As I am sure you know, a technique is just a technique. Therapy is all about finding out if a certain technique works for a certain client. Therefore in regard to this specific technique, if he can swallow on demand, you don’t need the dropper. But if he can’t, you do.

Let me be very blunt here.

Warning! Those of you who don’t know me need to be warned that I do not speak with political correctness. I find it to be an imposition on our freedom of speech and therefore a violation of the constitution. I will not be held responsible for anyone who is offended by the following comments…

Again… Let me be very blunt here.

I believe that we need a change of school culture.  We are seeing children with very low cognitive skills too much and students with mild speech problems and average intelligence or better too little.  I have a long-term goal to change this back to the common sense procedures that SLPs used to use.

I am teaching today’s SLPs to begin to repeat to their teams the following concept: “A child can speak only as well as he understands.” 

In general––

• Kids whose cognition is below the 6-month level should be saying no words and they should be making very few sounds.  They should not even be babbling. They should have no “communicative intent” and should not be able to use signs, gestures, or pictures for any meaningful purpose. They should be encouraged to make sound, any sound.
• Kids whose cognition is at the 6-10 month level are at the stage of “illocution.”  This is still a pre-language level.  They should have no concept of word and thus they should be saying no words.  They should only be making some spontaneous sound, and a few babbling-type noises.  Their sounds should be becoming regular, consistent, and repetitive however. In other words, they should have a few sounds that they say to the exclusion of everything else.  They should be getting good at repeating these sounds and every sound they make should be celebrated.
• Kids who function at 10-14 months of age should be saying one single word only. But because these kids usually have dysarthria too (due to neuromuscular disorder) they probably still have no words. These children may have a word or two that pops out occasionally but never on demand.  They should be in situations in which it is likely that they will say the word they have.  For example, if the child can say “keys” he should be encouraged to say keys many times per day. Each time he spontaneously produces the word should be celebrated. “Yeah! David is learning how to say keys!”
• Kids who function at the 14-18 month cognitive level should be saying 1-10 words at best. But because these kids usually have dysarthria too (due to neuromuscular disorder) they probably still have no words.  They should be using gestures, facial expressions, objects, and pictures, and some vocalizations to begin to communicate their wants and needs. They should not be able to practice words on demand, but words should be popping out here and there. These should be celebrated whenever they occur.
• Kids who function at the 18–24 month level should be saying 10-25 words (probably fewer), and up to 50 words at the very best. But because these kids usually have dysarthria too (due to neuromuscular disorder) they probably still have very few words.  They should be using these words consistently for communication purposes.  The words probably will be very hard to understand due to the dysarthria.  They probably will lock in on an incorrect way to say a word and they will say it that way for many years.  For example, perhaps the child’s name is Kristie, and she calls herself “Tee-Tee.” I would not expect this to change for a very long time.

Kids with very low cognition should not been seen multiple times per week. That is called “Babysitting.”  They do not change fast enough to warrant that much therapy.  Instead, we should be acting as consultants to the team about how to stimulate for a few basic communication routines that are functional for the child at home and at school. It only takes one time per month to do this, at most.

We need school psychologists to step up to the plate again and put cognitive ages on these kids.  In lieu of this information, we need to help the parents and team understand the child’s cognition.  We can help them understand the developmental level of the child’s play, his ability to understand vocabulary words, his ability to follow directions, and his ability to answer questions (with word, sound, gesture, sign, or picture).

Again: A child can speak only as well as he understands.

Add to that:  A child usually says far less that he understands.

One final note: We should not be assigning children with low cognition and neuromuscular disorder with the diagnosis of “apraxia.”  A child with low cognition and neuromuscular has “mental retardation” and “dysarthria.”  Three-to-five days per week of therapy will not change his IQ and therefore it will not change his verbal output.

Think about this: APRAXIA occurs in the ABSENCE of neuromuscular disorder while DYSARTHRIA occurs in the PRESENCE of neuromuscular disorder.

Now think about this: ALL the research in speech that has been done on apraxic kids since the beginning of time has been done without any assessment of their muscle tone.  Researchers have just been assuming that tone is okay.  Researchers are taking all kids with very severe artic/phono problems and calling them apraxic without ANY evaluation of their tone.

Therefore all the apraxia research done from the beginning of time through today should be thrown out and we should start over.  Researchers in the area of apraxia should be required to have an assessment of client tone done by an OT/PT to qualify the subjects for their research projects.  Those with hypertonicity or hypotonicity should be tossed out.

The definitions of apraxia and dysarthria speak for themselves––

• APRAXIA is a motor speech disorder that occurs in the ABSENCE of neuromuscular problems. It is a problem in the perception of movement, and therefore it causes problems in planning movement.  The result is severe articulation and phonological deficit.
• DYSARTHRIA is a motor speech disorder that occurs in the PRESENCE of neuromuscular problems.  It is a problem in the execution of movement.  The result is severe articulation and phonological deficit.

I have never faced this but I think this all boils down to what makes sense for him. It seems that the only things that get through to these clients are the things they can plug into their own logic.  If you can figure out what makes ideas get through to him, and if you could steer conversation toward that, then I think you could work out a plan.

For example, if he is rule-bound, perhaps you could teach him a rule: “No children above the age of X suck fingers or thumbs.” Then it would be logical for him to stop because he is beyond that age.  Perhaps the rule should be embedded into a series of general 5-10 rules about appropriate behavior in the classroom, at home, etc.

