Pam Marshalla, MA, CCC-SLP

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Questions and Answers 2006

Below is a quick guide to the 2006 posted questions and answers. You can jump to a specific question or read through all of them by scrolling down.

On Apraxia and Stubbornness
What does oral motor therapy have to do with speech?
On /R/ and Vowels
On Resonance
On Drooling
Frequency of oral motor therapy?
Older Children With Apraxia and Dysarthria
On Cerebellar Disorder
Guidance for Autism and Apraxia
On Keeping Attention
What is oral motor therapy?
Computer software recommendations?

APRAXIA AND STUBBORNNESS

03.27.06 - My preschool client with apparent childhood apraxia is not willing to participate and often walks away from or gets annoyed with therapy plans and procedures.

• He sounds like most of the kids on my caseload. Childhood apraxia comes with its pure stubbornness at times. But I don't think that "behavior" itself is always the issue. There is a reason for the stubborn behavior.
• What I usually see with preschool kids like this is that they are processing language like a much younger child - like an 18-to-24 month old child. That does not necessarily mean that he is "thinking" like a toddler. If he is becoming interested in the beginning basics of colors, numbers, shapes, sizes, alphabet, etc, then he probably is thinking (cognition, receptive language) like a peer or somewhere near there. Even so, he may be "processing" language like a toddler. I.e., he manipulates language and dialogues like a toddler.
• What does a toddler naturally do when someone is trying to get them to do something? And what happens when we try to get a toddler to attend to the things we want them to attend? Unless a toddler is captured by the item or activity we present, he usually refuses, ignores, selectively attends, walks away, responds with silence, tantrums, hits, etc. This is classic "terrible two" behavior -- the behavior associated with learning to take control of communication and events.
• A typical toddler does not know how to participate in communication with the kind of sophistication we expect from preschooler (3-5 year old) children. And a preschool child with apraxia often responds in the same way, usually by simply refusing, not responding, or by talking about what they want to talk about regardless of what you say.
• A typically developing toddler will want to lead, not follow, activities. If you change your approach to therapy in order to allow the child to lead the dialogue, you will have much more success. If you structure your dialogue so that he is more the initiator and you are more the responder, he will love therapy and he will come to love you. You will become his favorite person with whom to interact, and he will say more to you than to anyone else in the world. Gradually you can take more control.

WHAT DOES ORAL-MOTOR THERAPY HAVE TO DO WITH SPEECH?

Revised 2.27.08 - Most oral motor exercises are not identical to the movements required for speech. No English speech sounds involve tongue wagging, whistling, tongue clicks, tongue curls, etc. So what do oral motor exercises have to do with speech?

In 2007, I reviewed 73 textbooks, clinical guides, and conference proceedings in the areas of articulation, phonology, motor speech, feeding, dysphagia, orofacial myology, and oral motor. These books spanned the years 1912-2007. I was studying the history of jaw, lip, and tongue facilitation.

This literature review revealed that simple activities such as those you mention were discussed in a wide variety of these publications.

It is most important to note that these methods were NEVER recommended as a direct path to phoneme production.

Instead, very simple oral motor activities such as those you mentioned are recommended to:

• Facilitate overall sensory processing and movement skill for later phoneme production.
• Facilitate overall sensory processing and movement skill for later or simultaneous work on feeding or swallowing skills.
• Facilitate a client's attention and orientation to the oral mechanism at a gross level (to help him discover he has a tongue).
• Help the client begin to move the oral mechanism in gross movement patterns (to "vivify" oral movement).
• Achieve some other neuromuscular end (e.g., to increase tonus, increase range of motion, differentiate tongue from jaw or lip movements, facilitate midline integration of movement, normalize oral tactile sensitivity, and so forth).
• Assess oral motor skill: tone, ability to cross the midline, dissociation of tongue-from-jaw and tongue-from-lips.

Oral motor therapy is sensory and muscle training for phoneme production. We prepare the oral mechanism to function in certain mature ways so that it can call on those skills when learning phonemes.

