Stimulate /b/ by saying, “Bye-bye ball. Bye-bye.”
  • Older children and adults: Use alliteration while stimulating stridents /s/ and /ʃ/ with a tongue-twister –– “She sells seashells by the sea shore. Does she sell seashells by the seashore? If she sells seashells by the seashore, how many sea shells does she sell?”

Amplification

Make speech models louder. Amplification is one of the most direct ways to make a target salient. We can amplify for short periods of time or we can amplify specific targets. There are many ways to do this. See “Tools for Amplifying Speech” below for ideas.

Aspiration

Add an extra measure of exhaled air to the modeled phoneme. This is an effective method of calling attention to a phoneme, especially the voiceless stops /p/, /t/ and /k/ in the final position. Keep in mind that some clients perceive excessive aspiration on a final phoneme as an additional syllable, and they will say it with a vowel. This is called epenthesis. Example: Hat pronounced Ha—tuh. Think of this as a step between no final C, and correct production of the final C. It’s a step forward. The child is progressing from CV to CV-CV to CVC.

Auditory Bombardment

Read a list of words that contain the target while the client plays quietly and listens. Van Riper said we should make a target sound “ring” in the client’s ear. For example, if the target is /ʃ/, and the position is pre-vocalic, the client might be read the following words: Shoe, shop, shake, shower, shampoo, shine, shark, sharp, shove, shut, shoot, shave, sheep, shin, and show. The client’s job is simply to listen to the words as he plays quietly.

Baby Talk

Present models with prolongation of sound (cooing), developmental consonant substitutions, and infantile pitch and intonation. The use of baby talk has always caused controversy. But there is no doubt that baby talk and cooing call attention to one’s speech. “Ooooooo, dat puppy-doggie is soooooo cuuuuuuute! And wook at dat titty-tat. Mewwwwwwwww!”

Cease Production

Produce a target many times in sequence, and then suddenly stop or produce a different sound. Berry and Eisenson (1956) described the process of ceasing production of a target in a delightful game they called Sound Chairs which is played like Musical Chairs: “The children walk around the chairs as long as they hear a certain sound. When the teacher stops making the sound, the children sit down in the nearest chair. The child left without a chair is left out of the game.” Continue play until there is a winner. (p. 137).

Chaining

Teach one phoneme or syllable of a word at a time, and then bring them together in sequence. For example, teach the word goat like this: “Say, /g/… Say, /o/… Say, /t/… Now say, /got/.” Another variation of chaining is to model phonemes or syllables in sequence as the word unfolds. This can be done forward or backward. Here are examples of chaining by syllables in the word telephone:

  • Forward chaining: “Say, /te/… Say, /tele/… Say, /telefon/ .”
  • Backward chaining. “Say, /fon/… Say, /lefon/… Say, /telefon/.”

Classifying

Classify sounds or words by place, manner, voice, or distinctive feature. This is a cognitive activity that makes our clients listen carefully. It is a technique that has been used for decades. For example, Nemoy and Davis wrote that clients should work on “reclassification of words according to whether they begin with a vowel or a consonant [and] according to whether they begin with a voiced or voiceless consonant” (Nemoy and Davis, 1937, p. 26).

Creative Imagery

Van Riper said that we should assign “personalities” to target phonemes in order to pique the client’s auditory imagination. Here are classic examples that can be found in numerous old textbooks:

  • /p/ – Popping popcorn sound
  • /b/ – Bubbles bursting sound
  • /t/ – Timer/clock sound
  • /d/ – Stalled motor sound
  • /k/ – Crashing sound
  • /g/ – Frog sound
  • /w/ – Crying baby sound, “Wah-wah-wah…”
  • /l/ – Singing syllables sound, “La-la-la.”
  • /j/ – Yes sound/Agreement sound, “Yea-Yea-Yea.”
  • /r/ – Growling lion/bear/dog sound
  • “th” (voiceless) – Angry goose sound
  • “th” (voiced)- Smooth motor sound
  • /f/ – Angry cat’s sound
  • /v/ – Vacuum cleaner sound
  • /s/ – Snake sound
  • /z/ – Bumblebee sound
  • /ʃ/ - Quiet sound/Sleeping baby sound
  • “zh” (as in the word beige) – Airplane motor sound
  • /tʃ/ – Choo-choo train sound or sneezing sound, “Ahhh-chooo!”
  • “J” – Jumping sound, “Juh-juh-juh.”
  • /h/ – Panting dog sound

Dampen

Deaden, muffle, or stifle a target. Dampening sound almost always piques a client’s general auditory attention. Plug the ears, or speak through physical mediums like the hands, fingers, blankets, pillows, or stuffed animals. Also have the client plug his ears with his fingers or place his hands over his ears to muffle incoming sound.

Dramatic Flair

Create a mini dramatic scene that underlies the articulation work. Examples:

  • Act astonished as you produce a final /p/.
  • Be sinister as you produce the snake sound–– “Ssssss!”
  • Giggle as you produce a wildly exaggerated intonation pattern.
  • Boo-hoo as you produce a target sound incorrectly.
  • Act like producing a target phoneme causes you to cough, laugh, sneeze, fall over, or fall asleep.
  • Express relief as you say a sound correctly.
  • Choke on a sound you are making in the back of the mouth.
  • Pout as you pretend to be unable to produce a certain phoneme.

Exaggeration

Exaggeration is an old-time method of making speech sounds, words, and prosodic features salient. Speak louder/softer, longer/shorter, smoothly/with stacatto, with high or low pitch, and so forth. Exaggerate to teach new sounds. Exaggerate the client’s incorrect utterance to make it stand out to him.

Language Arts

Use stories, jingles, poems, songs, and so forth, to highlight a phoneme, syllable, word, or phrase. Today we call this literacy and we think this is a new idea. However virtually all the old time articulation therapy books recommended these ideas. For example, Sing Your Way to Better Speech (Gertrude Walsh, 1939) is an entire articulation curriculum that revolves around songs for speech improvement. Literacy satisfies the call to awaken a child’s awareness of a particular sound unit.

Homophones

Use words that sound the same but have different meaning. For example: Which–witch; Some–sum; There–they’re–their. Children really enjoy working with homophones once they understand what is so interesting about them. The drive to understand homophones causes children to listen hard. They are trying to reconcile the concept of same-sound-yet-different-meaning.

Imitate the Client

Say the same sound or word that the child does to help him discover what he can do and is doing. This is an old idea from the language literature, but I have yet to find the source for it. There are four types:

  • Echo: The immediate and exact imitation of a client’s utterance, whether correct or not.
  • Delayed echo: The exact imitation of a client’s utterance after a momentary pause.
  • Echo correction: The immediate imitation of a client’s utterance with correction of pronunciation.
  • Echo expansion: The immediate imitation of a client’s utterance with grammatical additions.

Intone

Add specific intonation to a target. Many therapists use the method called Melodic Intonation Therapy. This technique initially was developed as a method to stimulate expressive speech in adults with acquired aphasia (Albert, Sparks, & Helm, 1973). Music specialists say that the high-low pattern of the “Na-Na Sound” is the first way tone is organized in a child’s brain. (I learned this from personal acquaintances that are music teachers and vocal coaches.) The “Na-Na” pattern is especially useful to highlight the individual auditory signals of syllables with children. For example, say the word baby with high pitch on the first syllable and a lower pitch on the second syllable.

Isolate

Model phonemes, syllables, words, or phrases in isolation. Train the client to hear the target in isolation, then train him to hear it amid other more complex speech stimuli. For example:

  • Syllable: To teach the word telephone, model the isolated syllable “phone” and then model the whole word “telephone.”
  • Phoneme: To teach the word soap, model the isolated phoneme /s/ and then model the word “soap.”

Omit

Leave out a target. We omit a target to call attention to it. For example, to draw attention to the /r/ of the word car, we can model “ca….” The client’s ear is drawn to the missing phoneme. This causes him to listen hard for it in our next production. It also causes him to listen to it in his own next production. This is the skill of auditory closure at work.

Pantomime

Produce a target without breath or voice. Mouthing a phoneme, syllable, or word is a stimulation technique found in many old-time articulation therapy textbooks. This method captures a client’s visual and auditory attention. The client watches and listens harder because the acoustic signal is absent.

Pause

Hesitate or pause before or after a speech target. Pause before a target to engage the client’s anticipatory listening. Pause after a target to extend the time during which the client’s auditory system rings with the model sound.

Prolong

Say a target longer. Prolongation makes a target stand out, and it gives the client more time to listen to it. This is a good method to use with clients who take a moment to direct their auditory attention to our models. Prolongation can be used with any [+continuant] phoneme. This also is an excellent method for clients who are having difficulty with phoneme transition sequences. For example, prolong the vowel in the word car in order to give the client time to hear the transition movements from the vowel to /r/.

Remove

Remove distracting elements from around a target. For example, do the following when a client substitutes f/pl in the word please–– Remove the /l/ and model please as “pease.” This allows the client to hear and produce the /p/. Put the /l/ back in later.

Repeat

Modeling a target many times in sequence. Examples:

  • Repeat phonemes alone: “F… F… F…”
  • Repeat phonemes in words: “P… P… Pie”
  • Repeat syllables alone: “Or… Or… Or…”
  • Repeat syllables in words: “Or… Or… Organize”
  • Repeat words alone: “Shoe… shoe… shoe…”
  • Repeat words in phrases or sentences: That shoe… shoe… shoe… is mine.”

Rhyme

Use rhyming words for fun and focused attention. For example, make up lists of words that rhyme and that contain the client’s target–– car, bar, far, jar, star, par. Also use rhyming children’s storybooks such as those written by Dr. Seuss.

Schwa

Add a schwa after a target. This is called epenthesis. Most therapists consider it a deviant phonological pattern, but I consider it a step toward mature productions.

  • Final consonants: Add a schwa to draw attention to a final consonant. For example, model the word ball as “baw-luh.”
  • Clusters: Add a schwa after the first phoneme of a cluster so the client can hear both consonants. For example, model blue as “buh-lue.”

Separate

Separate the phonemes of a word. This allows the client to hear the individual phoneme units. Example: duck pronounced “d—u—ck”. This is a very old method, for example, “It is well to break up the words into single sounds or groups” (Ward, 1923, p. 29).

Shorten

Truncate the production of a target, and/or speak in a clipped, choppy, or staccato-like manner. Shortening a sound punctuates it. Speaking in a choppy manner helps draw the client’s attention to certain features. It is especially good for emphasizing syllables.

Silence

Don’t say anything after the client produces a target. Remain quiet for your turn in the therapy dialogue. This causes the client’s own utterance to resound in his ear. It causes the client to reflect back on his own production, a skill we call auditory self-monitoring.

Slow Down

Slow down all aspects of speech production in therapy. We can’t talk quickly and expect clients to talk slowly. Slowing the pace of everything said by you in therapy has an overall positive effect on slowing the client. We slow rate by over-emphasizing syllables. Traditional articulation therapy texts recommend slowing as a critical aspect of speech training. Motor speech disorders texts almost always recommend slowing rate of speech as a critical aspect improving intelligibility, especially in dysarthria.

