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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 changing a phoneme that should be [+Back] to [–Back]; that should be [+Anterior] to [–Anterior]; that should be [+Coronal] to [–Coronal]; that should be [+High] to [–High]; and so forth. We have to teach the client to produce /k/ with the correct distinctive features.

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.

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By Pam M – January 26, 2012

Lateral Lisp and Obesity?

Q: My daughter has a lateral lisp and obesity. The SLP cannot seem to get her to make the correct sounds. Can obesity interfere with learning these sounds?

I have never faced this situation with any client. However, from what I know about tongue function and the lisps, I do not see how obesity might interfere with learning correct tongue position for S, Z, Sh, Zh, Ch, or J.

Perhaps your SLP does not know how to fix a lateral lisp. This is very common today. You may have to seek additional help from another SLP.

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By Pam M – January 21, 2012

Lip-Biting Habit

Q: My client constantly bites her lower lip until it swells and bleeds. She is highly intelligent, five years old, hypertonic, and has vision difficulties. Do you have suggestions?

I have never faced this situation, but I believe that the principles of helping a child stop any oral habit would apply. You have to help the child recognize what she is doing, help her understand the problems it causes, help her develop a goal for stopping, set up a reward system for achieving certain levels of stopping, identify and alleviate factors which may be perpetuating the problem (e.g., stress in the home), design activities for sitting with “quiet lips” during increasing periods of time, etc.

This could be viewed as a family problem, not just the child’s problem. Therefore you will have to assess how much the family is invested in stopping this behavior. If they are unwilling to be a part of this, or don’t care, or can’t get it together to help, then probably the most you will be able to do is to help her stop at school or in therapy, wherever you see her.

However, if the child sees this as something she wants to stop, she can do this without parental involvement. Most kids aren’t aware of their oral habits, so simply learning about it sometimes will cause them to want to diminish it, especially if they come to realize that they are getting bigger and “big girls” don’t do these things.

You are riding a fine line between helping her become aware of the problem yet avoiding shaming her about it. Please keep in mind that the client also may need psychological intervention.

I hope this helps you think this through. My book called How to Stop Thumbsucking addresses the basics of eliminating any oral habit. It is easy to read and appropriate for therapists, educators, and parents.

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By Pam M – January 20, 2012

Don’t Let the Issue of Evidence-Based Practice Get You Down!

Q: I have been reading your book Becoming Verbal with Childhood Apraxia. The ideas sound great and very interesting, but I did not see a complete reference list. Are there specific research studies that support the techniques that you were describing in your book? The examples included were helpful. I need some more support because of the emphasis on the evidence-based practice.

There is no reference list at the end of the book because these are all my original thoughts based upon the work of Jean Piaget, who also wrote his original thoughts. Piaget is widely considered one of the “fathers” of modern child development.

There is a complete and terrible misunderstanding today of what the term Evidence-Based Practice means. According to ASHA, the EBP is comprised of three aspects:

  1. Evidence from the research lab. ASHA calls it “Current Best Evidence.”
  2. Evidence gained from clinical experience– ASHA calls it “Clinical Expertise.”
  3. Evidence from the client himself– ASHA calls it “Client/Patient Values.”

The book of mine that you referenced regards the second arm of the EBP. It is a book about what my 35 years of clinical experiences have taught me as I have worked with hundreds of clients. It therefore represents the second arm of the EBP. Think of it as one very experienced therapist giving advice to other less experienced therapists, or to the parents of the children involved.

Please do not allow yourself to get into the trap that we can only do in therapy those things that have been researched. Most therapists do thousands of things that have never been researched. We do whatever it takes to help our clients, and we most certainly cannot limit our practice to only those things that have been studied in a laboratory. In fact, most of what we do has never been researched, and most of what is researched we must expand upon and generalize in order to apply it to our clients.

Consider this: If a technique is “proven” to work with five-year-old children, is that “proof” that the method can be used with three-year-old children? If we only can do in therapy those things that current research supports, then the answer to that is NO. And if that is the standard we are going to apply to our practice, then we are finished. Why? Because most of what we need to do has never been researched.

Consider this: Think about teaching something very simply, like pronoun “I.” Have you ever seen any research on how to teach pronoun “I”? No. Yet tens of thousands of therapists must teach pronoun “I” every day. What are they to do? They are to figure out how to teach it without the benefit of research. Often they pass their own original ideas on to other therapists who also are hungry for more ideas.

This is what I have done in that book. I gathered together the thoughts and experiences I had over several decades to share with other therapists who are stuck exactly in the same place I was stuck 35 years ago. This is what therapists always have done: They help one another.

You have to take what is in that book and compare it to your own experiences. If the ideas prove valuable to you, then you use them. If they don’t, then you don’t. This is what we do with every single method we come across, whether it’s been researched in a laboratory, or learned from another therapist, or dreamed up, or stumbled upon.

Please read further on my blog about EBP for more ideas. I have listed many resources that explain what EBP really is.

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By Pam M – January 14, 2012

Articulation Therapy vs. Speech Improvement

Q: There seems to be a shocking lack of knowledge “out there” about how to do articulation therapy. I recently saw a girl with an R distortion who had been in therapy with another therapist for a year with no progress. I was able to get a correct sound from her in 15 minutes! The mother was amazed that I actually worked on tongue movement and placement.

I agree, and I think I know why this is occurring. The tried-and-true methods of traditional articulation therapy are being tossed aside for lack of research. If there is no modern-day “proof” that a method words, it simply is ignored or treated with distain. Thus modern generations of SLPs are not being taught the simple procedures of our founders.

We have gone full circle in our profession, back to articulation therapy the way it was done BEFORE Van Riper. Van Riper explained that the reason he wrote his first text in 1939 was to counter the then common practice of simply having clients repeat words over and over again as a way to correct phonemes. He said––

“All the clinician would do was to ask the client to repeat [words] after her… That would go on for an hour. They felt that such a bombardment would lead to error elimination. Can you imagine that?” (Van Riper, 1993).

Now we have young therapists being taught that that is the way to do articulation therapy. I went to a conference recently where a professor was teaching how to do articulation therapy by working in the classroom. She was advocating instructing all the kids at the same time by leading group activities. She was providing no individual instruction and said it was no longer necessary!