These methods have never been intended to be a substitute for articulation or phonological therapy.

SPORTS COMPARISON: Think about gymnastics. A world-class gymnast might lift weights as a part of his training. Why? What does lifting weights have to do gymnastics? Lifting weights improves aspects of motor learning: control, strength, endurance, speed, and so forth. Improvements in these aspects of motor control help the athletes underlying motor skills develop. BUT THE GYMNAST STILL HAS TO GET ON THE EQUIPMENT AND PRACTICE SPECIFIC STYLIZED MOVEMENTS.

SPEECH: Likewise, oral motor work prepares the jaw, lips, and tongue for the work needed for speech sound production. BUT THE CLIENT STILL HAS TO PRACTICE SPECIFIC STYLIZED MOVEMENTS. He still has to learn how to make the movements necessary to produce the phonemes himself.

R AND VOWELS

3.28.06 - I am having some trouble with a few /r/ students. I read parts of Successful R Therapy. One student has a pretty good initial /r/ and /ar/ words, but cannot do any other vowel+/r/. For example, /er/ comes out /ar/. The student does not appear to hear the difference in himself, but can hear it when I produce it differently. Is there any guidance you would be able to give me?

• If your client can do ANY R correctly attached to any other sound (either V+er or r+V) then you can teach him to separate the "R-part" from the Vowel.
• Thus if he can say "ar" then he could prolong it and say, "ahhhhhhhher."
• Then he could separate the two parts with silence and say, "Ahhhhhhhh..(silence)..er."
• That way he is learning to move his tongue into position for R in silence. I.e., the on-glide is silent.
• And then you have "er" isolated. This should be rehearsed enough to make it automatic.
• With a silent on-glide and "R" isolated, then you can begin to practice V+er and r+V by isolating each part.
• This is where you make sure the client is saying the vowels very clearly. Do not let him distort the vowels. Force him to say clean and crisp R's and clean and crisp V's. Use this time to train his ear to discriminate his own vowels. He must be able to catch himself producing incorrect vowels in order to carry this skill over to his R work.
• I talk about this in "Successful R Therapy" in Chapter 10, "Building the Transition Repertoire."

RESONANCE

4.11.06 - I have just picked up a young man of 14 years with a moderate degree of learning difficulties and a range of speech difficulties. He is in special school but has received very little direct therapy. He has a particularly hyponasal quality, and some hypernasality too. Would you view this as a priority? He is interested in singing and has been unmotivated by therapy, possibly due to its repetitive nature. He wondered if this might be a way to help him try a little harder with therapy. Any ideas?

- Frances, SLP/London, England

Traditional SLP's always consider nasality problems a priority

• HYPERnasality can have a devastating effect on intelligibility.
• HYPERnasal clients distort vowels by resonance and by oral position. This is a classic characteristic of dysarthria.
• HYPOnasality, on the other hand, usually has far less an impact on intelligibility. Thus, I find it less of a priority.

In terms of therapy, the approach can be the same wither the problem is hypo - or hypernasality.

• Make sure you understand the medical influence on this problem. Does the client have allergies, etc. related to the hyponasality? If so, medical intervention may help, but it may not.
• Make sure that there are no structural problems related to the hyponasality. Referral to ENT or a craniofacial team will be in order for this diagnosis. Structural problems (large adenoids, narrow nasal passages, etc.) may or may not be "fixable."
• Singing lessons is a viable and oftentimes excellent option for a client like this. Voice instructors seem to know far more about voice and resonance than we do from a practical standpoint. They have great vocabulary and technique to teach "head voice," "chest voice," "throat voice" etc. My oldest daughter has taken voice lessons since she was nine years old (she's now 20) and I have watched many of them. I have learned a lot about helping my clients project the voice in ways to achieve better resonance. It usually requires better posture, deeper inhalation and improved diaphragm control. Always it requires ear training. Singing lessons can help the client realize that there is nothing wrong with him, that he simply needs to learn a skill he does not have. If you can incorporate these types of techniques in your own therapy, you can keep him on your caseload.
• I like to use very specific techniques to teach oral and nasal airflow. I use flexible tubes in the following way:
  1. Place one end at the client's mouth and the other at his ear. Have him produce voice and listen.
  2. Then place one end of the tube at the client's nose. Again, let him produce voice and listen.
  3. Then place one end of the tube at YOUR mouth and nose (use another sanitary tube) and let him listen with his ear.
  4. Alternate producing oral and nasal voice, and help him discover how voice can be projected orally or nasally.
  5. Have the client feel his nose to discover the vibro-tactile element of oral and nasal voice