Speak Simultaneously

Speak the same sound at the same time with the client. This is a way to train children to listen very carefully. Both the therapists and the client say a sound, for example, /m/. The sound is prolonged so that both parties are saying it simultaneously. As the child alters the prosodic features of the sound (the voice, loudness, stress, pitch, etc), the therapist follows his lead so that they are always intoning the same sound together. Likewise, the therapist can make subtle changes in her own place, manner, or voice characteristics that the child must follow. This is an especially good method for teaching new vowels. Teach the client to prolong his error vowel. Then the therapist simultaneously produces a prolongation of the client’s incorrect vowel. Then the therapist slowly alters her own vowel so that it begins to sound like other vowels, including the target. More time is spent lingering over the target gradually. These subtle alterations help the client move toward the new vowel. If this is done simultaneously with prolongation of voice, the client will have enough time to process the changes with his ear as he makes the changes with his voice.

Stress

Placing emphasis on a target. Examples for the sentence “I live in Colorado.”

  • Stress a target phoneme: “I live in ColoRRRRado.”
  • Stress a target syllable: “I live in ColoRAdo.”
  • Stress a target word: “I live in COLORADO.”
  • Stress a target phrase: “I live IN COLORADO.”
  • Stress a target sentence: “Didn’t you hear me? I LIVE IN COLORADO!”

Substitute

Speak another phoneme in place of the target. Purposeful substitutions motivate clients to listen harder in order to catch us making errors. Example: Say “Woggie” for “Doggie” to highlight the initial /d/. Play with these variations. Young children love this!

Whisper

Produce a target with a breathy whisper. Whispering almost always piques a client’s general auditory attention. Whispering is an especially good tool to highlight voiceless-ness and frication. Whisper into a tube, box, or bowl to amplify the whisper and to make the target really stand out. See “Tools for Amplifying Speech” below.

Word Pairs

Produce words in pairs that are different by one phoneme. The single change causes the target to stand out. Presenting words in pairs generally considered a new idea traced back to 1974 when minimal pairs contrast training was proposed [LaRiviere et al, 1974]. But the idea goes way back. For example: “Drill in pairs: once/one, any/many, fought/fit…” (Blanton & Blanton, 1919, p. 245).

Classic Auditory Training

Traditional articulation therapy books stress the importance of auditory training, or ear training, in the development of speech. The ear is the primary feedback mechanism and the fine tuner of speech. It is the main system used to monitor adjustments to respiration, phonation, resonation, and articulation for speech improvement. The vast majority of clients with articulation deficit do not have hearing deficit. But these clients usually are not listening well to themselves or others, and they are not making comparisons between the two. Therapy is designed to develop these skills specific to the phonemes being taught.

Techniques

Anticipatory Listening

Getting ready to listen. We say all kinds of things to help clients get ready to listen: “Ready… Get your ears ready… Here it comes… Listen… Oh-oh. Wait…” Van Riper and Irwin described anticipatory listening beautifully in the following analogy––

“The foot racer, crouched for the start, tenses certain muscles in anticipation of the signal to go. He also ‘sharpens his ears’ and anticipates with a kind of inner rehearsal the sound of the pistol. He is doing some advanced listening. This experience of pre-hearing, of auditory alertness to an expected signal, is what we mean by anticipatory listening” (Van Riper and Irwin, 1958, p. 130).

Auditory Association

Recognizing the similarities between two sound units. This is the basis for Van Riper’s Association Method. Teach a new sound by calling attention to its similarity to another sound the client already can produce. Examples:

  • Place: Use /t/ to teach /s/
  • Manner: Use /ʃ/ to teach /s/
  • Voice: Use /s/ to teach /z/

Auditory Attention

Focusing on specific sound units as significant stimuli. Auditory attention is perhaps the most important first step in sound remediation. We must make the target grab the client’s auditory attention. For example, if the child’s cognitive level is at the two-year level, then we engage him in listening activities that normally would be interesting to a two-year-old.

Auditory Awareness

Becoming aware of the characteristics of a sound. Most authors agree that auditory awareness must work together with visual, tactile, and kinesthetic awareness for phoneme correction, however, “The auditory impression is the most potent sensory avenue of approach in speech teaching” (Anderson, 1953, p. 124). We help our clients become more aware of phonemes, syllables, and words by using any of the methods described in the opening section of this document.

Auditory Blending

Combining the phonemes of a word produced with separations between them into entire words. For example, model soap as “S—–oap”. The client might begin by speaking the word in separated units like the therapist did. Using his powers of auditory blending, however, the client will begin to blend the word soap together back into one single unit.

Auditory Closure

Completing a word by filling in the parts omitted. For example, model cat as “Ca….” The client fills in the final sound and says, “cat.” This work forces the client to search his auditory memory for the correct auditory image, to match his production to this image, and to close the target.

Auditory Comparing

Comparing one’s production to a community standard. This was a standard of practice before political correctness took over. It was called the comparator function (Van Riper and Irwin, 1958). The client must understand how most people within the speaking community pronounce a certain sound unit. We use words of comparison to help the client understand this: correct/incorrect, old/new, how you are doing it/how most people do it, how babies say it/how older children say it, how people from Boston say it/how people from Atlanta say it, and so forth.

Auditory Discrimination

Detecting differences between sounds in the language, and detecting differences between correct and incorrect productions. Next to auditory awareness, this is perhaps the most important skill we teach. Some clients have difficulty in this area, and others do not. Certain formal tests have been used in the past to measure these skills, but usually this is an informal assessment accomplished during the course of therapy. We teach the client to discriminate his target sound from all other sounds, and to discriminate the correct target from his error production.

Auditory Fatigue

The normal temporary loss of sensation following a period of stimulation. This is not a skill, but a lack thereof. For example, a client might be listening to himself as he performs quite well trial after trial, and then suddenly he becomes confused, or can’t do it correctly any more. We work in such a way that auditory fatigue is avoided. Auditory fatigue also can be a problem for speech-language pathologists at the end of a busy week.

Auditory Self-Monitoring

Listening to oneself talk. Deficiency in auditory self-monitoring can be a huge problem in many clients, and it is perhaps the greatest reason that carryover fails. “We must teach [the client] to scrutinize his own auditory feedback” (Van Riper and Irwin, 1958, p. 116). The most egregious example of this failure is seen in the client who is highly unintelligible in connected speech yet can pass an articulation test. This client must learn to listen to himself. We do this in therapy by taking away our judgments of his correct and incorrect productions, and by forcing him to make his own judgments. We ask the client, “How did you do on that one?”

Auditory Figure-Ground Discrimination

Selecting the relevant from the irrelevant auditory stimuli in an environment. This is also called auditory differentiation, selective listening, and competing messages integration. For example, this type of discrimination is needed when a child has to listen to his teacher’s verbal instructions being given in the front of the class while ignoring children whispering nearby. Poor auditory figure-ground discrimination can interfere with the development of both speech and language. Teach the client the following–– “We are not listening to that… We are listening to this….”

Auditory Fixing

This is Van Riper and Irwin’s term for listening while trying to produce a target, while oscillating around the correct position of the target, and then fixing one’s auditory attention on the correct production of the target––

“The new sound must be strengthened [and] repeatedly practiced. This is done to enable the new tactile and kinesthetic feedbacks to merge with the auditory feedback” (Van Riper and Irwin, 1958, p. 117).

Auditory Identification of Word Position

Identifying whether a phoneme occurs at the beginning, middle or end of a word. Early SLP’s developed this method but its value in articulation therapy has never been tested. It is a simple addition to treatment for children that generally helps them listen hard and become more aware of the target phoneme.

Auditory Localization

Locating the physical source of a sound, whether near or far, high or low, left or right, and so forth. The client’s auditory world is integrated with the world he perceives with his other senses. This is a primitive skill that develops during infancy, and it is not usually an issue in an articulation disorder. Problems with auditory localization generally are more a concern with severe motor speech deficit, sensory-motor issues, and language disorders.

Auditory Memory

  • Auditory sequential memory: Storage and retrieval of information requiring a specific order of input and recall. Therapy idea: Use visual sequences like blocks to help clients remember items in sequence.
  • Long-term auditory memory: Memory retained for an indefinite period of time. Therapy idea: Use concepts, contexts, cues, and drill to aid this.
  • Short-term auditory memory: Memory retained for only a relatively brief period of time. Therapy idea: Use chaining, review, and rehearsal.
  • Rote auditory memory: Storage and retrieval of information without comprehension. Therapy idea: Use rapid model-response to aid this.

Negative Practice

Listen to and practice the error.

“Deliberately contrasting the ‘wrong’ way and the ‘right’ way of an aspect of voice or articulation provides valuable ear training…. Juxtaposing incorrect and correct productions enables you to make auditory discriminations which would be impossible if you tried to say only the correct form; furthermore, it enables you to compare the tactile and kinesthetic sensations of the two articulations” (Fisher, 1966, p. 25)

Tools for Amplifying Speech

There are a variety of objects that can be used during the process of amplifying speech. Costs range from very expensive to no cost at all. Each object has its own benefit. Make sure to give young children time to experiment with these objects before you make them perform specific tasks with them. Otherwise they will be far too interested in the tool itself and will ignore what you are trying to teach them with it. Make sure to follow sanitary procedures at all times.

Mouth-to-Ear and Nose-to-Ear Tools

Tools that carry the child’s voice from his mouth or nose to his ear.  Examples: flexible tubing, Rapper Snapper, Oral and Nasal Listener, HearPhones, Elephones, TalkBack Tool, toy telephones, elbow joints, and hands.

Places and Spaces

Enclosed spaces that amplify a child’s voice.  Examples: cabinets, closets, boxes, hallways, stairwells, blankets, and children’s forts.

Small Amplifiers

Small items that amplify a child’s voice back to him. Examples: cups, bowls, EchoMics, funnels, megaphones, and cardboard rolls.

Electronic Equipment

Electronic equipment that can amplify a client’s voice back to him. Examples: Auditory Trainer, Phonic Ear, home stereo systems, and boom boxes that have microphones and earphones.

References

  • Albert, M., & Sparks, R., & Helm, N. (1973). Melodic intonation therapy for aphasia. Archives of Neurology, 29, p. 130–131.]
  • Anderson, V. A. (1953). Improving the Child’s Speech. New York: Oxford University.
  • Berry, M. F., & Eisenson, J. (1956). Speech Disorders: Principles and Practices of Therapy. NY: Appleton-Century-Crofts.]
  • Blanton, M. G., & Blanton, S. (1919). Speech Training for Children: The Hygiene of Speech. NY: The Century Company
  • Edwards, M. L. & Shriberg, L. D. (1983). Phonology: Applications in Communicative Disorders. San Diego: College-Hill.
  • Fisher, H. B. (1966). Improving Voice and Articulation. New York: Houghton & Milton.
  • LaRiviere, C. H., & Winitz, H., &, Reeds, J., & Herriman, E. (1974). The selective reality of selected distinctive features. Journal of Speech and Hearing Research, 17, p. 122-133.
  • Nemoy, E. M., & Davis, S. F. (1937-1954). The Correction of Defective Consonant Sounds. Magnolia, MA: Expression.
  • Van Riper, C. & Irwin, J. (1958). Voice and Articulation. Englewood Cliffs: Prentice-Hall.
  • Walsh, G. (1939). Sing Your Way to Better Speech. NY: E. P. Dutton & Company.
  • Ward, I. C. (1923, 1929, 1931). Defects of Speech: Their Nature and Their Cure. London: J. M. Dent and Sons.