This is old-time speech improvement, not articulation therapy.

I asked this professor about the learning differences and the problems in brain function that the truly speech impaired had. She seemed to have no idea what I was talking about, and she treated me as if I was off on some kooky tangent. I said, “But their brains don’t work the way the average child does. And what about oral movement? How will you train better jaw, lip, and tongue control in large group activities?” She just stared back at me. About half the audience knew what I was talking about, and the other half had no clue.

Unbelievable.

I am calling on all professors who teach articulation/phonology to get hold of an old Van Riper text and READ IT. I also am calling on them to carry a small caseload of clients themselves to actually discover what it takes to change phoneme production. There is no excuse for a professor of articulation/phonology not to know what articulation therapy really is. You have no business training students to do something you have no clue how to do. Learn it, or get an SLP with a Master’s Degree who knows how to do this to team-teach your class with you.

References

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By Pam M – January 10, 2012

L and R with Tonsils/Adenoids Problems

Q: I am seeing two elementary age brothers with a history of enlarged tonsils and adenoids that are not significant enough to warrant surgery according to the ENT. Both are difficult to understand because of their resonance issues. We are working on R and L with limited progress. I don’t know where to go with them. Speech is starting to impact reading and writing.

A child with mild-to-moderate upper respiratory problems and minor articulation errors is one of the most irksome situations we face. We know that the tonsil/adenoid problem is contributing to the speech problems, but the doctors say there is nothing to be done.

What did Charles Van Riper say we should do when faced with structural/medical problems that cannot be remediated? He said we should teach compensatory speech movements. We have to help them sound the best they can given their medical problems.

Begin with the vowels because they are probably the main root of the unintelligibility, and they may be the reason reading is being effected. Help the kids make round and resonant vowels with the mouth more open. Speaking a little louder usually makes them sound better. Sing the vowels with prolongation so they have time to process what they are hearing.  Help the client develop the image of the opera star and new auditory images of what their vowels should sound like.

Once the vowels begin to sound better, use the wide open “Ah” sound to teach R and L. In other words, teach the client to prolong/maintain his vowel sound as he moves his tongue into and out of position for L and R. Start with L: Ahhh-LLL-Ahhh-LLL-Ahhh-LLL… Teach these sounds more as if they were part of the vowel family.

The key here is that you have to teach the boys’ ears to recognize when they are being more oral and more nasal. Use a tube stretched from their mouths to their ears, and from their noses to their ears in order to teach them about their own resonance. These kids have their own internal image of what they sound like (as we all do), and this is what you are trying to re-shape. This is more akin to vocal training than it is to articulation therapy.

See the resonance keyword on this blog for more ideas.

Also, did you know that books of elocution that were published in the 19th century concerned both speech and voice for singing? Much can be gained from these early works. As a modern alternative, set yourself up to observe an excellent professional choir director or opera teacher at work with students. This is probably not your local church choir director, but a real professional who makes their living teaching the art of singing to people serious about the craft. Watch how they teach voice. You will learn far more about teaching voice and vowels than you ever will from the speech pathology community. These professionals know how to teach the voice and the vowels to be strong, round, and fully resonant.

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By Pam M – January 8, 2012

Use the Client’s R

Q: I attended your R course recently. It was wonderful! But I am stuck with one client. He has achieved a Tip R, but not a Back R. How much longer should I spend trying to help him get a Back R?

If the Tip R works to get the sound quality you want, then that’s what you do, and you forget about the Back R. It does not matter which one he gets.

Focus on what he can do. Make most of the session about what he is doing correctly. Review the slides from the class about working slowly and carefully on whatever he can do correctly. Build the program carefully from what he is doing right. DON’T jump to a whole bunch of different R words. Stick to what he has, and move in to words, phrases, sentences, and paragraphs with the R’s he is doing correctly.

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By Pam M – January 5, 2012

When to Refer to Orthodontia and ENT

Q: You mentioned orthodontic referral in one of your lectures on the lisps and R. I am wondering if you also refer to ENTs for issues relating to and resulting from mouth breathing.

I follow standard practices in SLP. Therefore I refer clients to orthodontics when there are indications that a dental malocclusion may exist, and when it seems to be interfering with sound production. I refer clients to an ENT when there are indications that there may be upper respiratory problems, undiagnosed oral structural issues, etc., that may be interfering with speech development.

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By Pam M – January 2, 2012

Frontal Lisp and Oral Stability

Q: I am seeing a 5-year-old male with interdental S, T, D, N, and L. He can say every sound correctly when reminded to keep back teeth together. Do I address all sounds at once or just S first? Should I still do cornerstone approach since he is stimulable or just work on drill and carryover?

As you know, each child is different. This is the process of trial and error. You will have to figure out what works best for HIM — isn’t that frustrating?

But beyond that, this is an issue of oral stability. See this post of Oral Stability and the Frontal Lisp for my thoughts.

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By Pam M – December 29, 2011

Eliminating Tooth Grinding

Q: I have two girls with Down syndrome who grind their teeth on a regular basis. They are the same age and function at about the same level. What strategies would you use to help with this area?

This is a tough question. We have no widely accepted strategies to eliminate tooth grinding other than the dental guard recommended by dentists. But my thinking has always been that if you can pinpoint the cause, then you can design a solution based on it. For example:

  • Some say that tooth grinding is due to stress. If so, reduce it.
  • Some say tooth grinding is just a habit. If so, use behavior modification to eliminate it.
  • Some say that tooth grinding in kids with lower cognitive skills is to relieve their boredom. If so, get the child busier.
  • Some say that the child is craving oral-tactile input. If so, give it to him by giving him oral play toys and things to chew on.
  • Some say that tooth grinding occurs in children with minor dental problems. Get the child to a good dentist for assessment, and make sure the family follows through with recommended treatment.

Let me be honest and reveal that I have never been able to completely eliminate a tooth grinding habit in a child with Down Syndrome. But many therapists talk about this as if they had, so I assume it is possible. I am going to get some input on this from other therapists and post a better answer soon.

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By Pam M – December 26, 2011

Robotic Speech

Q: My 7-year-old male client has a robotic speech presentation that interferes with intelligibility. He has low tone in the trunk and poor breath support. Do you have suggestions?