I used to fear facing clients with nasality problems because I found no real information on how to work with them. But over the years I developed this practical "tube" approach and have found it very useful. The key is to get the client's ear tuned into his own voice, and to allow him time to experiment with both oral and nasal sounds. Then he can learn to control the nasality purposefully.

By the way, this activity is one in which babies engage during the cooing stage at 2-3 months of age. During this time they experiment with oral and nasal voice (without the tube), and they learn to hear and feel the differences. This is an auditory-tactile learning activity organized in the brain during the early months of life, before babbling emerges. Kids need to be able to be differentially oral and nasal in order for all the vowel and consonant phonemes to emerge.

DROOLING

5.24.06 - My 3-year-old client with cerebral palsy continues to have so much saliva when he speaks. I am seeking information about how to address all the saliva and bubbles that he produces during speech.

- Judy, SLP

The key is to help your client:

1. Suck and swallow more often during everyday activities
2. Suck and swallow with greater efficiency
3. Maintain lip closure during oral rest

The real help is found by doing oral-motor and feeding work. Medications or surgery sometimes are necessary in severe cases.

My little book How to Stop Drooling introduces all these ideas in a simple format. It is a look at the behavior and it will help you see the overall process.

Also see: A Practical Approach to Saliva Control by Hilary Johnson and Amanda Scott (Communication Skill Builders, 1999.)
Drooling Remediation Program by Sara Rosenfeld Johnson

FREQUENCY OF OMT

Revised 5.2.07 - I have a five-year-old child with cerebral palsy, developmental delay, severe apraxic and dysarthria. Jaw control is limited, she drools, and the tongue retracts when feeding. I am told by her speech reports she needs oral motor work 3 times to 5 times a day. Might you have any suggestions on what I could do? She is in school speech three times per week for 30-minutes and she does see a PROMPT therapist. I did read your book Oral Motor Techniques in Articulation and Phonological Therapy which was great.

- K, mom

My experience has taught me that 3-5 times per day doing "oral-motor therapy" only makes sense if the therapy is very practical and can be incorporated into her everyday life. Here is an example of how OMT can be done 11 times in one day:

1. Before school - mom feeds her breakfast using the appropriate feeding methods (15 minutes)
2. 9:30am - play at mirror with mouthing toys during occupational therapy (15 minutes)
3. 10:45am - blowing through straws to make cotton balls roll across a table in speech-language therapy (3 minutes)
4. Noon - teacher aid feeds her lunch using appropriate feeding methods (15 minutes)
5. 1:00pm - "sing" songs in class with kazoo to encourage lip pressing and voice (5 minutes)
6. Waiting for bus - make funny faces with other children (stick out tongue, etc.) (1 minute)
7. Arriving home: give mommy ten kisses with correct mouth position when she gets off the bus (30 seconds)
8. After school snack - ice pop eaten as a cold stimulation to "wake up" the mouth, mom sits with her and reminds her to swallow every 45 seconds (5 minutes)
9. Dinner - applesauce, mashed potatoes and yogurt eaten with Nuk oral stimulator to encourage gnawing (20 minutes)
10. Bath time - making raspberry sounds in the water (10 times in 30 minutes)
11. Bedtime - talk with dad about the boo-boo she got that day. Practice a tight and exaggerated lip pucker as practice saying "Ooo" and "boo-boo." Read a Winnie-the-Pooh story and practice "Pooh" in the same way. (10 sounds in 10 minutes)