 

Posted in Articulation, Oral Motor.

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By Pam M – March 28, 2012

Evidence for Cues

Q: I am a SLP graduate student looking for some evidence-based practice to implement for a client diagnosed with childhood apraxia of speech. I watched the YouTube videos of your hand cues for placement, and I think they would work great. I was wondering if you had any research to support these cues, or if you obtained research elsewhere to support them.

A therapist doesn’t look for an evidence-based practice: A therapist creates one.

The EBP is formed when a therapist integrates information from three areas: (1) Laboratory research, (2) The therapist’s own clinical experiences, and (3) The needs of the client sitting across the table (see references below).

Do not get mislead by the incorrect idea that therapists only use methods that have been researched. Nothing could be further from the truth. Please see the references below, and search under “evidence based practice” on this Blog for more information on the real meaning of creating an EBP.

I have been a full-time clinician for 36 years, and I do not do the type of research on my methods that you are seeking. My cues were developed from working with hundreds of clients, an experience which often gives one far more information than that obtained from reading research.

Hard evidence about “cues” in general can be obtained by searching the ASHA journals online under the following key words: cue, cuing, gesture, tactile, and Blissymbolics. This is exactly what I am doing for my next book, which will have a chapter on the use of cues in articulation therapy. Also check the basic text you used in your articulation/phonology class. It should have a section on using cues in articulation and language therapy, and there should be references there.

References on the EBP

  • American Speech-Language-Hearing Association. (2010) Evidence-Based Practice. www.asha.org.
  • Dollaghan, C. A. (2007) The Handbook for Evidence-Based Practice in Communication Disorders. Baltimore: Paul H. Brooks.
  • Friedland, D. J. et al (1998) Evidence-Based Medicine: A Framework for Clinical Practice. New York: McGraw-Hill.
  • Justice, L. (2008) Evidence-based terminology. American Journal of Speech-Language Pathology, Vol 17, No 4, November. Pp x-x.
  • Sackett, D.L., Rosenberg, W.M.C., Gray, J.A.M., & Richardson, W.S. (1996) Evidence-based medicine: What it is and what it isn’t. British Medical Journal, 312, 71-72.
  • Sackett, D. L., & Richardson, W.S., & Rosenberg, W., & Haynes, R.B. (1997) Evidence-Based Medicine: How to Practice and Teach EBM. Edinburgh: Churchill Livingstone.
  • Schooling, T. (2010) Systematic Review of Oral-Motor Exercise. The ASHA Leader, May 18, 2010, p. 12.

Posted in Apraxia and Dysarthria, Evidence-Based Practice.

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By Pam M – March 25, 2012

Age of Treatment Onset for Frontal Lisp

Q: How young will you see a child for an interdental/frontal lisp?

Yours is one of the toughest questions to answer because there are different perspectives and different reasons for early treatment.

If there is a speech problem only, most therapists in the public schools seem to wait for a child with a frontal lisp to turn 7 years of age and older. However, I meet many school SLPs who see these kids in kindergarten and first grade. Therapists in private practice tend to start these clients at anywhere from four-to-six years of age, and I have met private practitioners who begin at age two years. The upshot of all this is that this is completely up to you and your sense of the child and his home situation.

In my private practice, I often see four- and five-year-old children for these types of problems, and I do so when the child is absolutely ready and/or the parent is pushing for it. I like to begin when the child knows s/he has a problem. I also prefer to begin with this age group if a parent does not know how to back off and let the child mature. (There seems a lot more of that these days.) I also make medical and dental referrals as early as possible if there seems to be respiratory or orthodontic issues related to the frontal lisp.

I also have worked on these errors in two- to four-year-old children. For me this therapy usually includes activities to help eliminate sucking habits that are present, and activities to keep the tongue inside the mouth while making the “Snake Sound” (S), the “Quiet Sound” (Sh), and the “Choo-Choo Train Sound” (Ch). I also begin teaching the alphabet song, making sure that they are saying the whole thing with the tongue inside the mouth. I use a mirror, pictures, cues, and over-focus on E position for oral stability, and other simple introductory ideas, and I usually do not work on specific tongue position. Keeping the tongue inside the mouth and producing different forms of stridency are the main ideas. Perfection of sound quality is not a goal for me.

Often I simply show parents how to do this at home. I teach the parents how to have these activities “come up” during the course of the day. In actual fact, this is therapy, but it is not weekly traditional therapy like one might do with an elementary school child.

If the parents are overbearing, obnoxious, demanding, or demeaning to their children, and I do not feel comfortable having them intervene in their child’s speech development, I have these little tykes come in for weekly treatment. This way I can teach the parents how to talk with their children in ways that foster safe and secure growth and development. Occasionally I have to refer these parents for their own psychological counseling.

If teaching a very young child to pull the tongue inside the mouth for all the sibilants results in him producing a lateral lisp (which does occur occasionally), then I back off completely. I focus on T in simple words like “eat” and “out” instead. This provides practice for keeping the tongue inside the mouth, and is the foundational tongue position for all the sibilants.

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By Pam M – March 22, 2012

Treating a Whistled S

Q: My client started with a frontal lisp. Now he is now producing a “Whistling S.” How do I correct this?

A whistling S usually is an S that is being made in just the right place that whistling occurs. Simply have your client begin to move his tongue-tip higher or lower, slightly more forward or back, or slightly more to the left or right as he prolongs his S. You are searching for the place that works to alleviate the whistle and achieve the best sound quality on S for him. That is all a matter of trial and error. You are training his ear to hear the fine differences that occur in the sound quality as he moves his tongue-tip by millimeters at a time in one direction and then another.

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By Pam M – March 18, 2012

Using the Syllable Method for R

Q: I recently attended your seminar on R therapy. I have a student who can say “growl” but that’s it. Should I use your syllable method?

Yes! Use the syllable method!

If he can do the word “growl”, then he should be able to say “grah” by taking the end of the word off. Then if he can say, “grah”, he should be able to say “ground”, “grouch”, “grout” and so forth. Just make sure to make the words into two distinct syllables, and exaggerate each one:

  • “Ground” will be pronounced “Grah” (pause) “Ound”
  • “Grouch” will be pronounced “Grah” (pause) “Ouch”
  • “Grout” will be pronounced “Grah” (pause) “Out”

Then put these words in simple phrases, sentences, and paragraphs.

Keep the pauses between the two separated syllables as long as you need to. Help him learn to blend the syllables back together into one.

You are on your way!

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By Pam M – March 15, 2012

What is Oral Stability?

Q: You use the phrase “lack of stability” in relation to oral motor function. What do you mean by “stability”?

I will have a full chapter on oral stability in my next book to be called The Marshalla Guide to 21st Century Articulation Therapy. Until then, the following is something I wrote in an article for the Oral Motor Institute:

Stabilize Oral Movements

To stabilize is “to make or become stable” (Jewell & Abate, 2001, p. 1656) or “not likely to change” (p. 1656). Stability is a fundamental concept in motor therapy. “We must have a stable base from which to develop movement and functional skills. Without that stability, our function or mobility is less controlled [and may be] impossible” (Morris & Klein, 2000, p. 62). There is interplay of stability and mobility in all movement. Stability does not mean rigid or fixed, however. Stability is relative and dynamic: one part of the body holds relatively still so that another part can move with greater accurately. The body stabilizes proximally while moving distally. “Generally, the central or proximal parts of the body are the first to develop stability or become controlled. From a controlled, proximal base of stability, the infant can have the possibility of greater mobility and more refined distal control” (Morris & Klein, 2000, p. 62). “Postural control of a part of the body always precedes movement control of that part” (Mysak, 1980, p. 105).

Speech-language pathologists utilize techniques to stabilize the jaw for improved lip and tongue mobility. “The ability to stabilize the jaw creates the needed prerequisite for the development of skilled and refined tongue and lip movements” (Morris & Klein, 2000, p. 63). Techniques to stabilize the cheeks and face are used to improve lip mobility. Techniques to stabilize the back lateral margins of the tongue are used in order to facilitate improved mobility of other parts of the tongue. And techniques to stabilize the hip and should girdle, and the head and neck, also are incorporated in order to facilitate improved jaw mobility. “The emergence of stability and mobility functions is an essential part of speech skill development” (Fletcher, 1992, p. 13). Techniques to facilitate oral stability are found in a variety of speech texts. Examples:

  • To stabilize the jaw for improved tongue mobility for production of lingua phonemes: “Using a bite block to stabilize the mandible and reduce mandibular support during speech may help to increase independent lingual movement and result in improved oral articulation for speech … [The] bite block is placed between the first molars on one or both sides … With the block in place and following a period in which the child adjusts to the presence of the block, a series of speech sounds and sound sequences are presented for imitation by the child” (Crary, 1993, p. 224).
  • To stabilize the lips and facial muscles with low muscle tone: “Play patty-cake, peek-a-boo, and other children’s games that incorporate patting, tapping, stroking, and other types of tactile and proprioceptive stimulation of the cheeks and lips. Tapping can be done directly around the temporomandibular joint to provide better jaw stability for lip and cheek mobility” (Morris & Klein, 2000, p. 445).
  • To stabilize the back of the tongue for eliminating a frontal lisp: “We can help our clients keep the tongue inside the mouth by developing [the tongue's] back lateral stability” (Marshalla, 2007, p. 115). Techniques include: “draw a picture,” “stroke the zones,” “smile,” “bite gently on the zones,” “establish the butterfly position,” “hold the butterfly position,” and “spread the back of the tongue” (p. 115-116).

References

  1. Crary, M. A. (1993) Developmental Motor Speech Disorders. San Diego: Singular.
  2. Fletcher, S. G. (1992) Articulation: A Physiological Approach. San Diego: Singular.
  3. Jewell, E. J., & Abate, F. (2001). The New Oxford American Dictionary. NY: Oxford University.
  4. Marshalla, P. (2007) Frontal Lisp, Lateral Lisp. Mill Creek: Marshalla Speech and Language.
  5. Morris, S. E., & Klein, M. D. (2000). Pre-feeding skills: A comprehensive resource for mealtime development. Austin: Pro-Ed.
  6. Mysak, E. D. (1980). Neurospeech therapy for the cerebral palsied: A neuroevolutional approach. NY: Teachers College Press.

 

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By Pam M – March 10, 2012

“Ruh” – Blocking Out The Old Motor Memory

Q: I attended your conference on Frontal Lisp, Lateral Lisp, and Distorted R a few weeks ago, and I have been trying your methods. Your L-to-R tapping method has WORKED on my toughest clients! They can say “Ruh” but we don’t call it “R”––we call it “The way back L.” On all of your material, you have it typed out as “Ruh.” I am hesitant to write it that way for word practice because then my clients have been reverting back to the old way of saying R. So far I’ve been just typing “Luh-b” (for “Rub”). Any suggestions?