Usually a robotic voice makes an unintelligible child more intelligible. So maybe your client is using the robotic presentation to help him be more intelligible. In other words, maybe he knows (unconsciously) that when he speaks with equal stress on each syllable more people can understand him more often. He may be using the robotic presentation as a strategy to boost his intelligibility.

If so, I would not want to take the robotic presentation away from him. Instead I would teach him to use slightly more variety of intonation on the monotone. Maybe this should this be considered a fluency case?

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By Pam M – December 22, 2011

Oral-Motor/Artic Client

Q: My student has very uncoordinated oral movements and severely unintelligible speech. He is unable to elevate his tongue-tip, and therefore does not produce any alveolars. His S and Z are very frontal––like Th––and he reduces S-blends. How do I teach alveolars, and do I concentrate on S-blends or correct production of S and Z?

Your client requires a whole semester class on how the body works, and how that plays into speech movement development. Questions like yours are the hardest ones for me to answer in this format because, on the surface, it sounds like he just has trouble with phonemes, but I know that he has much bigger problems. That is why I have been putting off writing back to you. I almost don’t know where to start. So let me say a few things, and you can get back to me for further clarification on any part of it —

I saw a client very similar to yours a few weeks ago in Texas, so this is fresh on my mind ––

1) He is highly unintelligible, and he has uncoordinated OM movements, probably because he is unstable. His mouth is unstable, and probably his whole body is unstable. He probably has slightly low tone, and therefore is fixing somewhere along the spine, in the jaw, in his face, somewhere, to stay upright The combination of low tone and high tone mixed together causes his oral mechanism to be inconsistent in the way it moves. This wreaks havoc on jaw positioning, and lip and tongue positioning as a result. He needs to develop a stable jaw from a stabile body, and a tongue that is stable in the back. I don’t know if you know how to do that. This is dysarthria.

2) Don’t worry about S and Z so much when a client has no lingua-alveolars as you said your did. The lingua-alveolar phonemes emerge because the jaw begins to move up-and-down, not because the tongue begins to move. I would stimulate him for T, D, N, L, S, and Z all at this time, but I would let his jaw do the work. That means that he will substitute Th/S and Th/A. He should do that. That’s where his OM skill development is. He is at an infantile level of jaw-lip-tongue control. Therefore he will produce these phonemes like an infant would––by mostly using his jaw, and by positioning the tongue forward. Get the jaw to move MORE to stimulate these anterior phonemes.

3) He needs to learn how to move his tongue independently from his jaw. This occurs as the jaw begins to stabilize in an upward position. Therefore, I also would stimulate T, D, N, L, S, and Z with the jaw stabilized. Place something between his molars to force the tongue to move independently. Stabilize the jaw LOW for T, D, N, L to force the tip to elevate higher. Stabilize the jaw HIGH for S and Z to force the tongue to stay in the mouth more.

4) Unintelligibility also is due usually to imprecise vowels, dropped syllables, rapid rate, etc. Work on exaggerating speech. Have him speak up, speak out, and exaggerate. Practice words, phrases, and sentences of 1-5 syllables in BIG, JIGANTIC PRONUNCIATIONS.  Over-exaggerate. Practice “elephant” as “E-LE-PHANT!” Focus on the syllables. Focus on the roundness and full resonance of the vowels. Make the productions BIG. And teach him to listen to himself do all of this.

5) In regard to the clusters, I usually find it easier to get the clusters first in the final position — Cats, rats lights, boats, books, bikes… This is easier for these kids than Sp, St, Sk… It seems to be easier to sequence frication AFTER the other consonants that before them. It’s easier to say Ts that St… That way you can bring frication in right away.

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By Pam M – December 19, 2011

The Long T (again)

Q: I bought your book Frontal Lisp, Lateral Lisp recently and am trying your “Long T Method.” My client can do T but not Ts. Is there still hope that I can use the Long T method or should I skip to something else? I only tried an aspirated T during one session so far.

Patience!  One session is not enough to know if a method will work or not.

Also, you seem to be trying to get him to say S.  The point of the Long T method is NOT to say S.  It’s for kids who cannot say S.

Do not try to get him to say S or Ts.  Get him to blow more air after the T.  Tell him, “Don’t say S.”

Then use this gross aspirated T in place of Ts in words like cats, boats, lights….  Tell him, “I do not want you to say S… I just want you to blow more air on your T.”

You are tricking him into producing Ts by telling him not to produce S.

See my other postings on the lateral lisps for more ideas.

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By Pam M – December 16, 2011

Work the Lateral Lisp Slowly

Q: I have had success with your “Long T Method” for teaching S and Z with my adolescent lateral lisper, but he continues to break down in reading and in conversation, he can do Sh and Zh on words, but he can’t do Ch or J at all. Where do I go from here? Can I expect braces to help improve his speech?

Braces will not help.  This is not a tooth problem.  It is a tongue movement problem.

You are trying to go to fast. Take your time. He needs to be lead slowly and carefully through each phoneme.  You are expecting that just because he can do one thing that he should be able to do all things.  Client who are difficult do not generalize skills that way.

You have taken my class on lateral lisp, so you will know what I am saying here –– You have used T to teach S and Z, but you also need to use E to teach Sh and Zh, and then you need to use Sh and Zh to teach Ch and J.

This is all explained in my seminar handout.  Go back and look at each of these slides carefully.

And when you work on sentences and paragraphs, make sure they are void of all other words that contain sibilants.  And make sure you are using straws throughout to double check that that airstream is in fact midline.

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By Pam M – December 13, 2011

The Tools of Articulation Training

Q: I am confused over the term NS-OME (Non Speech Oral Motor Exercises). Some people are saying that we cannot use things like toothettes, bite sticks, whistles, or straws in therapy. I use many things like this in therapy. Shouldn’t we do whatever we can to help our clients learn to make speech sounds?

Your question is a good one.  Yes, we are supposed to use whatever we can to help our clients learn to produce speech sounds.  Van Riper said it like this ––

“Every available device should be used to make the student understand clearly what positions of tongue, jaw, and lips are to be assumed” (Van Riper, 1954. p. 238).

But this ideas has come under criticism today because of the new notion of the NS-OME ––

“Party horns…blow ticklers…bubbles…straws… Items like these are being used across America to treat a wide range of communication disorders… [This] has elicited spirited debate (to put it mildly) among SLPs and communication scientists” (Powel, 2008, p. 374).