Just getting the child's mouth to work better will not help her expressive speech and language much. Most kids with CP need SL therapy simply to help them become more verbal, more interactive, to say more words more often, to engage in dialogue, to speak up and speak out, to punch out syllables so they can become more clear, to speak through the mouth and not the nose, to use better intonation patterns, not to prolong and distort sound in words, to speak clearly differentiated vowels, etc. These are the things that make them more intelligible. Getting the mouth to work better is only one small part of the overall plan.

OLDER CHILD WITH APRAXIA AND DYSARTHRIA

7.2.06 - I am a speech-language pathologist at a children's hospital. I have a boy that I see for therapy who is severely (whole body) apraxic. He has been coming to therapy for years at this hospital and has been through multiple therapists. He is intelligible and we are currently working on /l/ and /l/-blends. He substitutes n/l. I feel like he has reached a plateau. He also receives therapy in school. He has most sounds except vowels, diphthongs, some blends, and all voiced consonants. These areas have been targeted in the past with progress made and a plateau reached as well. Any ideas? I'm lost and his mother does not want to give up therapy at this hospital.

• If his vowels and diphthongs are distorted, he has nasality problems, and he has difficulty controlling voice onset, this sounds like dysarthria. He is probably a kid who is both apraxic and dysarthric.
• The apraxia shows up more in the early years as a LACK of sound. But as phonemes are gained, the continued distortion of vowel sounds is the dysarthria. If it is dysarthria, there should be rate and rhythm problems too. The nasal substitutions are more a dysarthric problem as well.
• The problem most of us have is that we think in terms of learning consonants. This is not where the problem is with dysarthria. The problems that interfere with clear speech in dysarthria are rate, rhythm, prosody, resonance, voicing onset and distortion of sound.
• Focus on prosodic elements: Rate, rhythm, projection of voice, loudness, intonation, voicing and "punching out" syllables. Make him speak up, speak out, perhaps speak a little louder.
• Focus on Resonance: Oral vs. nasal sound. Help him learn to remain oral at all times except for /m, n/, ng/. Teach him to remain oral while producing all the glides. Help him tune his ear towards oral resonance. To him it feels and sounds normal to be overly nasal. Help him learn to hear than and to force a more oral sound.
• Focus on Vowels: Clarity on individual vowels. Begin with the earliest developing vowels - ee, oo, ah, oh, uh. Work on the vowels in isolation. Prolong them together so he has time to hear the acoustic parameters of each. Work on saying single-syllable words with clear vowels. Start with CV words: go, see, no, me, do, bee, etc.
• Focus on Diphthongs: Make sure he is producing clear single vowels on each end of the diphthong. Work on CVV words: hi, bye, you, now, etc.
• Focus on Rhythm Through syllable maintenance: work on punching out the correct number of syllables in words.
• Focus on Voicing: Teach him to turn his voice "on" and "off" at will. Teach him to control the transition between turning his voice on and off in a sequential speech act. I like to have kids practice sequences like:
  1. Ah---H---Ah---H---Ah...
  2. Sss---zzz---sss---zzz---sss...
  3. Shhh---zhhh----shhh---zhhh...
  4. This way they learn to turn the voice on and off at will without having to change oral movement too. Then move on to single syllable words like "so" during which they have to be voiceless on the "s" and then turn voice on as they transition to the vowel. Have the child prolong the "s" and slowly transition into the vowel so he can hear and control the voice onset.
  5. Focus on on Clusters by making two syllables out of them, For example, pronounce "blue" as "buh---lue. " Pronounce "brown" as "buh---rown." Teach him to give himself more time to produce each element of the cluster.
  6. The topic of dysarthria has gone out of favor in recent years as the topic of apraxia has taken over. But long term kids like the one you have described are dysarthric. The dysarthria takes longer to resolve when we ignore these underlying issues.