Perfect, wonderful, amazing, excellent. I agree with your findings. I also don’t mention R if it messes up the client. We are on the same page.

If you review my handout, you will see that I wrote one slide in the morning lisp section that says, “Tell your client, ‘Don’t say S.’ ”

Then, when I was showing the class how to do the R methods in the afternoon, I repeated several times the instruction, “Don’t try to say R. Just do what I tell you.”

I call this “Blocking out the old motor memory.”

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By Pam M – March 6, 2012

Stimulating Tongue-Back Elevation for K and G

Q: I cannot get K or G out of my client although I think I have tried every trick in the book! For example, I have used modeling, auditory bombardment, tactile cueing, using a tongue depressor to hold the tongue-tip down, using a tongue depressor to push the back of the tongue down to create the reflex to get it to pop up, putting sweet taste on the velum to get back of tongue to reach for it, using gravity, having him look up while saying “k”, and making the “crashing” sound while playing with cars. I cannot get him to keep that tongue tip down.

Everything you are doing sounds great, but I think you might be doing one method wrong. You wrote that you were “using a tongue depressor to push the back of the tongue down to create the reflex to get it to pop up.” Let me straighten this out. You may be doing it right and just writing it wrong, I’m not sure. It’s hard to put some of this stuff into words…

Basically we don’t “push the back of the tongue down to create a reflex to get it to pop up.” I think you are combining the Tongue Retraction Reflex with the idea of using Resistance to teach tongue-back elevation.

1. We can stimulate the TONGUE RETRACTION REFLEX to get the tongue to retract back and hump up.

To do this we stimulate the upper surface of the tongue, from tip-to-back down the midline. As some point, usually about 1/2-way back to 2/3-way back, the tongue will retract, meaning that the whole tongue will retreat backwards and hump up to form itself into a ball that occludes the oropharyngeal area. The balled-up tongue forms rather a “plug” for the oropharynx. We continue to tease the tongue (tap it) so that it stays up there momentarily. While it’s up there, ask the client to say H gently. If it works, it will cause him to say H while the whole tongue is balled up toward and pressing gently up against the velum. This will sound like a VELAR FRICATIVE or VELAR RASPBERRY. Now you have the “crashing sound” that can be shaped into K.

2. We can use RESISTANCE to stimulate upward movement of the back of the tongue.

To do this we press DOWN gently on the back 1/3 of the tongue with a tongue depressor while asking the client to “Push it up.” This literally teaches him to push upward with the back of the tongue. If he can’t do it, use something with more power––like a cold metal spoon, or a Nuk with its nubs. To make this even more powerful, and actually simpler, have him do this to himself with a tongue depressor, or have him use his own finger so he can feel the upward movement of the tongue-back.

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By Pam M – March 1, 2012

Final C’s: Recommended Methods

Q: My client produces final consonants inconsistently. Do you suggest using minimal difference pairs? Multiple oppositions? I have tried targeting individual sounds as well as teaching several sounds at the same time. I’m wondering what methods you recommend.

I use every technique I have ever heard of. I believe that all methods have value. Our job is to pair the right technique to the right client at the right moment. A certain technique might work perfectly well with one client and not at all for another. Also, a certain technique might work perfectly well with a client one day and not the next. This makes therapy a process of trial and error. It’s not the method. It’s the process of figuring out how the client learns, and doing that. It’s a process of figuring out how to get certain ideas into our clients’ heads, and how to get them back out again.

Having said that, I have written about stimulating final consonants before. Please see:

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By Pam M – February 26, 2012

The Jay Leno Effect

Q: Does your explanation of techniques to address jaw and tongue stability pertain to clients with the Jay Leno phenomenon? Does the E technique help those kids with lisps related to this facial structure?

Jay Leno's profile

Jay Leno's profile

Techniques to address oral movement are for oral movement problems. As you have noted, Jay Leno has an oral structural problem, too. Structure and function are addressed differently together.

I have never worked with Leno, so my analysis of his situation is cursory and speculative, of course. He appears to have an oral structural problem that consists of at least the following––

  1. The mandible may be too large relative to a normal maxilla,
  2. The maxilla may be too small relative to a normal mandible.
  3. The mandible and maxilla may not fit together appropriately because the mandible is too large AND the maxilla is too small.
  4. There are other unknown orthodontic/facial structural problems that cannot be known without proper cephalometric analysis.

I think Leno’s problem may be #2 predominantly. The outstanding feature of his face is the large chin, of course. But if you look beyond the chin, you see that the middle third of his face appears squashed in. (This is the same structural problem classic of Down Syndrome.)

Once we determine the problem with the hard structures (the jaw, palate, and teeth), now we look at the function of the soft tissues (the lips, and tongue). I always analyze tongue movement and position relative to both the upper and lower front teeth. Looking more carefully at Jay, I do not believe that he actually protrudes the tongue between the front teeth during speech; therefore I do not think his tongue is unstable because of poor back lateral stability.

My hunch is that Jay’s tongue has very little room to move in the front because of a small maxilla. The tongue probably is the right size relative to the jaw, and therefore is in correct position relative to the lower teeth. But Jay’s speech comes across as a type of frontal lisp because the front of the tongue doesn’t have enough room to move. [Keep in mind that this is all speculation due to limited assessment.]

Assuming we are correct, a client who has a bone problem like this needs corrective orthodontia/surgery, or he need to learn to keep his tongue unnaturally further back. In that case, using E and other methods to pull the tongue further in would be what I would do.

My course of action for Jay Leno would be this:

  1. Refer for orthodontic evaluation. No further work on his speech should be attempted before we understand how the structural problem relates to it. This is good old-fashioned articulation therapy at work. Structure and function interplay.
  2. Once the structure is understood, we can determine a course of action together with the client. Therapy options would include at least the following:
    • Do nothing and keep things just the way they are. This is a client’s option. Wish him well as you dismiss him from therapy.
    • If orthodontia/surgery is not an option, teach the client to compensate for his structural problem. For Jay that probably means to teach him to keep his tongue further back away from his front teeth by teaching a more posterior back-lateral position. I also would teach him to over-articulate to improve clarity. (I assume Jay is already doing these two things to a certain extent. I would love to see him speak when he is tired and not in front of an audience. I wonder if that tongue comes out.) This also is good old-fashioned articulation therapy at work. Van Riper said to teach compensation when structural problems could not or would not change.
    • If orthodontia/surgery is an option right now, initiate them first. Hold off on articulation therapy until after the structure has been changed. Re-test speech after the structural change has been made, and initiate therapy if necessary. Therapy may not be necessary after the structure has been changed.
    • Orthodontia/surgery can be a viable option for some clients later in life. This is especially true for children. In these cases, teach the client to compensate for the problem while it exists, and dismiss him until after the structural changes have been made. Then re-test to determine if therapy is needed.

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By Pam M – February 22, 2012

Stimulating [+Anterior] Phonemes with a Thumb Sucking Habit

Q: My client only produces [+Back] consonants K and G, and he sucks his thumb. His tongue is beginning to move for L. Do you think that the thumb sucking is keeping his tongue retracted?

Tongue retraction can have many causes including an oral habit like thumb sucking. It also can be the result of oral-tactile hypersensitivity that is causing the tongue to pull back and high in a perpetual “high guard” position. It also is a problem when oral muscle tone is too high. It also can be a simply habit.

From a speech motor perspective, the anterior sounds P, B, M, W, T, D, N, and L come in when the jaw begins to move up-and-down. Therefore babies begin to babble primarily with [+Anterior] consonants because the jaw begins to oscillate up-and-down. The up-and-down jaw movement pattern causes the lower lip to bang upward against the upper lip, and it causes the anterior tongue to bang upward against the upper lip and gums (or teeth if the child has any). This movement pattern emerges between 4-6 months of age when the jaw also begins to oscillate up-and-down in spoon-feeding.

A child who produces no [+Anterior] consonants and who principally backs his consonants may not have activated the jaw’s basic up-down oscillating movement pattern. The thumb may be preventing the pattern from emerging if it is in the mouth much of the day and/or night. The thumb acts to hold the jaw and anterior tongue in a low position. This can prevent both the jaw and the tongue from becoming active for the anterior consonants.

Whether the thumb is the cause of the lack of anterior phonemes in this case is uncertain. This depends on how often and for how long the thumb is in the mouth. I would want to find out if the client keeps the thumb in the mouth for five minutes at a time, or for hours at a time, when he is awake. At night I would want to know if the child sucks his thumb only for a few minutes to fall asleep, or if he sucks it off-and-on throughout the entire night. We need to know about frequency and duration of thumb sucking.

My preference would be to help the family understand that the thumb sucking must go. Although we have no “proof” in the laboratory sense that thumb sucking causes problems with the emergence of anterior phonemes, we certainly can say that it might be for this child. The only way to know if thumb sucking is affecting the child’s speech is to eliminate it. My book called How to Stop Thumbsucking has many ideas about how to go about this. Another book on this topic by Rosemary Van Norman also is good. [Van Norman, R. (1999) Help for the Thumb-Sucking Child. NY: Avery]

In terms of stimulating the anterior phonemes, my preference would be to stimulate all of them in babbling sequences and words with “Ah” without trying to stimulate any one in particular. In other words, I like to cause the [+Anterior] feature to emerge first. I worry about the particular phoneme second.

Simple CV and CV-CV words would be my preference. For example:

  • CV: pah (pop), bah (bye), Mah (mom), Wah (water), Tah (hot), Dah (dad), la (singing sound), na (no)
  • CV-CV: pah-pah (grandpa), bah-bah (bye-bye or bottle), Mah-mah (momma), wah-wah (water), tah-tah (bye-bye), dah-dah (dada), lah-lah (the yellow Telletubby or the word “yellow”), nah-nah (grandma, nanny, no-no)
  • CV-CV in the diminutive form: doggie, kitty, birdie, horsie, mommy, daddy, baby, nanny, blankie (blanket), etc.

As I stimulate emergence of these sounds, I make sure the child is producing them with big up-and-down jaw movements, and I don’t worry about what the lips or tongue are doing. The jaw has to do this work first. I stimulate for appropriate lip and tongue movements only after the sounds emerge with the big jaw movements.

I also would teach the lingua-alveolars T, D, N, L in babbling sequences with the tongue OUTSIDE the mouth at first so that the anterior portion of the tongue is banged upward against the upper lip and teeth. This will “awaken” the anterior portion of the tongue. Bring it inside the mouth later, only after the [+Anterior] phonemes begin to emerge.

I also would be providing some oral-tactile experiences to awaken the lips and anterior tongue.

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By Pam M – February 20, 2012

What is a Tongue Thrust?

Q: Is four years old too early to address a tongue thrust?