Let me help you with this by sharing a section from my next book.  The following is abstracted from The Marshalla Guide to 21st Century Articulation Therapy, in a chapter entitled “The Tools of Articulation Training.”  I have copied parts of the introduction to that chapter here.  The chapter itself, when the book is published, will contain an extensive list of these tools and how to use them.

The Marshalla Guide to 21st Century Articulation Therapy

The Tools of Articulation Training

Where did the idea to use an object to train speech movement come from?  Who first advocated these practices?  Is this a modern idea without historical backing?

History

The fact is that the use of objects to teach speech movement is not a new idea.  Van Riper called these the “old traditional methods” (1947, p. 185) and wrote that they have been around for hundreds of years.  He wrote about them in his discussion of phonetic placement methods ––

“For centuries, speech correctionists have used diagrams, applicators, and instruments to ensure appropriate tongue, jaw, and lip placement.  [These] phonetic placement methods are indispensable tools in the speech correctionist’s kit… Every available device should be used to make the student understand clearly what positions of tongue, jaw, and lips are to be assumed”  (Van Riper, 1954, pp. 236-8).

Van Riper said that both verbal descriptions and instruments were to be used in the process of phonetic placement.  In recent decades, however, some writers of modern articulation texts have downplayed the importance of using instruments, and they have focused our attention on using verbal descriptions.  In fact, some textbooks lead one to believe that the phonetic placement method is only about describing speech movements.  But Van Riper’s original writing clearly takes us beyond the simple verbal instruction.  Van Riper said that phonetic placement is the process of using “every available device” to guide speech production.

Van Riper devoted several pages of the early editions of his text to the use of tools in phonetic placement, but apparently he felt clumsy in their use –– “In our experience, they are more dramatic than useful” (1947, p. 187).  Van Riper was the one who drew our attention most solidly to ear training.  He wrote that ear training was the most important aspect of any articulation program.  He said that we always should start the teaching of any phoneme by modeling it –– a process he called the stimulation method.  However, in that same paragraph, the great therapist said that objects must be employed when ear training alone fails.  He wrote, “…when the stimulation method fails, they [objects] must be used” (1947, p. 186).  Van Riper insisted that using objects was a valuable method of teaching phonemes.  He said that these items don’t need to be used when the client succeeds with auditory methods alone, but that objects must be employed when simple model-and-imitate methods are not enough.

Early Tools

When early editions of Van Riper’s book were published, phonetic placement devices were constructed of the only materials available at the time including wood, cotton, feathers, metal, glass (mirrors), paper, cardboard, cloth, rubber, leather, and other natural substances.  Van Riper’s referenced Scripture (1912) for these methods, for Scripture was the first to write about them in the United States.  Scripture described how to use tongue depressors, tooth props, handkerchiefs, rubber hoses, rubber wedges, rubber bulbs, “breath indicators,” metal rods, feathers, tissue paper, toothpicks, pencils, “probes,” “applicators,” “a bent laryngeal electrode,” and a “velar hook made of a rubber pen holder.”  He even used a Bunsen burner to teach clients about airflow (Scripture, 1912, p. 122–172).

In 1925, Borden and Busse published a book of phonetic placement techniques that also was highly recommended by Van Riper.  These New York University Speech Clinic professors discussed a number of probes they called “mechanical intervention and stimulations” (Borden and Busse, 1925, p. 159).  These instruments were constructed of wires, metal plates, wood, and rubber, and were designed to teach the client how to place the lips and tongue for phoneme productions.  Their tools were named as follows ––

  • Fricator: A flat metal plate on a handle used to hold the blade of the tongue down.
  • Fraenum Fork: A forked metal brace used to push the tongue into position.
  • S-Concentrator: A thin, hard rubber tube (like a bent straw) used to achieve midline frication.
  • Ladator: An odd-shaped tool used to hold the lips out of the way.
  • Ruvator: A flat metal plate on a handle used to hold the back of the tongue down.
  • Bent metal tongue depressor: A bent metal object that looked like today’s laryngeal mirror that was used to inhibit tongue’s “tendency to bunch up.”
  • Ordinary wooden applicator: A thin wooden stick used to create a narrow central groove of the tongue.

The tradition of using objects in articulation therapy originally came to the U.S. from Europe.  An article published in France in 1965 described a series of tools, called guide-langue, that were being used for speech correction at the time (Borel-Maisonny, 1965).  These were a set of 24 metal tools that were constructed like laryngeal mirrors, first made of metal and later plastic.  Each was comprised of a long thin handle with a shape on the end.  The shapes were of balls and paddles of various sizes, shapes and widths.  The tools were designed to teach jaw, lip, and tongue placement for all phonemes.  The Borel-Maisonny article contains schematic illustrations depicting how to use them to teach phonetic placement.  Borden reminded us of these tools in 1984 ––

“Speech pathologists in France, called orthophonists, carry around with them a tool kit with all sorts and shapes of oral probes for pushing the tongue around and for increasing awareness of tactile sensation in the mouth”  (Borden, 1984, p. 57).

In my thirty years of travel across the US and Canada to teach continuing education courses, I have met scores of international speech-language professionals––therapists from Poland, Germany, France, England, Russia, Brazil, Romania, the Czech Republic, and many other countries.  These professionals invariably approach me during breaks to explain that they were taught phonetic placement methods by using tools back in their home country.  They are confused as to why SLP’s in the United States are not trained in these basic methods today.

Today in the USA

The use of tools in articulation therapy today often gets lumped under the broad heading oral-motor techniques because they are used to guide oral (jaw, lip, tongue, velum) movements or positions for phoneme production.  The term oral-motor simple means “mouth movement.”  Modern textbooks that limit their discussion to only those methods that have been studied under the rigorous standards of today’s research methods have banned these ideas from their pages, or they mention them with obvious skepticism.  But old textbooks on articulation therapy are filled with them, and the methods survive in books with the term oral-motor in their title.  Prominent among these are Oral-Motor Techniques in Articulation and Phonological Therapy (Marshalla, 1992), and Oral-Motor Techniques for Speech Clarity (Rosenfeld-Johnson, 2001).