CEREBELLAR DISORDER

7.14.06 - My granddaughter, Stephanie, is 4-1/2 years old and diagnosed with apraxia. She was born with the cerebellum not fully developed and is classified as having cerebral palsy. Her speech is non-existent, although I can get her to make a variety of sounds in different pitches. In class she seems not to be attending at all. The SLP reported that until Stephanie can let her touch her face and put a spatula on her tongue, she can do little. She is thought to be quite bright. She signs a little but this is not encouraged at her school and she has lost the ability to a certain extent. I cannot bear to think of her growing up unable to speak.

I am going to be blunt and straightforward in my remarks about your granddaughter. Please remember that I am speaking in generalities since I have never seen this child in person. I have, however, worked with many like her over 30 years.

• A cerebellar disorder means that Stephanie has a severe neuromuscular disorder. That means that it will take her a long time to speak, she will learn very slowly, and most likely she will have difficulty her entire life.
• With a cerebellar disorder, Stephanie is not just apraxic. She also will be dysarthric. Apraxia manifests as a severe lack of sound in the early years. Thus she will be very slow to gain expressive speech. Once sounds and words begin to emerge, however, dysarthria will manifest as a severe distortion of sound. Thus, once she speaks, she probably will be very hard to understand for a very long time. There also is a tiny chance that she will not speak at all. But there is a good chance when will become quite verbal. TIME WILL TELL.
• You stated that she is "bright." Many families believe that just because their child seems to understand more than he or she can say, that there is nothing wrong with the child's intelligence. This may or may not be the case. Stephanie may have comprehension problems too. I cannot state this with certainty, and it can be difficult to tell when the child has no expressive speech. The way to determine intellectual level is to have her tested by a psychologist who can do non-verbal testing (intelligence testing that does not require spoken responses). This is also problematic, however, because her motor skills are delayed as well. You can get a sense of her comprehension by asking yourself honestly if she thinks about the things that a typical 4-1/2 year old does. For example, is she interested in the alphabet, numbers and colors? Your local SLP should have some guidelines for you in this, or pick up a simple book on speech and language development, and look at the sections on receptive language and cognition. I have seen children with this disorder on both ends of the spectrum: those who are very bright and those with significant mental retardation. Time will tell in Stephanie's case.
• You stated that she "seems not to be attending at all." This is part of the neuromuscular disorder. A cerebellar disorder leaves a child with limitations in all physical development, including the ability to settle oneself. This is part of her developing sensorimotor integrative status. I hope she is being seen by a motor specialist - either an occupational or a physical therapist - who is attending to her development in this area. That is the professional with whom to speak about arousal and attention. Keep in mind, however, that just because she does not look like she is attending does not mean that she isn't.
• Stephanie needs multiple paths of expression because verbal speech will develop so slowly. I cannot understand a school system that does not encourage at least gestures, signs and pictures to encourage communication in children who have severe expressive communication disorders. That makes no sense. These children are as hungry to communicate as any child.
• She needs to be encouraged to use the voice she has. For example, if she brings you a book and says, "eh," you can assume that she said "read" or "book" or "grandma will you read this to me." Respond to her as if she said an intelligible word. Even tell her that you heard her word. You might say, "Read? Okay." This will reinforce her for saying the "word" she did say, and it will encourage her to speak more. I have written about this process in my little book, Becoming Verbal with Childhood Apraxia.
• I loved what you said about "talking" with her with pitch and intonation variations. If you listen to my CD's called Apraxia Uncovered, you will see how important intonation and pitch variation is in the development of verbal speech. That program outlines the entire process of sound development in fine detail. Stephanie will grossly follow that developmental path. She sounds like she is integrating "Stage Two: Speechifying." Work there and expect her to grow into the next stage soon. In "Stage Three: Honing," she will begin to use more consonants.
• Clarity on vowels will be the most important element of her intelligibility because it will take years for her to learn all the consonants. Teach her to say the basic early vowels (ee, oo, ah, oh, uh) now. Then expect her to say "oo" for "shoe" and so forth. Basic vowel clarity begins to emerge during the very first stage, "Stage One: Phonating."
• Finally, I am troubled by your statement about the spatula. It sounds like Stephanie is hypersensitive. I would expect oral hypersensitivity with a cerebellar disorder. However, this notion that nothing can be done until sensitivity level changes is, unfortunately, a common misconception about oral-motor therapy. It is not true. Stephanie can learn to move her mouth in many ways before she will let someone touch her face. With a cerebellar disorder, a child must learn voluntary control of the mouth. Teach her to begin to control her mouth movements in basic ways. For example, tell her:
  • "Open you mouth big, big, big. Say, 'Ahhhh.'"
  • "Close your mouth tight. Say, 'Mmmm.'"
  • "Smile big, big, big. Say, "Eeee.'"
  • Make a little circle with your mouth. Say, "Oooo."
• Explicit information about what her mouth can do will be important for speech development. A mirror will help her see what her mouth is doing. Help her look directly at your face and mouth.