The term “tongue thrust” has had many meanings through the years. It can mean:

  1. A strong forward thrusting of the tongue following the swallow.
  2. A reverse swallow pattern.
  3. An infantile suckle-swallow pattern.
  4. An interdental tongue protrusion on all lingua phonemes..
  5. An interdental tongue protrusion on all the lingua-alveolar phonemes.
  6. An interdental tongue protrusion on the all the sibilants.
  7. An interdental tongue protrusion on only S and Z.

To which are you referring? Your answer will help me give you an appropriate answer to your question.

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By Pam M – February 16, 2012

Teaching Co-articulation Movements

Q: I have a student, who has been working on R, and who can make it at the word and sentence levels, but who cannot seem to co-articulate automatically. He still articulates each sound individually within words. For example he does not automatically round his lips for the word “core.” When I say the word “core” my mouth stays rounded for the entire word however they don’t do this. Why don’t their minds just naturally catch on to coarticulation after so many years of diligent work?

My contention has been for many years that the inability to generalize newly learned articulation skills is what makes some of the hardest clients so hard. We probably never will know why. Their brains simply don’t do this on their own. Therefore some of our most difficult clients need to be led slowly and carefully through all levels of therapy including the level at which co-articulation occurs.

The motor speech scientists of the early 20th century(1) argued that the syllable (and not the phoneme) was the basic motor unit of speech. They said that the vowel was the main “movement” or “shape” of the syllable, while the consonants were “auxiliary” or “additional” movements added to the basic shape. They said that when we produce a syllable, the mouth first shapes itself for the vowel, and it holds this shape while the consonants are added to it. The reason your lips stay round throughout the word “core” is because the mouth assumes the O position first, and it holds this position while C and R are added to it.

This is what I do to teach this skill:

  1. Teach the client to make and prolong an exaggerated O.
  2. Then have him hold the O sound while he moves his tongue into and out of R position in sequences. He is holding the entire mouth in the O shape, not just the lips. He will end up saying OOO-R-OOO-R-OOO-R-OOO… with the mouth in the O shape the entire time.
  3. Now do this with other vowels.
  4. Now ad a consonant before the vowel. For example, have him say OOO-R-DOO-R-DOOO-R…
  5.  Now do this with several different vowels and several different consonants.

Now you are truly teaching what McDonald(2) called the “overlapping ballistic movements” required in co-articulated speech. You are taking the focus away from R and the vowels, and putting focus on the movements of the syllables. The syllable is made by shaping the mouth for the vowel, and by then adding consonant movements to that basic shape.

References

  1. For example: Stetson, R. (1928) Motor phonetics. USA: North Holland Publishing. Stetson can be read today in: Kelso, J. A. S., & Munhall, K. G. (Eds.) (1988).  R. H. Stetson’s motor phonetics: a retrospective edition. Boston: College-Hill.
  2. McDonald, E. T. (1964) Articulation testing and treatment: A sensory-motor approach. Pittsburgh: Stanwix House.

 

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By Pam M – February 12, 2012

Fixing an Inhaled S

Q: My client inhales on S. I have tried using a straw and a cotton ball to teach him about airflow. He does fine with these, but he doesn’t transfer the skill to S. Help!

Your client probably continues to inhale on S because he “thinks” he is trying to say S. He has an auditory/motor memory for his own S that he is continuing to access. You have to help him learn to block access to this memory. Here are some ideas:

  1. Tell him NOT to make an S, but just to blow through his teeth.
  2. Drop back to T and have him practice with inhalation and exhalation, back and forth. Then move on to S. Tell him to make it just like T.
  3. Have him make a T into a straw and make the sound “longer” (highly aspirated). I call this a “Long T.” Then work on words with final Ts. Such as hats, cats, lights, and boats. But tell him NOT to make an S, just a “Long T.”
  4. Consider making the auditory experience more powerful by switching from a straw to a tube that can reach directly from his mouth to his ear. This may help him to hear the difference between exhalation and inhalation on his S or on his Long T.
  5. Use negative practice: Have him practice the inhaled S in order to become more aware of what he is doing wrong.
  6. Make sure you are modeling inhaled and exhaled S sounds for him, and have him judge whether you are making each on inhalation or exhalation. This would be the basis of old-fashioned auditory training.
  7. Hold a piece of tissue paper against the mouth. The old timers called it a “tissue flag.” Have the client inhale his S so the flag pulls against and hold against his mouth. This will teach him more about how he is inhaling his S. As he is inhaling the S so the tissue presses against his mouth, tell him to blow. The tissue should fly away. Then see if he can transfer the skill to an inhaled and then an exhaled S.
  8. Have him inhale the S as he usually does, then hold the oral position while he pants. In other words, have him pant through his inhaled S. This will make it inhaled and exhaled, back and forth. Use the tube for listening harder.
  9. Switch to other phonemes for a while. Use any voiceless phoneme. For example, use Sh. Have him inhale and exhale through Sh, back and forth while listening in the tube.
  10. Some of the old-timers used saliva to teach exhalation of S. Teach the client to spit a tiny bit of saliva through his teeth, like an S.

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By Pam M – February 9, 2012

Explaining “Articulation” and “Oral Motor”

Q: I have been arguing with a colleague about “oral motor” and “articulation.” She does not seem to know what an articulation deficit is. She disputes the notion of an “articulation deficit,” and claims that there are only “phonological deficits.” Can you help me? I know what I mean, but I can’t seem to put it in the right words for her to grasp. I need help explaining what an “articulation deficit” is, and help in relating this to “oral motor.”

In my opinion, this is all a matter of perspective.  One can view a client’s inability to produce /k/ as in the word “cookie” as a phonological deficit, an articulation deficit, or an oral-motor problem depending upon one’s view.  Perhaps the following explanations will help. I have put my advice at the close.

Articulation Deficit

The traditional definition of “articulation” comes from speech science, and it goes something like this:  Speech is the coordinated effort of four speech movement subsystems––

  • Respiration refers to the movements of breathing for speech.
  • Phonation refers to the movements of the vocal folds and larynx for speech.
  • Resonation refers to the movements of the velopharyngeal mechanism for speech.
  • Articulation refers to the movements of the jaw, lips, and tongue for speech.

Following the above, and strictly speaking, an “articulation deficit” therefore is a speech defect (1) that is the result of incorrect jaw, lip, or tongue movement. The term “articulation deficit” has been generalized through the years, however, and has been used to refer to any and all problems in phoneme production.  For example, children who inhale instead of exhale on /s/ are classified as having an “articulation deficit.” But strictly speaking, this is an inability to control respiration, not articulation.

Oral Motor

The term “oral motor” simply is a term used to discuss “mouth movements” and therefore it means the same thing as “articulation.”  Both of these terms refer to improper movements of the jaw, lips, and tongue.(2) An “articulation” deficit is a speech problem that is the result of incorrect “mouth movement” or “oral movement.”  Thus an “articulation deficit” is an “oral motor problem.”

Phonological Deficit

The term “phonology” refers to the way in which phonemes are used within a language––“The part of linguistics concerned with ‘putting together’ or ‘putting sounds into words” (Bernthal and Bankson, Articulation and Phonological Disorders. Boston: Pearson, 2004, p. 47). However, over time and since the 1970s, the term “phonological deficit” has come to refer to any and all problems with phonemes. Therefore, many modern professionals use the term “phonological deficit” today to encompass any phoneme problems.

Distinctive Features

When the study of phonology entered the field, it began with a discussion of “distinctive features” or “phonetic features”: “The totality of phonetic features can be said to represent the speech-producing capabilities of the human vocal apparatus” (Reference: Chomsky and Halle, 1968, The Sound Patterns of English). What are the “speech-producing capabilities of the human vocal apparatus”? Put most simply, they are movements: A human can close the mouth, open the mouth, lift the tongue-tip, lift the tongue-back, lift the velum, exhale, and so forth. These movements comprise speech.

It’s All The Same Thing

In my opinion, we should stop arguing about all this because these are all different terms to describe the same thing. Take the client who cannot produce /k/ and who substitutes t/k. We can view this from any of the perspectives offered above––

  • Articulation: The error is one of substituting one phoneme for another. We have to teach him to produce /k/ instead of /t/.
  • Oral-motor: The error is the result of an inability to lift the back of the tongue. We have to teach the client to lift the back of the tongue instead of the front of the tongue to produce /k/ instead of /t/.
  • Phonology: The error is one of fronting: of opening syllables only or predominantly with front consonants. We have to teach the client to open syllables with /k/ as well as /t/.
  • Distinctive Features: The error is one of making the target [-Back] when it should be [+Back], and so forth.

Advice

Is it not completely obvious that this is all the same thing? We are fighting over vocabulary words. My advice to you is to let your colleague think whatever s/he wants to think. What does it matter what the error or the correction process is called? Just do therapy the way you think it should be done and let your colleague do likewise. Congratulate your colleague for the excellent work s/he is doing by pointing out how good the clients sound: “Wow! You have really done a great job with Billy and Sally! They sound a lot better!” When s/he criticizes your perspective, simply say, “That’s an interesting perspective… I’ll think about that…” and move on. Celebrate the diversity of perspectives, and honor the similarities. Consider sharing this QA with the whole staff, but don’t assume this person will change because of it. Remember: Every person opens his or her own eyes.

Footnotes

  1. Van Riper’s definition of “defective speech” has stood the test of time: “Speech is defective when it deviates so far from the speech of other people that it calls attention to itself, interferes with communication, or causes its possessor to be maladjusted.”  Reference: Van Riper, C. (1939) Speech Correction: Principles and Methods. Englewood Cliffs: Prentice-Hall.
  2. The term “oral motor” began to be used in the 1970s when SLPs began to work together with OTs and PTs who already were using the terms “gross motor” and “fine motor.”  The term “oral motor” allowed us to begin to talk with OTs and PTs about “articulation” in speech.  This was a concept that was new to OTs and PTs because at the time motor professionals were using the term “articulation” only to refer to the relationship of one bone to another. (For example, the femur “articulates” with the pelvis at a ball and socket joint known as the acetabulofemoral joint.) When OTs and PTs heard the term “articulation” in reference to speech, they immediately thought of the temporomandibular joint. They did not view “articulation” the way we do––as in the “articulation” of the “articulators.”  The term “oral motor” helped us begin to speak with OTs and PTs about oral movement in speech and feeding.

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By Pam M – February 4, 2012

The Roots of Oral-Motor Therapy: A Personal View

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 March, 2011, and revised in April, 2011. Download the original PDF here.

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The Roots of Oral-Motor Therapy: A Personal View

By Pam Marshalla, MA, CCC-SLP
Speech-Language Pathologist

Time

The 1970’s was a time when SLP’s begin to work in multidisciplinary and transdisciplinary teams with OT’s, PT’s and other professionals. For the first time, SLP’s and motor specialists were sharing their thoughts and ideas regarding therapy with one another. The oral-motor movement began in this decade in schools, hospitals, and clinics. These were clinical ideas born of the exchange of information, not research results.

