Pam Marshalla Online | Questions and Answers 2008

Questions and Answers 2008

Below is a quick guide to the 2008 posted questions and answers. You can jump to a specific question or read through all of them by scrolling down.

On Spitting Out Toothpaste
A Classic 5-Part Problem
Oral Motor Therapy versus Non-Speech Oral Motor Exercises
Oral Motor Techniques in History
Two Different Motor Pathways Argument
Vowels in Late Talkers
The "Butterfly Position"
Pacifiers and Apraxia
Techniques for "Long E"
Very Limited Speech
Horn Programs and Articulation Therapy
Toddler With Autism
Patience and the Lateral Lisp
Elocution and Intelligibility
Autism and Mouthing Behavior
Time Off From Therapy
Becoming Verbal With Autism and Apraxia
Lisps and Missing Front Teeth
Inhibiting Lip Interference During Phoneme Learning
Orofacial Myology
The R Crisis
Oral Motor Treatment and NS-OME
EBP - Chopping Down The Trees to Save The Forest
Stimulating Lip Movement
Teaching SH
Counseling Parents About Articulation Deficit
Sound-Activated Toys
Diagnosis of Apraxia: Necessary to Start Treatment?
The Essence of Therapy with Little Kids
CAS and Self-Esteem in Therapy
Childhood Apraxia and Dysrthria: Frequency of Therapy

SPITTING OUT TOOTHPASTE

1.17.08 - How can we teach our five-year-old child on the autism spectrum to spit out his toothpaste after brushing?

Perhaps you could start with a solid object, like a rubber ball.

SAFETY TIP: Use a ball large enough to fit in his mouth but not too small that he might swallow it. Also make sure it doesn't taste bad. Some rubber objects taste really bad.

Have him learn to put the ball in his mouth and then "spit" it out to drop it into the sink. That might work to teach him the concept of "spitting." Reward him for spitting in ways that make sense to him.

If he can begin to understand the concept, then maybe he will be able to generalize it to spitting out toothpaste.

The problem with autism spectrum kids, however, is one of generalization. The child may not be able to generalize the idea from the ball to toothpaste. You may have to do some experimenting with other objects, foods, pictures, etc.

WARNING: Your child actually may over generalize the concept of spitting to other items (like saliva or food) just like all kids do. You will have to teach him when to spit and when not to spit. This also can be difficulty for a child on the autism spectrum.

Let me know what you do decide to do, and let me know the results so I can post them here.

CLASSIC 5-PART PROBLEM

1.17.08 - My client has an inter-dental lisp, possibly a tongue thrust, a high narrow palate and an anterior open bite. He also has difficulty with /r/ in all positions. I only saw him one time and do not want to waste time in therapy. Should I send him to the orthodontist before beginning therapy? Is there anything I can do in terms of exercises to help him?

This client represents most of what I call the 5-Part Problem:

An anterior open bite with a high arch palate
A reverse swallow pattern
A frontal lisp. He may also have
An oral habit like thumb or finger sucking, and
An open mouth resting posture.

These five patterns are integrally related to one another and you need to treat all three problems together. The client needs:

Orthodontic management to close the bite
To eliminate the oral habit
To establish a closed-mouth resting posture with the tongue back
To establish a normal swallow
To learn to keep the tongue back while articulating

The problem with R is a separate one. The R is not necessarily effected by the other problems, although the whole oral-motor problem is over-riding his speech. You can treat the R while all the rest is going on.

May I suggest my two texts: Successful R Therapy, and Frontal Lisp, Lateral Lisp. I cover all of this in those two volumes.

OMT vs. NS-OME

1.19.08 - What is the difference between "oral motor therapy" and "non-speech oral motor exercises"?

Therapy is a process comprised of techniques. Exercise is one type of technique.

This topic has been discussed extensively in "Oral Motor Treatment" vs. "Non-speech Oral Motor Exercises": Historical Clinical Evidence of "Twenty-two Fundamental Methods." Volume No. 2, Monograph No. 2, 9 April 2008, Oral Motor Institute.