AUTISM AND APRAXIA

10.12.06 - We have a 7-year-old son who has a diagnosis of moderate autism. About a year ago it was suggested that he has apraxia as well. He is completely nonverbal. We have read Becoming Verbal with Childhood Apraxia. Using some of your suggestions, he now imitates about four sounds. It is so frustrating because as soon as we get him to imitate a sound, he loses mastery of an old one - one step forward, one step back. He attends a private school that does ABA. Can you give us some guidance?

- Patti, mom

• A child like yours is one of the most difficult in terms of developing verbal speech. I do not want to discourage you, but children on the autism spectrum are some of the most problematic when it comes to developing verbal speech. Some develop no speech whatsoever. Others become highly verbal. Only time, treatment and education will tell.
• Have you heard of PROMPT? It is a technique that works very well with many different children. It may work for your child. It is a systematized way of cueing children to produce speech sounds.
• You should be reading in the area of autism and talking with more autism experts. Someone with expertise on getting kids to talk like me can take you so far. You really need a broad understanding of the learning style of your child.
• It sounds like your boy can read. If so, and even if he can't, you can use written words and pictures for a long time as a means of communicating. I always recommend building a 3-ring binder speech book that contains pictures and words about the child's life.
• For example, let's say you make a page about getting ready for school in the morning. On the page you would draw stick figures of your son, clothes, breakfast, the school bus, etc. Write key words like "bus" "milk" "socks" "shoes" etc. And phrases like "eat breakfast" "brush my teeth" "get dressed." That page then is used to "talk about" getting ready for school. He points and you talk. Many pages are created that represent many activities during his typical week.
• This becomes a communication tool he can use to "talk" to many people - mom, dad, grandma, teacher, etc. It becomes what all children want - a means to talk about themselves. This is much more important to them than learning to say phonemes. It should be used as well as pointing to pictures of things he wants.
• And finally, I would not think that "time is slipping away." These kids need time. They tend to become gradually more verbal with time, with some not really talking much until much older. This may take the pressure off. Think about what you want him to be able to do by the time he is 21. Focus more on what he can do and is doing. Build up those areas while continuing to stimulate verbal speech.

ATTENTION

10.12.06 - My six-year-old daughter has oral and verbal apraxia and developmental coordination disorder. She has a difficult time keeping up her levels of concentration throughout the school day. One teacher tells me that Hannah needs to "attend" and that she is concerned about Hannah's "attention deficit." Do you know of any resources that would help explain how her diagnosis affects her ability to focus?

- Nancy, mom

• Probably the best place to begin is The Out-of-Sync Child by Carol Stock Kranowitz (2005, Penguin). It was written for parents. There are several book companies that sell it.
• Please keep in mind that your daughter also may have an attention deficit disorder. Sometimes these problems go unrecognized because of the other problems that are more obvious.