Terms

At that time, OT’s and PT’s already were using the terms gross motor and fine motor to discuss the development, disorders, assessment, and treatment of whole body movements. The term oral motor came along as we added the discussion of oral movements for feeding and speech into the mix. The term came about as a natural outcome of team discussions. The term non-speech oral-motor exercise (NS-OME) was not used, and did not exist, at that time. The NS-OME is a new term made up after the evolution of oral motor therapy. It has no part in Pam’s personal history of oral-motor.

New Information

The decades of the 1970’s and 1980’s also was a time when speech and motor therapists in the US began to have broad access to information about feeding, dysphagia, motor speech therapy, orofacial myology, sensorimotor integration, neurodevelopmental treatment, and the structure of the infant oral mechanism. Therapists were attending many multiple-day seminars on this material, they were sharing information across disciplines, and they were reading whatever publications came along. This was a time of tremendous expansion of ideas related to oral movement. Again, this was clinical information, not research reports.

Key Seminars

There were several key seminars that took place in the 1970’s that had nation-wide influence on the thoughts of OT’s, PT’s and SLP’s. Some of these seminars were recorded, transcripts were produced, and the bound material was sold to tens of thousands of therapists who were working worldwide.

The key person around whom all the early oral-motor/feeding seminars were based was Dr. Suzanne Evans Morris. Dr. Morris was a speech-language pathologist who had studied dysphagia under Jerilyn Logemann, did her doctoral research on infant feeding development, and studied neurodevelopmental treatment (NDT) with Karl and Berta Bobath (the developers of NDT) in England. Dr. Morris was the one who brought NDT back to the US.

As Dr. Morris finished her PhD on feeding development, she began to teach seminars and the term oral-motor began to have regular use. Many of these training seminars were taught through a grant program at the Curative Workshop of Milwaukee, WI (first known as the Kiwanis Children’s Center). According to Dr. Morris, “The grant program was to develop a demonstration project for feeding and pre-speech development for children from Birth to 3 years with a diagnosis of cerebral palsy. It was referred to by our group simply as ‘The CP Project.’  It began in 1969. In approximately 1973 we went into the demonstration phase of the project in which we selected 10 (?) centers throughout the USA to replicate the program.  Each center sent a team of therapists to Milwaukee for a week-long series of training workshops” (personal correspondence, March, 2011). From there a variety of therapists were teaching oral-motor seminars nationwide.

The following seminars and publications represent important publications of Dr. Morris’ early work.

1977

  • Wilson, J. M. (Ed.) (1977) Oral-motor function and dysfunction in children. Conference proceedings. Chapel Hill: University of North Carolina.

This was perhaps the most important beginning to oral-motor. This 3-day conference focused on feeding development, disorders, assessment and treatment, and there was one section on speech. The seminar was multi-disciplinary and included presentations on structure, function and neural control of the oral and pharyngeal mechanism. The presenters included Suzanne Evans Morris, Ph.D., Suzann Campbell, Ph.D., Joan Werner, Ph.D., James Bosma, M.D., Constance Evans, M.A.C.T., Sandra Radka, M.A.C.T., and Janet Wilson, L.P.T. This was a 4-day seminar presented on May 25-28. This transcript was bound in green and became known as “The Green Book.”

1977

  • Morris, S. E. (1977) Program guidelines for children with feeding problems. Edison: Childcraft.

This set of program guidelines developed out of therapy with families. It was intended to help therapists to problem solve the causes of, and to design remediation plans for, feeding problems. It discussed the topics of limited food preferences, oral-tactile hypersensitivity, frequent gagging, drooling, and so forth. This book was bound in yellow and became know as “The Yellow Book.”

1981

  • Morris, S. E. (1981) The normal acquisition of oral feeding skills: Implications for assessment and treatment. Seminar handbook. NY: Therapeutic Media.

This 4-day seminar was presented on June 20-23, and was taught exclusively by Dr. Morris. It included information on normal oral-motor development, differential diagnosis of feeding problems, anatomy and physiology review, assessment, and treatment of feeding problems. This seminar also included information on “parallel patterns” of oral-motor development in feeding and speech production, a pre-speech assessment questionnaire and scale, and a section on “the development of stability and mobility in the oral-pharyngeal system.” This transcript set the stage for transferring information about oral-motor development, assessment, and remediation from feeding to speech. This transcript was bound in blue and became known as “The Blue Book.”

1983

  • Morris, S. E., and Klein, M. D. (1983). Pre-feeding skills: A comprehensive resource for mealtime development. Austin: Pro-Ed.

This book immediately became the ultimate reference for concepts of oral-motor and feeding therapy. This book was first published in 1983 and revised in 2000. In the 1980’s this book quickly became known as “The Bible of Feeding Therapy.”

Transfer to Articulation Therapy

Since Van Riper, SLP’s have known that certain clients had mouths that simply did not function well. Van Riper called them “clumsy-tongued individuals” and “the slow of tongue.” Therefore, once therapists began to understand basic concepts about oral-motor development, assessment, and treatment in regard to feeding, they immediately began to translate this information into articulation therapy. Some began to present continuing education seminars on these ideas.

Pam Marshalla was the first to take the concepts of oral-motor that were being taught in regard to feeding, and to bring them publicly into articulation therapy in the seminar format. Her company, Innovative Concepts, was formed in 1982 and was based in Urbana, IL. It was the first ASHA-approved continuing education company to present seminars on oral-motor and articulation. She taught two-day seminars called “Tactile-Proprioceptive Stimulation Techniques in Articulation Therapy” and “Oral-Motor Techniques in Articulation Therapy.” Eventually her company also offered seminars by Sara Rosenfeld-Johnson, Charlotte Boshart, and others interested in oral motor. Marshalla’s early presentations and publications on oral-motor include the following:

1978

  • Marshalla (Rosenwinkel), P., & Kleinert, J. E. O., & Robbins, R. L. (1978) “Tactile-proprioceptive stimulation techniques and the frontal lisp.” Paper. Illinois Speech and Hearing Association Convention. Chicago, IL.

1979

  • Rosenwinkel, P. (Marshalla), & Kleinert, J. E. O., & Robbins, R. L. (1979) “Remediation of severe speech and language disorders: A pre-speech sensorimotor developmental model.” In Selected papers: Current trends in the treatment of language disorders presented at the 1979 annual convention of ASHA, Atlanta, GA. M. S. Burns & J. R. Andrews (Eds.) Evanston: Institute For Continuing Professional Education.

1982

  • Marshalla, (Rosenwinkel), P. (1982) “Tactile-proprioceptive stimulation techniques in articulation therapy.” Seminar handbook. Champaign, Illinois: Innovative Concepts in Speech and Language Therapy.

First ASHA-approved seminar on oral-motor and articulation therapy.

  • Marshalla, P. (1982) The Innovative Concepts Speech and Language Therapy Newsletter, Vol. 1 No. 1. Urbana, IL: Innovative Concepts. Published from 1982-1989.

Pam began to publish her ideas about oral-motor and articulation therapy in this bi-monthly newsletter. Available today as published archives.

1985

  • Marshalla, (Rosenwinkel), P. (1985) “The role of reflexes in oral-motor learning: Techniques for improved articulation.” Seminars in Speech and Language. Pp. 317-336. NY: Thieme.

Marshalla suggested this issue of Seminars that was devoted to the relationship between speech and swallowing. It was edited by Jerilyn Logemann.

1992

  • Marshalla, P. (1992) “Oral-motor techniques in articulation and phonological therapy.” Seminar handbook. Seattle, WA: Innovative Concepts.

1992

  • Marshalla, P. (1992) Oral-motor techniques in articulation and phonological therapy. 2-day seminar recorded in Huntington Beach, CA. Seattle, WA: Innovative Concepts.

1995

  • Marshalla, P. (1995) Oral-motor techniques in articulation and phonological therapy. Kirkland, WA: Marshalla Speech and Language.

This book was written to include the information discussed in the original 1992 seminar of the same title.

References

The following books, articles, and seminar transcripts have been in instrumental in developing Pam’s concept of oral-motor techniques. These have been put into chronological order to show the development of ideas throughout the decades.

[This list does not include references to the modern and unrelated concept of the non-speech oral-motor exercise to which Pam does not subscribe.]

Pre-1950 – Early Underpinnings

1928

  • Stetson, R. (1928) Motor Phonetics. USA: North Holland Publishing.

1937

  • Gessell, A. & Ilg, F. L. (1937) Feeding behavior in infants. Philadelphia: Lippincott.

1938

  • Stinchfield, S. M., & Young, E. H. (1938). Children with delayed or defective speech: Motor-kinesthetic factors in their training. Stanford: Stanford University Press.

1939

  • Van Riper, C. (1939) Speech Correction: Principles and methods. Englewood Cliffs: Prentice-Hall.

Van Riper talks about “clumsy-tongued individuals,” and the “slow of tongue.”

1950’s – Basic Concepts

1952

  • Gessell, A. (1952) Infant development. NY: Harper and Brothers.
  • Froeschels, E. (1952) Dysarthric speech: Speech in cerebral palsy. Magnolia, MA: Expression.

1954

  • Fairbanks, G. (1954) Systematic research in experimental phonetics: A theory of the speech mechanism as a servosystem. JSHD, p. 133–139.

1954

  • Fay, T. (1954) The use of pathological and unlocking reflexes in the rehabilitation of spastics. American Journal of Physical Medicine, 33, p, 347-352.

1955

  • Young, E. H., & Hawk, S. S. (1955) Moto-kinesthetic speech training. Stanford: Stanford University Press.

1957

  • Morley, M. (1957) The development and disorders of speech in childhood. Baltimore: Williams and Wilkins.

This book had a principle focus on children with motor speech disorders. The author was practicing in England where she was exposed to the treatment procedures of the Bobaths who develop neurodevelopmental treatment – NDT. Morley was encouraged to write this book by Van Riper himself who wanted to see these ideas brought to the United States.

1960’s – Building Ideas

1962

  • Illingworth, R. S. (1962) An introduction to developmental assessment in the first year: Little Club Clinics in developmental medicine #3. London: National Spastics Society in association with William Heinemann (Medical Books).

1963

  • Illingworth, R. S. (1963) The development of the infant and the young child: Normal and Abnormal, 2nd edition. Baltimore: Williams and Wilkins.

1964

  • McDonald, E. T., & Chance, B. (1964) Cerebral palsy. Englewood Cliffs: Prentice-Hall.
  • McDonald, E. T. (1964) Articulation testing and treatment: A sensory-motor approach. Pittsburgh: Stanwix House.

1965

  • Ronson, I. (1965) Incidence of visceral swallow among lispers. Journal of Speech and Hearing Disorders, 30, p. 318-324.

1966

  • Crickmay, M. C. (1966) Speech therapy and the Bobath approach to cerebral palsy. Springfield, IL: Charles C. Thomas.

1967

  • Bosma, J. (Ed.) (1967) Symposium on oral sensation and perception. Springfield: Charles C. Thomas.
  • Gibson, J. J. (1967) The mouth as an organ for laying hold of the environment. In Bosma, J. (Ed.). (1973). Oral sensation and perception. Springfield: Charles C. Thomas. (p. 111–136).
  • McDonald, E. T. & Aungst, L. F. (1967) Studies in oral sensorimotor function. In Bosma, J. (Ed.). Oral sensation and perception. Springfield: Charles C. Thomas. (p. 202–220).

