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

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

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

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

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

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

Tapping

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

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

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

Reference

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

Words to Practice With Big Up-Down Jaw Movements

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

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

Incisors

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

Missing Front Teeth

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

Malocclusion

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

Analysis

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

Treatment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Reference

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

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

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

Once per day? Ten times per day?

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

5 minutes? 5 hours? All night long?

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

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

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

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

These are the types of things I would try…

Use a Vowel

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

Use a Tube

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

Pinch the Nose Closed

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

Use a See-Scape

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

Use Tissue Paper and a Tube

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

Use the Fingers to Feel Vibration

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

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

Differential Diagnosis

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

In Speech

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

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

The Differences Between Apraxia and Dysarthria

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

The Similarities Between Apraxia and Dysarthria

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

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

The Final Analysis

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

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

What I Wish

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

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

The Problem We Have Today

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

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

The real questions are quite basic:

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

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

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

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

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

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