OMT

11.29.06 - What is oral-motor therapy?

This is the definition I use: Oral-motor therapy (OMT) is the process of facilitating improved jaw, lip and tongue function. Oral-motor techniques can be used in any of the following therapies: articulation, phonology, dysphagia, feeding, orofacial myology, and occupational or physical therapy.

You can discover the importance of speech movements by engaging in a simple procedure. Count aloud from one to ten. Did anything move? Now count aloud from one to ten without moving anything. Can it be done? You should have remained silent during this second task because one cannot speak without moving. OMT is used in speech therapy to develop oral speech movements. At its very core, speech is movement of four basic speech subsystems as follows:

• Breathing Movements
  The process of speaking requires that we breathe, and breathing requires the body to move. Try this: sit up nice and straight and inhale deeply, then exhale. You should have felt your chest expand and contract as you breathed in and out. The process of breathing for speech requires special movements of the chest so that the lungs can expand and contract. Like an accordion, air rushes in when the lungs are expanded, and air is pushed out when they are contracted. This is movement that must develop properly for mature speech.
• Voicing Movements
  Some sounds are made with the voice "on" and others with the voice "off." Press your fingers gently but firmly onto your voice box so that you can feel the cartilage under the skin. Now say, "Ahhh." Do you feel the vibrations of sound made in your voice box? Continue to hold and say, "Ssss." This time there is sound made at the mouth but no vibration in the voice box. Mature speech requires the ability to turn the voice "on" and "off" at very specific times. This requires the development the tiny muscles that control the cartilages of the larynx itself.
• Resonating Movements
  Sound can travel through the mouth or nose. Say, "Ahhh" and notice that this sound comes out the mouth. Now say, "Mmmm" and notice that the mouth is closed and the sound travels out through the nose. The mechanism that controls this direction of airflow is located at the back of the mouth and is known as the velopharyngeal mechanism. You might know it as the "punching bag" that hangs down in the back of your mouth. Somewhat ike a draw string purse, this mechanism opens and closes the passageway to the nose. When it is open, sound can travel into and through the nose. When closed, sound travels through the mouth. Mature speech requires that children learn how to make this sphincter open and close at specific times for specific speech sounds.
• Oral Movements In order to speak correctly, one must move the mouth (jaw, lips and tongue) in specific ways. Say, "Mmmm" and notice how your lips touch together. Now say, "Nnnn" and notice that your lips do not touch but that your tongue cleaves to the roof of your mouth. These two sounds (phonemes) are very similar. What makes them different is the way the mouth is positioned. Every speech sound is made with a specific prescription of jaw, lip and tongue position. The jaw can move up, down, left, right, forward, back and in rotation. The lips can pucker, round and retract. And the tongue can lift and lower its tip, sides, middle and back. It also can stretch forward and back for speech. Mature speech requires that the jaw, lips and tongue move maturely in all directions, and that they do so both independently and in coordination with one another. Literally, this is what oral-motor therapy is: the process of facilitating improved jaw, lip and tongue movements for speech.

COMPUTER SOFTWARE

12.09.06 - Do you have any computer software recommendations for a student with verbal apraxia?

I am not your resource for this kind of information. Find a therapist in your area who has expertise in computer hardware and software. Most school districts and children's hospitals have at least one person on staff whose job it is to keep up with these products. Also talk to the software companies that sell the equipment. They have salespeople who will teach you all about their equipment. Many will send a rep to your school to demonstrate.

One program I am familiar with is SATPAC (Systematic Articulation Training Program Accessing Computers). According to the author, Stephen Sacks, "SATPAC is an articulation/phonology software program incorporating facilitating contexts, coarticulation, and natural prosody at a conversational rate with numerous repetitions of the target sound to quickly remediate deficits. Target sounds are established, generalized and transferred through the use of nonsense words, real phrases and sentences that move the student systematically to normal conversational competence. There are also 4 CVCV lists which move from easiest (reduplication) to hardest (random combinations)." See SatPac for more information.