1968

  • Mysak, E. D. (1968) Neuroevolutional Approach to Cerebral Palsy and Speech. NY: Teachers College.

1970’s – Exploding Ideas

1970

  • Cratty, B. J. (1970) Perceptual and motor development in infants and children. Los Angeles: McMillan.
  • Dunlap and Streicher Institute for Speech and Hearing (1970) A new theory based on oral habits as causal factors in speech development. Monograph.
  • Weinberg, B., & Liss, G. M., & Hillis, J. (1970) A comparative study of visual, manual, and oral form identification in speech impaired and normal speaking children. In J. Bosma (Ed.), Second Symposium on Oral Sensation and Perception. Springfield, IL: Charles C. Thomas.

1971

  • Bobath, K. (1971) The normal postural reflex mechanism and its deviation in cerebral palsy. Physiotherapy, 57 (11).
  • Powers, M. H. (1971). Functional disorders of articulation: Symptomatology and etiology. In L. E. Travis (Ed.), Handbook of speech pathology and audiology. Englewood Cliffs: Prentice-Hall, p. 837-875.
  • Powers, M. H. (1971). Clinical and educational procedures in functional disorders of articulation. In L. E. Travis (Ed.), Handbook of speech pathology and audiology. Englewood Cliffs: Prentice-Hall, p. 875-910.
  • Sakada, S. (1971) Response of Golgi-Mazzoni Corpuscles in the Cat Periostea to Mechanical Stimuli. In Dubner, R. & Kawamura, Y. (Eds.) Oral-Facial Sensory and Motor Mechanisms. New York: Appleton-Century-Crofts.

1972

  • Fiorentino, M. R. (1972) Normal and abnormal development: The influence of primitive reflexes on motor development. Springfield, IL: Charles C. Thomas.

1973

  • Bosma, J. (Ed.). (1973). Fourth symposium on oral sensation and perception. (NIH, DHEW Publication No. 73-546). Washington: U.S. Government Printing Office.
  • Rosenbek, J. C., & Wertz, R. T., & Darley, F. L. (1973) Oral sensation and perception in apraxia of speech and aphasia. Journal of Speech and Hearing Disorders, 16, p. 22-36.

1974

  • Bower, T. G. R. (1974) Development in infancy. San Francisco: W. H. Freeman.

1975

  • Darley, F. L., & Aronson, A. E., & Brown, J. R. (1975) Motor speech disorders. Philadelphia: W. B. Saunders.

1976

  • Towen, B. (1976) Neurological development in infancy. London: William Heinemann.
  • Zelazo, P. (1976) From reflexes to instrumental behavior, in L. P. Lipsett (Ed.) Developmental psychobiology: The significance of infancy. Hillsdale, NJ: Lawrence Erlbaum.

1977

  • Bower, T. G. R. (1977) A primer of infant development. San Francisco: W. H. Freeman.
  • Bosma, J. (1977) Structure and function of the infant oral and pharyngeal mechanism. In Wilson, J. M. (Ed.) Oral-motor function and dysfunction in children. Conference proceedings (p. 33–65). Chapel Hill, NC: University of North Carolina.
  • Mason, R., & Simon, C. (1977) An orofacial examination checklist. Language, Speech and Hearing Services in the Schools. 8, pp. 155-163.
  • McNutt, J. C. (1977) Oral Sensory and Motor Behaviors of Children with /s/ or /r/ Misarticulations. JSHR, 20, p. 694-703.
  • Morris, S. E. (1977) Assessment of children with oral-motor dysfunction (Section II), and Treatment of children with oral-motor dysfunction (Section III). In Wilson, J. (Ed) Oral-motor function and dysfunction in children. Seminar proceedings. Chapel Hill: U. North Carolina. Pp. 106–208.
  • Morris, S. E. (1977) Program guidelines for children with feeding problems. Edison: Childcraft.
  • Wilson, J. M. (Ed.) (1977) Oral-motor function and dysfunction in children. Conference proceedings. Chapel Hill: University of North Carolina.

1978

  • Ayres, A. J. (1978) Sensory Integration and Learning Disorders. Los Angeles: Western Psychological.
  • Campbell, S. K. (1978) Oral sensorimotor physiology. In Oral-motor function and dysfunction in children, Wilson, J. M. (Ed.). Conference proceedings, May 25-28, 1977. Chapel Hill: University of North Carolina.
  • Marshalla (Rosenwinkel), P., & Kleinert, J. E. O., & Robbins, R. L. (1978) Tactile-proprioceptive stimulation techniques and the frontal lisp. Paper. Illinois Speech and Hearing Association Convention. Chicago, IL.
  • Morrison, D., & Pothier, P., & Horr, K. (1978) Sensory-motor dysfunction and therapy in infancy and early childhood. Springfield: Charles C. Thomas.
  • Oller, D. K. (1978) Infant vocalizations and the development of speech. Allied Health and Behavioral Sciences Journal, 1 (4) Pp. 523-549.

1979

  • Rosenwinkel, P. (Marshalla), & Kleinert, J. E. O., & Robbins, R. L. (1979) Remediation of severe speech and language disorders: A pre-speech sensorimotor developmental model. In Selected papers: Current trends in the treatment of language disorders presented at the 1979 annual convention of ASHA, Atlanta, GA. M. S. Burns & J. R. Andrews (Eds.) Evanston: Institute For Continuing Professional Education.

1980’s – Broadening Ideas

1980

  • Bobath, K. (1980) Clinics in Developmental Medicine No. 75, A neurophysiological basis for the treatment of cerebral palsy: 2nd edition of CDM 23, The motor deficit in patients with cerebral palsy. Spastics International Medical Publications. London: William Heinemann Medical Books.

1980

  • Kent, R. (1980) Articulatory and acoustic perspectives on speech development. In The communication game: Perspective on the development of speech, language and non-verbal communication skills. Reilly, A. P. (Ed.) Pediatric Round Table: 4. (Pp. 38-42) Johnson & Johnson. United States.
  • Murry, T., & Murry, J. (1980) Infant communication: Cry and early speech. Houston: College-Hill.
  • Mysak, E. D. (1980). Neurospeech therapy for the cerebral palsied: A neuroevolutional approach. NY: Teachers College Press.

1981

  • Garliner, D. (1981) Myofunctional therapy. Coral Gables: Institute for Myofunctional Therapy.
  • Morris, S. E. (1981) The normal acquisition of oral feeding skills: Implications for assessment and treatment. Seminar handbook. NY: Therapeutic Media.
  • Steefel, J. S. (1981) Dysphagia rehabilitation for neurologically impired adults. Springfield: Charles C. Thomas.

1982

  • Marshalla, (Rosenwinkel), P. (1982) Tactile-proprioceptive stimulation techniques in articulation therapy. Seminar handbook. Champaign, Illinois: Innovative Concepts in Speech and Language Therapy.
  • Marshalla, P. (1982) The Innovative Concepts Speech and Language Therapy Newsletter, Vol. 1 No. 1. Urbana, IL: Innovative Concepts. Published from 1982-1989.
  • Farber, S. D. (1982) Neurorehabilitation: A multisensory approach. Philadelphia: W. B. Saunders.
  • Salek, B., & Braun, M., & Palmer, M. M. (1982) Early detection and treatment of the infant and young child with neuromuscular disorders. Conference transcription, June 1982, Boston, MA. NY: Therapeutic Media.
  • Stainback, S. B., & Healy, H. A. (1982) Teaching eating skills: A handbook for teachers. Springfield: Charles C. Thomas.

1983

  • Morris, S. E., & Klein, M. D. (2000, 1983). Pre-feeding skills: A comprehensive resource for mealtime development. Austin: Pro-Ed.
  • Illingworth, R. S. (1983) The normal child: Some problems of the early years and their treatment, 8th edition. Edinburgh: Churchill Livingstone.
  • Logemann, J. (1983) Evaluation and treatment of swallowing disorders. San Diego: College-Hill.
  • Perkins, W. H. (1983) Dysarthria and Apraxia. NY: Thieme-Stratton.

1984

  • Jaffe, M. B. (1984) Neurological impairment of speech production: Assessment and treatment. In Janis Costello (Ed.) Speech Disorders in Children. San Diego: College-Hill.
  • McNeil, M. R., & Rosenbeck, J. C., & Aronson, A. E. (Eds.) (1984) The dysarthrias: Physiology, acoustics, perception, management. San Diego: College-Hill.
  • Ruscello, D. M. (1984) Motor learning as a model for articulation instruction. In Speech disorders in children: Recent advances. J. Costello (Ed.) (Pp. 129-156) San Diego: College-Hill.

1985

  • Kennedy, J G., & Kent, R. D. (1985) Anatomy and physiology of deglutition and related functions. Seminars in Speech and Language. 6 (4) pp. 257-274.
  • Larson, C. (1985) Neurophysiology of speech and swallowing. Seminars in Speech and Language, 6 (4). Pp. 275-292.
  • Logemann, J. (1985) Preface. Seminars in Speech and Language, 6 (4).
  • Logemann, J. (1985) The relationship of speech and swallowing in head and neck surgical patients. Seminars in Speech and Language, 6 (4) Pp. 351-359.
  • Marshalla, (Rosenwinkel), P. (1985) The role of reflexes in oral-motor learning: Techniques for improved articulation. Seminars in Speech and Language. Pp. 317-336. NY: Thieme.
  • Morris, S. E. (1985) Developmental implications for the management of feeding problems in neurologically impaired infants. Seminars in Speech and Language. 6 (4). Pp. 293-316.
  • Robbins, J. (1985) Swallowing and speech production in the neurologically impaired adult. Seminars in Speech and Language, 6 (4). Pp. 337-350.

1986

  • Wolf, P. H. (1986) The maturation and development of fetal motor patterns. In Motor development in children: Aspects of coordination and control, M.G. Wade and H. T. A. Whiting (Eds.), Martinus Nijhoff, Dordrecht, p. 77-96.

1987

  • Langley, J. (1987) Working with swallowing disorders. England: Winslow.

1988

  • Hanson, M. L. (1988) Orofacial myofunctional disorders: Guidelines for assessment and treatment. IJOM, 14 (1).
  • Hanson, M. L., & Barrett, R. H. (1988) Fundamentals of orofacial myology. Springfield: Charles C. Thomas.
  • Kaplan, A. S., & Williams, G. (1988) The TMJ book. NY: Pharos Books.
  • Kelso, J. A. S., & Munhall, K. G. (Eds.) (1988).  R. H. Stetson’s motor phonetics: A retrospective edition. Boston: College-Hill.
  • Oetter, P., & Richter, E. W., & Frick, S. M. (1988) M.O.R.E: Integrating the Mouth with Sensory and Postural Function. Hugo, MN: PDP.

1990’s – Focusing on Speech and Feeding

1990

  • Lynch, J. I. (1990) Tongue reduction surgery: Efficacy and relevance to the profession. Asha, 32, January.
  • Gunzenhauser, N. (Ed) (1990) Advances in touch: Pediatric round table #14. Skillman: Johnson & Johnson.