Many of the old-time phonetic placement methods also have survived in a several books designed to preserve them.  Prominent among these are Eliciting Sounds: Techniques and Strategies for Clinicians (Secord et al, 2007), Sound Strategies for Sound Production (Gilbert and Swiney, 2007), and The Late Eight (Bleile, 2006).

Today’s Tools

The introduction of plastic and vinyl to the production of household objects has caused a virtual explosion in the number of items that might be utilized today for stimulating the movements and positions necessary for phonetic placement.  The SLP practicing in the 21st century can chose from hundreds of items in order to follow Van Riper’s early directive to use every available device with clients who do not imitate phonemes well.  In essence, we now have tools to teach almost all aspects of respiration, phonation, resonation, and articulation control, from producing voice for a basic vowel, to elevating the back lateral margins of the tongue for an /r/.

Everyday objects are being used in this endeavor.  These include dental floss holders, tongue cleaners, kazoos, baby chew toys, tooth brushes, horns, bubble wands, lip retractors, lip gloss, dental wax, plastic straws, coffee stirrers, whistles, gummy bears, licorice whips, toy harmonicas, eyedroppers, laryngeal mirrors, and many other items.

Professional tools designed to stimulate specific oral movements in speech and feeding have and are being developed as well.  These include, for example, Chewy-Tube®, LifteR®, Toothette®, SpeechBuddies®, Ark Probe®, LipGym®, Jaw Grading Bite Blocks®, and the Z-Vibe®. The old See-Scape® and TalkBack® tools also fit in this category.  And of course, the tongue depressor probably is the most widely used professional tool of them all.

I believe that old-time practitioners who wrote the traditional books would have been thrilled to have the cornucopia of today’s objects available for phonetic placement.  They, like us, were creative and devoted people who would do just about anything to help their clients learn to produce better speech sounds.  It is perhaps unfortunate that some of these procedures have come to be called oral-motor techniques because the new term has caused much confusion and heartache within the profession.  These procedures were never intended to replace traditional articulation therapy methods, as some have assumed, nor were they intended to compete with methods of phonological therapy.  Modern SLP’s, who use a wide variety of toys and tools in their practice, simply have taken the old phonetic placement methods to new heights.  They are using new tools to accomplish old goals devised many years ago for phonetic placement.

Are These Non-Speech Oral-Motor Exercises?

Every writer of the phonetic placement methods, of oral motor techniques, has discussed the use of these toys and tools within the context of a complete articulation therapy program. Compare these quotes from Van Riper, Marshalla, and Rosenfeld-Johnson ––

  • 1958:  “The therapist…is attempting to give the case the appropriate location and formation.  As soon as this has been achieved, the therapist stimulates the case with the correct sound”  (Van Riper, 1958, p. 147).
  • 1992:  “One does not eliminate other aspects of a client’s articulation or phonological program in favor of doing oral-motor therapy alone. One utilizes oral-motor techniques as one engages in a program of articulation and phonological treatment”  (Marshalla, 1992, p. 16).
  • 2001:  “It is a tactile teaching technique which supplements traditional therapy… Please remember that the exercises in this manual do not replace anything you are using now”  (Rosenfeld-Johnson, 2001, p. 1).

The application of tools and toys in articulation therapy today is NOT a process of using “non-speech oral-motor exercises” as has been accused of late (e.g., Powell, 2008; Ruscello, 2008; Lof, 2008; Lof and Watson, 2008; Lass and Pannbacker, 2008).  There is nothing “non-speech” about them.  These methods are expanded descriptions of articulation techniques that have been around for hundreds of years.  These arethe traditional methods.

Unfortunately, when phonology entered the field in 1968 (Chomsky and Halle, 1968; Jacobson, 1968), our focus was turned to distinctive features, and then to phonological processes, and many of the old methods of phonetic placement were ignored as a result.  There even was much discussion that we did not even need the old methods any more.  But the problems of phonetic placement did not go away.  We still had kids with lateral lisps, frontal lisps, and distorted /r/.  We still had kids who could not lift the back of the tongue to produce /k/ and /g/, who could not lift the sides of the tongue for the sibilants’ groove, who could not press their lips together for /p/ and /b/, who could not lift the velum to produce an oral sound, and so forth.  Therapists continued to search for ways to get cooperative movement from the jaw, lips, tongue, and velum in order to achieve their speech targets.

Ideas to facilitate better oral movement for speech and feeding were being described as oral motor techniques in the late 1970’s.  Therapists, like myself, who were combining ideas about articulation, phonology, feeding, dysphagia, orofacial myology, motor speech disorders, neurodevelopmental treatment, and sensorimotor integration, began to teach others how to utilize these methods.  The old phonetic placement methods had been elevated to a new vista that combined articulation with many decades worth of new information about postural reflexes, muscle tone, gradation of movement, stability and mobility, flexion and extension, and other concepts borrowed from motor therapists.  A new perspective of speech movement had emerged and it was called oral-motor.  It was a combination of old ideas about phonetic placement with new ideas about movement itself.

As in all things, the more an idea is spread, the thinner the concept becomes.  By the 1990’s, some speech-language professionals had begun to substitute blowing horns and wagging the tongue for traditional articulation procedures.  This was an error.  One cannot replace good old-fashioned ideas about teaching phonemes or phonological patterns with wagging the tongue or blowing whistles.  Why this error began to occur, I cannot say for certain.  My best guess has been that, for whatever reason, these therapists did not learn traditional articulation therapy well in the first place, and they knew almost nothing about the old phonetic placement methods.  Therefore, when exposed to the new ideas about oral motor techniques, they thought that this was all that articulation therapy was.  But that is an incorrect view.  Oral-motor techniques get the mouth to move better, but they do not substitute for broader ideas about phoneme stimulation.  They are techniques that are used within a program of articulation therapy.  They are used for phonetic placement as well as to help prepare the oral mechanism for the movements necessary for phoneme production.

Despite the lack of university support, countless thousands of SLPs practicing in the North America use certain tools in the training of speech today.  Evidence that these objects are being used widely comes from product catalogues that teem with these items.  These toys and tools are being used despite the fact that very few of them have undergone the rigors of laboratory research considered so important today.  Tremendous controversy on the subject exists as a result.  Researchers cry out for restrictions in the use of such methods while practicing clinicians use what is available to them as always.  Practicing clinicians cannot wait for the research to come in.  They must act in practical and logical ways every day, just as they always have.  Using toys and other objects in therapy is part of the creative process of articulation therapy that was recommended by Van Riper and the other traditional masters ––

“There are no doubt almost as many ways of carrying out these basic principles as there are clinicians” (Van Riper and Irwin, 1958, p. 118).