I worked with one very rigid four-year-old who was like this. When he went to his 3-year dental checkup he overheard his dentist say that thumb sucking was not bad.  So for the next year the boy insisted that he should be left alone to suck his thumb.  But then the dentist reversed this opinion at the boy’s four-year checkup.  The doc mentioned that the boy had to stop because it was beginning to ruin his occlusion and the boy quit the next day.

You never know what will cause a child to comprehend and accept a new idea, especially when they have Autism or Asperger’s Syndrome

Yes!  If the child has hypotonia then this is dysarthria.  Whenever you have muscle tone problems of a global nature, then dysarthria is the diagnosis.  Dysarthria is a speech movement problem that is the result of muscle tone disturbance. (See definitions below)

It is common for children with low muscle tone to have speech movement problems, but the specific phonetic and phonological errors will be specific to the child.

In general all kids with severe speech disorders have the same basic problems to various degrees–– final consonant deletion, initial consonant deletion, cluster reduction, cluster deletion, prevocalic voicing, fronting and/or backing, stopping, stridency deletion, syllable deletion, etc.  Dysarthric kids usually have vowel distortion, and both apraxic and dysarthric kids usually have an incomplete vowel set.  Diphthongs often are shorted into single vowels and the schwa is over-used in both groups.  Distortion of phonemes and the supersegmentals is the hallmark of dysarthria.

A client with a motor speech disorder needs to be viewed from all four speech movement subsystems–– Respiration, phonation, resonation, and articulation (jaw, lip, and tongue movement).  His are not simple phoneme errors.  His phoneme errors are the result of problems in the four movement subsystems.

In terms of therapy, the short and simple answer is that you work on phonemes and phonological processes just like you would for any other client, but you add work specifically to get the child to understand how his body works to inhale, exhale, prolong exhalation, turn his voice on and off, make sound oral and nasal, and move his jaw lips, and tongue in better patterns of mobility and stability.  That is why therapists use blow toys, mirrors, tubes, and so forth.  In the case of dysarthria, exaggeration is a key piece of treatment.  Over-pronunciation is a key to clarity.

Classic Definitions of Dysarthria

“Dysarthria comprises a group of speech disorders resulting from disturbances in muscular control.  Because there has been damage to the central or peripheral nervous system resulting in some degree of weakness, slowness, incoordination, or altered muscle tone.”

From: Darley, F. L., & Aronson, A. E., & Brown, J. R. (1975) Motor Speech Disorders. Philadelphia: W. B. Saunders.

“A generic label for a group of motor speech disorders caused by weakness, paralysis, slowness, incoordination, or sensory loss in the muscle groups responsible for speech”

From: Brookshire, R. H. (1992). Introduction to Neurogenic Communication Disorders. St. Louis: Mosby.

This is what I would be thinking about–––

Teach him to prolong the sound he has––the schwa. And teach him to tolerate your hands on his jaw. Once he can prolong his schwa and tolerate your hands, move his jaw up-and-down while he is vocalizing.

If he can prolong his sound while you are moving his jaw up-and-down, then you will have created a vowel babbling sequence.  Research shows that babies babble with vowels before they babble with CVs, and that might be what this kid needs.

The jaw moving up-and-down while vocalizing is called a movement “frame.” Once the frame is developed, then it should be played with, rehearsed, stabilized.

MacNeilage (1998) proposed that “cycles of mandibular oscillation” underlie the basic up-and-down jaw movement patterns of babbling and early speech.  This up-and-down pattern is called a “frame” and it was postulated that the frame evolves from chewing.

Therefore chewing activities would be appropriate here too.

The jaw going up-and-down in this frame will make the schwa turn into several different vowels, and you are on your way.  You have taught him how to Vowel Babble.

Next, teach him to move the jaw up more firmly.  If that happens, consonants will emerge.  It is the jaw banging upward within the up-and-down movement frame that causes the anterior consonants to emerge––P, B, M, W, T, D, N, L.

Reference

• MacNeilage, P. F. (1998). The frame/content theory of evolution of speech production. Behavioral and Brain Sciences, 21, p. 499-546.

This is not the type of activity that you do for 15 minutes.  Weave it in-and-out of other SL activities you are doing.  Use the dropper procedure every 90 seconds while she is otherwise engaged.  You want to stimulate her to swallow every 90 seconds while she is doing other things. 

Carryover ideas should start right from the first day of therapy, no matter the client’s age. That means that you are planning for and thinking about and stimulating for carryover from the first day, and you are dropping in ideas here and there.

For example, let’s say your child is learning to keep his tongue in his mouth. He can work on that during a therapy session, and he also can be encouraged to keep his tongue in “while we are driving to the store.” That way you are taking his therapy ideas right into his “real world.”

I have only seen a few children with Mobius Syndrome, and those were seen for diagnosis only.

As I understand it, facial paralysis is the main problem and the paralysis can involve some or all of the facial muscles, particularly the upper lip in most cases.

The breadth and scope of the paralysis will guide speech involvement.  One client I saw had paralysis only in the upper lip.  Since the upper lip moves very little in speech, her speech was excellent.  She could not smile, however, and that was the family’s concern. Clients with more areas of involvement will have more difficulty.

One article I read years ago demonstrated that these kids improve in speech slowly over the years and that we should not give up on artic. (Sorry, no reference, article missing).

I would treat a Mobius client simply as another case of dysarthria– distortion due to muscle tone impairment. I would use exaggeration of speech as my main focus. I also would use quick stretch on the facial muscles to see if I could stimulate their function.  And I would use resistance to stimulate more active facial movement.

I also would search the web for more info. I am sure there are SLPs posting info about their therapy with these clients.