ORAL MOTOR TECHNIQUES IN HISTORY

2.23.08 - I have heard you say that oral motor treatment is not new. What do you mean?

Dr. Charles Van Riper, the "father" of articulation therapy said that techniques to manipulate mouth movements and positions, for speech sound production, were centuries old in Europe. In the 1960's, Mildren Berry and Jon Eisenson said that articulation therapy was "as old as the Hitites."

Last year I began an investigation into the use of methods to facilitate oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) technques in history. I read 84 textbooks in articulation, phonology, motor speech, feeding, dysphagia, orofacial myiology, and oral motor, to discover how these methods were used from 1912 until 2007. I discovered that 95% of these books described, discussed, or recommended the use of oral motor techniques in their discussions of solutions for articulation error. Thus, oral motor techniques are not new.

I kept a list of the terms that were used to identify these methods. Here are the terms listed from oldest to newest:

"Tongue gymnastics" (Scripture, 1912)
"Maxillary, labial, lingual and velar gymnastics" (Borden & Busse, 1925)
"Exercises for weak or relaxes muscles" (Travis, 1931)
"Strengthening and stereotyping the motor patterns" (Kantner & West, 1933)
"Manipulation" (Nemoy & Davis, 1937)
"Visual, tactile, and kinesthetic approaches" (Anderson, (1953)
"Improving the speed and precision of the articulatory musculature" ... "Tongue exercises" (Van Riper, 1954)
"Definite stimulation to speech muscles" (Young & Hawk, 1955)
"Strengthening the visual-tactile cues" (Berry & Eisenson, 1956)
"Increasing the flexibility of the articulators" (Berry & Eisenson, 1956)
"Sensory-motor procedures" (McDonald, 1964)
"Improving the function of the jaw, lips, and tongue" (McDonald & Chance, 1964)
"Direct manipulation" (Winitz, 1975)
"Activities preliminary to speech production" (Darley, Aronson & Brown, 1975)
"Sensory stimulation to evoke movement" and "external control of involuntary, abnormal movement" (Campbell, 1978)
"Extraoral and intraoral stimulation technique" (Vaughn & Clark, 1979)
"Neurospeech therapy" (Mysak, 1980)
"Myofunctional therapy" (Garliner, 1981)
"Various approaches ... along the sensory-motor continuum" (Hanson, 1983)
"Oral motor control exercises" (Logemann, 1983)
"Motor practice" (Ruscello, 1984)
"Motor sensory targets" (Borden, 1984)
"Lip and facial exercises" (Groher, 1984)
"Myotherapy" (Hanson & Barrett, 1988)
"Articulation subsystem exercises" (Dworkin, 1991)
"Physiological approach" (Fletcher, 1992)
"Muscle training" (Love, 1992)
"Oral motor techniques" (Marshalla, 1992)
"Improving sensory and motor functions within physiologic processes" (Brookshire, 1992)
"Mechanical positioning of the patient's articulators" (Brookshire, 1992)
"Oral motor treatment" (Arvedson & Brodsky, 1993)
"Oral motor phonetic drills" (Crary, 1993)
"Motor programming approaches" (Hall, Jordan & Robin, 1993)
"Therapeutic exercises" (Tuchman & Walter, 1994)
"Increasing physiologic support" by following "principles of motor learning" (Duffy, 1995)
"Motor approach" relying heavily upon "principles of motor learning" (Yorkson, Beukelman, Strand, & Bell, 1999)
"Treatment strategies and activities ... for improving oral motor skills" (Morris & Klein, 2000)
"Oral motor exercises for speech clarity" (Rosenfeld-Johnson,, 2001)
"Tongue and lip awareness activities" (Bauman-Waengler, 2004)
"Oral-motor activities", "oral-motor training", "oral motor instructional activities" (Bernthal & Bankson, 2004)
"Touch cues" (Bleile, 2006)
"Methods and techniques that can be used when the client cannot produce a target sound at all" (Secord et al, 2007) (My personal favorite!)