References

  • Bleile, K. (2006) The Late Eight. San Diego: Plural.
  • Borden, G. (1984) Consideration of motor sensory targets and a problem in perception. In Treating Articulation Disorders: For Clinicians by Clinicians. Winitz, H. (Ed.) pp. 51-66. Baltimore: University Park Press.
  • Borden, R. C., & Busse, A. C. (1925) Speech Correction. New York: Crofts.
  • Borel-Maisonny, S. (1965) Correction des erreurs motrices de la parole. Reeducaticu Orthophonique, No. 10.
  • Bosley, E. C. (1981) Techniques for Articulatory Disorders. Springfield: Charles C. Thomas.
  • Chomsky, N., & Halle, M. (1968) The Sound Pattern of English. NY: Harper & Row.
  • Gilbert, D. W., & Swiney, K. A. (2007) Sound Strategies for Sound Production. Austin: Pro-Ed.
  • Jacobson, R. (1968) Child Language Aphasia and Phonological Universals. The Hague: Mouton.
  • Lass, N. J., & Pannbacker, M. (2008) The application of evidence-based practice to nonspeech oral motor treatments Language, Speech and Hearing Services in the Schools, 39, p. 408-421.
  • Lof, G. L. (2008) Controversies surrounding nonspeech oral motor exercises for childhood speech disorders. Seminars in Speech and Language 29, 4, p. 253-255.
  • Lof, G. L., & Watson, M. M. (2008) A nationwide survey of nonspeech oral motor exercise use: Implications for evidence-based practice.  Language, Speech, and Hearing Services in the Schools, 29, 4, p. 392–407.
  • Marshalla, P. (Unpublished manuscript) The Marshalla Guide to 21st Century Articulation Therapy. Mill Creek, WA: MSL.
  • Marshalla, P. (1992) Oral-Motor Techniques in Articulation and Phonological Therapy. Mill Creek: Marshalla Speech and Language.
  • Powell, T. W. (2008) “The use of nonspeech oral motor treatments for developmental speech sound production disorders: Interventions and interactions.” Language, Speech and Hearing Services in the Schools, 39, p. 374-379.
  • Rosenfeld-Johnson, S. (2001) Oral-Motor Exercises for Speech Clarity. Tucson: Talk Tools.
  • Ruscello, D. M. (2008) An Examination of Nonspeech Oral Motor Exercises for Children with Velopharyngeal Inadequacy. Seminars in Speech and Language 29, 4, p. 294-303.
  • Scripture, E. W. (1912) Stuttering and Lisping. NY: Macmillan.
  • Secord, W. A., & Boyce, S., & Donohue, J., & Fox, R., & Shine, R. (2007) Eliciting Sounds: Techniques and Strategies for Clinicians. NY: Thomson Delmar Learning.
  • Van Riper, C. (1958, 1954, 1947) Speech Correction: Principles and Methods. Englewood Cliffs: Prentice-Hall.
  • Van Riper, C. & Irwin, J. (1958) Voice and Articulation. Englewood Cliffs: Prentice-Hall.

 

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By Pam M – December 10, 2011

Phonological Policies

Q: My school district has been suggesting that we work on stopping before s-clusters, and I thought that would be a mistake leading to lots of frustration for both the SLPs and the students. Do you have any comments?

I think that whenever we set policy –– “my district has been suggesting that we work on stopping before s-clusters” –– we are forgetting the individual child.

There is no hierarchy or policy that should “work.”  What “works” is what works for that individual child, not what “should work” for everyone.  For example ––

  • One child will learn clusters before singletons, and another will learn singletons before clusters.
  • One child will learn a postvocalic S before a prevocalic S, and another will do it in the reverse.
  • One child will learn all his [+Anterior] sounds first and have great difficulty with the [+Back] sounds, while another child will get all his [+Back] sounds right away yet have tremendous difficulty gaining the [+Anterior] sounds.

It is not a curriculum we are teaching.  We are designing individualized programs that work for individual children. What does the term “IEP” mean?  It means Individualized Educational Plan.

To set a policy for approaching phonological skills means to ignore the important concepts of stimulability, readiness, and trial-and-error.  It also means to ignore who we really are –– we are people who help others in the ways that they can be helped.  We are not people who shove pre-set curriculums down our students’ throats.

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By Pam M – December 6, 2011

When “Ate” sounds like “Hate”

Q: When my 4-year-old client says a word that begins with a vowel, he adds /h/ before it –– “Ate” sounds like “Hate.” What are your thoughts?

Let me answer this according to four different scenarios ––

1.  Client generally uses no frication at all:  If the client was not yet using any fricatives or affricates, and the extra appearances of H were just a fluke, then I would stimulate all eleven sounds for a while till the whole set starts coming in –– Th, Th, F, V, S, Z, Sh, Zh, Ch, J, H.  Then I would worry about that extra H.

2.  Client has started acquiring frication and is overgeneralizing:  I may not bother to address this problem just now because the client simply may be in the process of acquiring frication, he is overgeneralizing, and he is doing so with H.  He is putting H where it doesn’t belong, and that’s okay for now because he needs to.  If this were the case, I would work on a lot of words that started with H so he could over-work it for a while –– He, him, his, hers, hot, hold, happy, hat, hit, home, home run, Harry, Harvey, hippo, etc.

3.  Client has all his fricatives and affricates:  If all the fricatives and affricates were in, or mostly in, and this truly was a simple problem of adding an extra H, I would use minimal pair words to teach him to hear, see, feel, and comprehend the difference between words with and without initial H.  For example, I might use ––

Heat –– Eat
Hit –– It
Hate ­­–– Ate
Head –– Ed
Hat –– At
Hoops –– Oops
Hone –– Own
Haul –– All
Hum –– Um
Who –– Oo

4. This is true prevocalic devoicing:  If the client truly could not turn his voice on as he initiated words, and he had to start a vowel with his voice off, I would teach him more about his voice.  I would teach him to turn it off and on at will by combining amplification and palpation of the neck (feel the vibration in the vocal folds with the hands).  Then I would teach him that he has to turn it on when he says a vowel.  I would have him practice whispered vowels and voiced vowels, back and forth, so he can hear and feel the differences.  Then I might go on to whispered words versus voiced words.