1991

  • Langley, M. B., & Thomas, C. (1991) Introduction to the neurodevelopmental approach. In M. B. Langley & L. J. Lombardino (Eds.) Neurodevelopmental strategies for managing communication disorders in children with severe motor dysfunction. Austin: Pro-Ed.
  • Langley, M. B.,  & Lombardino, L. J. (Eds.) (1991) Neurodevelopmental strategies for managing communication disorders in children with severe motor dysfunction. Austin: Pro-Ed.
  • Fisher, A. G., & Murray, E. A., & Bundy, A. C. (1991) Sensory integration: Theory and practice. Philadelphia: F. A. Davis.
  • Mason, R., et al (1991) The role of the speech-language pathologist in assessment and management of oral myofunctional disorders. Asha Supplement No. 5.
  • Moore, C. A., & Yorkson, K. M., & Beukelman, D. R. (1991) Dysarthria and apraxia: Perspectives on management. Baltimore: Paul H. Brookes.
  • Nelson, C. A., & De Benabib, R. M. (1991). Sensory preparation of the oral-motor area. In Neurodevelopmental Strategies for Managing Communication Disorders in Children with Severe Motor Dysfunction, Langley, M. B. & Lombardino, L. J. (Eds.) Pp. 131-158.
  • Wilbarger, P., & Wilbarger, J. L. (1991) Sensory defensiveness in children aged 2-12: An intervention guide for parents and other caregivers. Santa Barbara: Avanti.

1992

  • Ansel, B., & Windsor, J., & Stark, R. (1992) Oral volitional movements in children: An approach to assessment. Seminars in Speech and Language, 13 (1) Pp. 1-13. NY: Thieme.
  • Fletcher, S. G. (1992) Articulation: A physiological approach. San Diego: Singular.
  • Marshalla, P. (1992) Oral-motor techniques in articulation and phonological therapy. Seminar handbook. Seattle, WA: Innovative Concepts.
  • Marshalla, P. (1992) Oral-motor techniques in articulation and phonological therapy. 2-day seminar recorded in Huntington Beach, CA. Seattle, WA: Innovative Concepts.
  • Orlikoff, H. (1992) The use of instrumental measures in the assessment and treatment of motor speech disorders. Seminars in Speech and Language, 13 (1). NY: Thieme. Pp. 25-38.
  • Robbins, J. (1992) The role of oral motor dysfunction on swallowing: From beginning to end. Seminars in Speech and Language, 13 (1). Pp. 55-69.
  • Rosenfeld-Johnson, S. (1992) A three-part treatment plan for oral-motor therapy. Seminar handbook. Seattle: Innovative Concepts.
  • Stone, M., & Faber, A., & Raphael, L. J., & Shawker, T. H. (1992) Cross-sectional tongue shape and linguopalatal contact patterns in [s], [∫], and /l/. Journal of  Phonetics, 20, p. 253-270.
  • Unser, M., & Stone, M. (1992) Automated detection of the tongue surface in sequences of ultrasound images. Journal of the Acoustic Society of America, 91, p. 3001-3007.

1993

  • Johnson, H., & Scott, A. (1993) A practical approach to saliva control. San Antonio: Communication Skill Builders.
  • Boshart, C. (1993) Oral-motor techniques: Remediate your single-sound artic cases in half the time! Seminar Handbook. Seattle: Innovative Concepts.
  • Gangale, D. (1993) The source for oral-facial exercises. East Moline, IL: Linguisystems.
  • Hall, P., & Jordan, L., & Robin, D. (1993) Developmental apraxia of speech: Theory and clinical practice. Austin: Pro-Ed.
  • Ruscello, D. M. (1993) A motor skill learning treatment program for sound system disorders. Seminars in Speech and Language, 12 (2). Pp. 106-118.
  • Zimmerman, J. (1993) The tongue, the teeth and resistant speech problems. Seminar handbook. Seattle: Innovative Concepts.

1994

  • Tuchman, D. N., & Walter, R. S. (1994) Disorders of feeding and swallowing in infants and children. San Diego: Singular.
  • White, R. (1994) Sensory integration and neurodevelopmental therapy. Seminar handbook. Seattle: Innovative Concepts.

1995

  • Marshalla, P. (1995) Oral-motor techniques in articulation and phonological therapy. Kirkland, WA: Marshalla Speech and Language.
  • Kaufman, N. (1995) The Kaufman speech praxis test for children. Detroit: Wayne State University.
  • Vatikiotis-Bateson, E., & Ostry, D. J. (1995) An analysis of the dimensionality of jaw motion in speech. Journal of Phonetics, 23, p. 101-117.

1996

  • Frick, S., & Frick, R., & Oetter, P., & Richter, E. (1996) Out of the mouths of babes.  Hugo, MN: PDP.

1997

  • Guiard-Marigny, T., & Ostry, D. J. (1997) A system for three-dimensional visualization of human jaw motion in speech. Journal of Speech, Language, and Hearing Research, 40, p. 1118-1121.
  • Marshalla, P. (1997) Drooling: Guidelines and Activities. Temecula, CA: Speech Dynamics.
  • McNeil, M. R. (1997) Clinical management of sensorimotor speech disorders. New York: Thieme.
  • Ostry, D. J., Vatilikiotis-Bateson, & Gribble (1997) An examination of the degrees of freedom of human jaw motion in speech and mastication. Journal of Speech, Language, and Hearing Research, 40, p, 1341-1351.
  • Rosenfeld-Johnson, S. (1997) The oral-motor myths of Down Syndrome. ADVANCE Magazine, August 4.

1998

  • Marshalla, P. (1998) Thumbsucking. Temecula, CA: Speech Dynamics.

1999

  • Kent, R. D. (1999) Motor control: Neurophysiology and functional development. In A. J. Caruso and E. D. Strand (Eds.) Clinical management of motor speech disorders in children. NY: Thieme.
  • Gibbon, F. E. (1999) Undifferentiated lingual gestures in children with articulation/phonological disorders. Journal of Speech and Hearing Research, 42, p. 382-397.
  • Van Norman, R. (1999) Help for the thumb-sucking child. NY: Avery.
  • Yorkston, K. M., & Beukelman, D. R., & Strand, E. A., & Bell, K. R. (1999). Management of motor speech disorders in children and adults. Austin: Pro-Ed.

2000’s – Continued Therapy Input / Studies on Jaw, Lip, and Tongue Movements

2000

  • Solomon, N. P. (2000) Changes in normal speech after fatiguing the tongue. Journal of Speech and Hearing Research, 43; p. 1416-1428.

2001

  • Bahr, D. C. (2001) Oral motor assessment and treatment: Ages and stages. Boston: Allyn & Bacon.
  • Marshalla, P. (2001) How to stop drooling. Marshalla Speech and Language. Kirkland, WA.
  • Marshalla, P. (2001c How to stop thumb sucking. Marshalla Speech and Language. Kirkland, WA.
  • Rosenfeld-Johnson, S. (2001) Oral-motor exercises for speech clarity. Tucson: Talk Tools.

2003

  • Hanson, M. L., & Mason, R. M. (2003) Orofacial Myology: International Perspectives. Springfield: Charles C. Thomas.

2004

  • Marchesan, I. Q. (2004) “Lingua frenulum: Classification and speech interference.” IJOM 30, November. Pp. 31-38.
  • Marshalla, P. (2004) Successful R therapy. Mill Creek, WA: Marshalla Speech and Language.
  • Smith, A., & Zelaznik, H. N. (2004) Development of functional synergies for speech motor coordination in childhood and adolescence. Developmental Psychobiology, 45, p. 22-33.
  • Solomon, N. P. (2004) Assessment of tongue weakness and fatigue. IJOM 30th Anniversary Edition. IAOM.

2005

  • Iskarous, K. (2005) Patterns of tongue movement. Journal of Phonetics, 33, p. 363-381.
  • Rosenfeld-Johnson, S. (2005) Assessment and treatment of the jaw: Putting it all together: Sensory, feeding and speech. Tucson: Talk Tools.
  • Rosenfeld-Johnson, S. (2005) Drooling remediation program for children and adults. Tucson: Talk Tools.
  • Smith, A. (2005) The developing speech motor system: Integrating muscles, movements and syntax. In Biologic and physiologic foundations of speech motor control. 15th Annual NIDCD-Sponsored Research Symposium, Asha Convention.

2007

  • Marshalla, P. (2007) Marshalla oral sensorimotor test. Greenville: SuperDuper.
  • Marshalla, P. (2007) Frontal lisp, lateral lisp. Mill Creek, WA: Marshalla Speech and Language.
  • Marshalla, P. (2007) Oral motor therapy is not new. Oral-Motor Institute, 1 (1) September. www.oralmotorinstitute.org.

2008

  • Bahr, D. C. (2008) A Topical Bibliography on Oral Motor Assessment and Treatment. Oral Motor Institute. 1, 2, January 16. www.oralmotorinstitute.org.
  • Marshalla, P. (2008) Oral motor techniques vs. non-speech oral-motor exercises. Oral-Motor Institute, 2 (1). www.oralmotorinstitute.org.
  • Palmer, P. M., & Jaffe, D. M., &McCulloch, T. M., & Finnegan, E. M., & Van Daele, D. J., & Luschei, E. S., (2008) Quantitative contributions of the muscles of the tongue, floor-of-mouth, jaw, and velum to tongue-to-palate pressure generation. Journal of Speech and Hearing Research, 51, p. 828-835.

2009

  • Bahr, D. C., & Rosenfeld-Johnson, S. (2009) Treatment of Children with Speech Oral Placement Disorders (OPDs): A New Treatment Paradigm Emerges. Unpublished manuscript.
  • McLeod, S. & Singh, S. (2009) Speech sounds: A pictoral guide to typical and atypical speech. San Diego: Plural.

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By Pam M – February 1, 2012

Resistance: The Most Powerful Oral Motor Technique

Q: What can I do to help my client learn to elevate his tongue-tip to produce /t/ and /d/?

Any part of the tongue can be taught to elevate by providing something against which it can press. This is called “resistance.” (Resistance is not used to build strength. That is a misconception of the “anti-OM” crowd). Instead, resistance is used to develop specific new movement patterns.

  • Press down lightly on the tongue-tip with a tool and ask the client to push up against it with the tip. This will encourage tip elevation.
  • Press lightly down on the tongue-back with a tool and ask the client to push up against it with the back. This will encourage tongue-back elevation.
  • Press lightly down on the sides of the tongue with a tool and ask the client to push up against it with the sides- This will encourage side elevation for the central groove.

In my opinion, resistance is the most powerful, effective, and efficient way to teach any part of the tongue to elevate. Also use it to teach the lower lip to elevate to the upper lip or upper teeth.

Any firm tool can be used to do this, such as a tongue depressor, finger, bite stick, or toothbrush handle. Follow sanitary procedures at all times.

Posted in Articulation, Oral Motor.

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By Pam M – January 26, 2012