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By Pam M – December 3, 2011

Emerging Lateral Lisp in 12-Month-Old

Q: I am an SLP and my 12-month-old daughter is developing a lateral lisp on her first words! Help!!!

I believe this to be one of the worst positions in which an SLP can find him- or herself.

We can teach midline sibilants to very young children, even toddlers, if we approach the acquisition of frication/stridency the way an infant does.  I would do these three things now ––

1. Teach her to make a lingua-labial raspberry.  Put the tongue between the lips and blow.  This should habituate midline airstream.  Don’t practice this sound if she stiffens her tongue and makes it think and hard along the midline, and if the sound comes out laterally.  Make it soft and floppy so the tongue stays loose.  This is gross midline airstream work.

2.  Teach her to spit.  I know you probably don’t want her spitting, but most little kids learn to spit before they ever learn specific fricatives.  Spitting is done with the two lips together (bi-labial spitting), and with the tongue-tip between the lips (lingua-labial spitting).  This also is gross midline airstream work.

3. Don’t try to teach her S just yet.  Instead, make sure she is making an excellent T with the airstream coming out the midline. Play with making T into a McDonald’s straw.  Hold the straw outside the front teeth at midline.  Blow the T through the straw into a bowl of milk or a cup of juice.  Or, better yet, take it away from the feeding experience and make it a bathtub play activity.

4. Choose a simple word that ends with T that she can acquire easily, like Eat, Out, or That.  Teach her to punch out that final T.  (Most toddlers turn final T into final TS, which then turns into final S.)

5. Make sure she is learning Long E (as in “Eat”).  The Long E position situates the back lateral margins of the tongue against the palate for the underpinnings of the midline airstream.  If she already can do E (which she probably can), teach her to pant through the E position. She will be making a midline airstream.  A few months down the road, teach her to round the lips while she makes this sound.  It should turn into Sh.  Practice saying “Shhh” to baby dolls, etc.

That’s all I would do for now, with special concentration on the first four.  The fifth item gets more to the sibilants themselves, and it is probably way too early for that now.

Remember: 

  • Be mom first and therapist a distant second.
  • Do this is ways that she doesn’t know anything is going on.
  • Don’t develop tension around speaking.  You don’t want to create dysfluencies.  Abandon all of it if tension begins to develop.
  • Also, remember that she still will be brilliant even if she doesn’t have 1000 words by age two years.  I know this is hard for an SLP, but hold back on the language stimulation a little.  Give her time for her articulation skills to catch up with her brain and her vocabulary.

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By Pam M – December 1, 2011

What Evidence-Based Practice (EBP) Really Means

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 mid- 2011. Download the original PDF here.

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What Evidence-Based Practice (EBP) Really Means

Q: It is surprising to me that you find it reasonable to pass on non-evidence based ideas. I don’t think this meets a best practice standard at all. I’m curious to know how you demonstrate efficacy this way.

The term “Evidence-Based Practice” has been bandied about and distorted. EBP does not mean that we only use methods that have been researched in a laboratory.

For example, have you ever used a mirror in therapy to help a client understand how to position the articulators for a speech sound? I hope so. Is there any evidence to support this idea? No. Does that mean that we can no longer use a mirror in therapy? I hope not.

In an Evidence-Based Practice, the SLP takes what has been demonstrated in laboratory research, and puts that together with what she has learned through direct clinical experience, and what the client needs/wants/prefers. Here are four sources of this idea:

1. According to ASHA, an evidence-based practice is one that integrated evidence from the LAB, from the CLINIC, and from the CLIENT himself. ASHA’s logo for the EBP is a triangle, with each side of the triangle representing one of these ideas. You can view this on the ASHA website and here, to the right.

2. Sacket et al, the original authors of the EBP, have stated in their textbook, “External clinical evidence [i.e., research] can inform, but can never replace, individual clinical expertise.” Evidence-Based Medicine: How to Practice and Teach EBM. Edinburgh: Churchill Livingstone, p. 3-4). They insisted that laboratory evidence alone can never dominate ones decisions about therapy. [Sacket, D., & Richardson, W.S., & Rosenberg, W., & Haynes, R.B. (1997) Evidence-Based Medicine: How to Practice and Teach EBM. Edinburgh: Churchill Livingstone, p. 3-4]

3. Laura Justice, editor of the American Journal of Speech Language Pathology, contrasts EBP with “empirically validated treatments” (a treatment that has been validated by empirical research). She wrote: “…one’s use of an empirically validated treatment is not the same as engaging in EBP” (p. 324). Using EBP, the clinician “systematically gathers and integrates information (i.e., evidence) from a variety of resources, including scientific evidence [LAB], prior knowledge [CLINIC], and client preferences [CLIENT], to arrive at a decision” (p. 324). [Justice, Laura (2008) “Evidence-Based Terminology” Laura, Editor, AJSLP, 17, 4, November 2008]

4. Carol Dollaghan says that and EBP is the conscientious, explicit, and judicious integration of best available: External evidence from systematic research (LAB), Internal evidence from clinical practice (CLINIC), Evidence concerning the preferences of a fully-informed patient (CLIENT). [Dollaghan, C. A. (2007) The handbook for evidence-based practice in communication disorders. Baltimore: Brook.

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By Pam M – November 29, 2011

Stopping Stopping (Organizing the “Hissing Sounds”)

Q: In my therapy with kids who have the stopping process, I typically start with S-clusters and S in the postvocalic position.  It seems they develop the idea of “fricative-ness” more easily this way and, from there, they more easily go on to prevocalic S.  I find that starting with prevocalic S often leads to a lot of frustration because they learn “sock” as “stock,” and so forth. Can you comment on this?

First, we have such a mess in dividing sounds into groups called fricatives, affricates, stridents, and sibilants.  What confusion.  I propose that we call Th, Th, F, V, S, Z, Sh, Zh, Ch, J, and H with only one term –– “The Hissing Sounds.”

So let’s talk about stimulating the Hissing Sounds when they are absent.

My experience is exactly the same as yours. The Hissing Sounds come in much more easily at the ends of words ––

  • I usually begin with word final Ts –– Hats, cats, lights, boats…
  • Then I move on to postvocalic voiceless Th, F, S, Sh, CH –– Bath, Off, Bus, Fish, Ouch
  • Then I move on to postvocalic S-Clusters with P and K –– Books, Cups…
  • Then I go on to word-initial position S-Clusters with Sp, st, sk, sm, sm, sl, sw –– Spoon, star, skate, smoke, snake, sweater, slide
  • Then I go to the prevocalic sounds Th, F, S, SH, CH, H –– Think, Four, Sock, Shoe, Choo-choo, Hot

But of course this is just a plan in my head. I always probe for stimulability and go with what the client shows me he/she is ready for. So that means sometimes I abandon the whole thing and just work on H… or Sh… or Ch… or F… of S… in whatever position is working for the client.

FYI, I began to reorganize my presentation of these phonemes in this way after having read Smith (1973). This book is a detailed month-by-month analysis of one child’s developing phonological system.  Smith studied his own son and found that stridency emerged first at the end of words, particularly after he had learned final T.  I began to apply this idea to my clients and found it to be a much better approach than introducing hissing at the beginnings of words first.

Also, I heard Barbara Hodson speak in 2006, and she said the same thing.  She said that if a child cannot get initial S, we should abandon it, go to final S-clusters, and then to final S. And eventually we should return to initial S.

References

  • Hodson, B. W. (2006) Enhancing Phonological Skills and Metaphonological Skills of Children with Highly Unintelligible Speech. Seminar Handbook. Bellevue, WA: Belay Learning. March 17.
  • Smith, N. V. (1973) The Acquisition of Phonology: A Case Study. London: Cambridge.

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By Pam M – November 27, 2011

Prioritizing the Frontal Lisp and Cluster Reduction

Q: My client is beginning to use S-blends, but she does so with an interdental lisp. Do I treat the phonological process first and let her lisp, or treat the lisp first and then the process? Or should I do both concurrently?  I am worried about reinforcing the lisp.

I would work on the phonology first to stimulate the use of the phoneme within the language.  Then I would address place of articulation.  That’s the way I would organize it in my head, at least, because that’s the way it evolves in normal development.  For example, it is very common for a two-year-old to develop plural (Hats, cats…) with interdental tongue placement on S. The child gets the phonological pattern first, and then she sorts out place of articulation.

Having said that, I would be stimulating normal oral stability all the way along, but I will not describe that process here.  That way, as the S emerges, it will be produced in a stabile way –– with the jaw high and the tongue in.

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By Pam M – November 23, 2011

Need for Differential Diagnosis

Q: I have a six-year-old male client that has phonological and articulation problems. What should I target first in therapy?

Therapy always is based on the differential diagnosis.  It is impossible to answer that question without information about the client’s entire phonological and articulation repertoire. Selection of therapy targets will be very different depending upon many factors.

One makes decisions about therapy based upon a complete overview of what is going on.  If you read through this blog, you will see that I have answered many questions about how to stimulate this or that phoneme or phonological.  However I have never answered a question that stated, “My client has a problem with speech, what should I do?”  The question is far too broad and far too void of basic information that can help you make these kinds of decisions.

To make decisions about where to start in therapy one has to have information in at least the following areas. This is the core of the differential diagnosis for an expressive speech disorder, in my opinion ––

Cognition

The client’s cognitive status, IQ, or cognitive age equivalency.

Receptive Language

The client’s receptive language level, vocabulary age, ability to follow directions, ability to answer questions.

Expressive Language Level

The client’s expressive language level. Non-verbal? Babbling? One-word level? Two-word level? Etc.

Hearing

The status of the hearing mechanism.

Oral Structure

The status of oral structure.

Oral Function

What is the status of oral (jaw, lip, tongue, velum) control?

Phonology

A complete inventory of phonological patterns.

Distinctive Features

An accounting of the distinctive features the client does and does not use.

Consonants

A complete inventory of all the consonants that the client does and does not use.

Vowels

A complete inventory of all the vowels the client does and does not use.

Diphthongs

A complete inventory of the diphthongs she does and does not use.

Voice, Resonance, Prosody, and Fluency

A simple accounting of each area.

Feeding

My analysis always includes an assessment of feeding skills as well, however I realize that this is not taught as a standard of practice.

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By Pam M – November 18, 2011

Sliding Jaw on /R/

Q: I have an elementary client who figured out how to say R all by herself, but she shifts her jaw to one side to accomplish it. I have tried to get her to stop lateralizing the jaw, but then she can’t produce R. Should I worry about this?

I would not try to take her away from what she has achieved on her own. She is proud of it!

Instead, let her keep producing the R with the jaw lateralization for now. Stabilize the acoustic quality like this for weeks/months.  Then, down the road and when you feel that the time is right, have her look in the mirror and decide for herself if she wants to speak with her jaw sliding to the side for the rest of her life.

The Effect of this Problem

There is a political talk guy on cable news who does this –– Dick Morris.  He slides his jaw to the left on every R he makes.  It is soooooo distracting and takes away from his message.  It is not “wrong” per se, because the acoustic quality of R is there, but the elocutionists never would have stood for it.  You might have your client watch this fellow online.  He is everywhere on YouTube.

Minor visual elements like this are very distracting to the listener.  An SLP can see what the person is doing wrong.  But the average person simply thinks that the speaker talks funny and therefore must not be very smart.

A Message to Celebrities

By the way, if you are Dick Morris and are reading this, CONTACT ME!  I can help you with this.  You are far too smart of a guy to be burdened with this minor speech error.

And the rest of you celebrities with minor but very distracting speech errors… You know who you are… CALL ME!

And all you young female actresses in films, television, and commercials who are speaking with that awful GLOTTAL FRY…   STOP IT!  It’s not cute or sexy.  You are ruining your voice.  You will have very little voice left by the time you are in your fifties.  You depend on your voice for your livelihood, for goodness sakes.

Get thee to a voice specialist!   Many excellent speech-language pathologists and vocal coaches can help you find your real voice so you can speak like the grown intelligent women that you are.

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By Pam M – November 15, 2011