TWO DIFFERENT MOTOR PATHWAYS ARGUMENT

2.27.08 What is your argument when others say that we should not be doing oral motor techniques because there are two different motor pathways, one for speech and one for simple movement?

I agree that simple non-task-specific exercises (i.e., "non-speech oral-motor exercises" or NS-OME) do not help speech. This is what recent research demonstrates.

For example, if one were to ask a child to move the jaw up-and-down as an "exercise," this indeed would have nothing to do with speech. Moving the jaw up-and-down will not make new phonemes appear, nor will it correct distorted or substituted phonemes.

This type of simple non task-specific activity has its uses, however. It might help the client discover he has a jaw that can move. A non task-specific activity might, as Charles Van Riper said in 1939, vivify oral movement. Certain phonemes may emerge as a result of the client's new discovery. But this is gross oral motor work that usually has a limited direct benefit to speech. The older articulation texts referred to this type of activity as "preparation" for speech, "warm-up" exercises, and as ways to encourage "flexibility of the articulators."

Now, if you were to help your client learn to move his jaw up and down, and then you were to teach him how to move it that way in order to produce a specific phoneme within a specific syllable, then you are teaching him a speech movement. For example, if you were to teach him to move his jaw up and down, and then you were to teach him to move his jaw up-and-down to say "bah-bah" for the word "bye-bye," then you are teaching him how to move his jaw for speech. Now you are creating a speech movement pathway.

The articulation literature from the beginning has always suggested that some clients need to learn the movement first, and then to use that movement in a speech production. What "oral motor treatment" brings to the table is a new understanding of how movements are organized, how they develop over time, how they breakdown, and how to facilitate them. The ideas come from occupational and physical therapy, neurodevelopmental treatment, sensorimotor integration, neurology, kinesiology, and other scientific endeavors. In an oral motor treatment regime, we are applying principles of motor therapy to the movements of speech. After all, speech is movement.

VOWELS IN LATE TALKERS

3.15.08 - In your seminar on apraxia and dysarthria, you talked about how vowels (V) are more important to remediate than consonants (C) in children with very low language and severe motor speech disorders. Do you recommend the same thing for children who simply seem to be "late talkers"? Should I model the vowel instead of the consonant to obtain the words I am stimulating?

With kids who just look like "late talkers", I would model both the C and the V as usual, but I would make sure to use the right vowel. For example:

Don't model: "Buh-buh-ball"
Do model: "Baw-baw-ball"

Keep in mind that in the class we were talking about motor speech disorders. Developing vowels in a child with a motor speech disorder helps boost his intelligibility while we are waiting months and years for his consonants to emerge.

Also remember that the vowels set the vocal tract into fundamental positions, and that consonants are movements added to it. Kids with apraxia and dysarthria often need to learn both of these movement parameters.

A child who potentially is just a "later talker" should have no trouble with the positions of the vocal tract set by the vowels. And he should be able to add consonant movements quickly once he starts talking more. Therefore, we can model the C and the V right from the start.

THE "BUTTERFLY POSITION"

3.18.08 - You use the term "Butterfly Position" in Successful R Therapy. Is this something new? Did you make this up, or does it come from somewhere else?

I made up the term "Butterfly Position" in 1978 during a workshop I was teaching. I have used the term ever since in workshop handouts and books I have written.

The "Butterfly Position" refers to the ability to shape the tongue into a position that has a low midline and high sides. This tongue shape should be seen in tongue from birth onward. It is a sign of normal neurological development in the newborn. It also has been called "Hills and Valleys", "The Bowl", "The Cup", the "Tongue Gutter" and more.

Since devising the term myself, I subsequently have heard it used elsewhere. For example, Carol Bowen uses it in some of her material on articulation. I don't know if she also made it up herself, or if she read it somewhere else.

Someone once emailed and accused me of "stealing" the term and not giving credit where credit was due. But I did not steal it. Unfortunately the accuser did not tell me who was due the credit, and we have had no more communication since. If you find other sources for the term "Butterfly Position," please pass it on to me and I will gladly post it here.

PACIFIERS AND APRAXIA

3.31.08 - Our son is 28 months old and just starting to talk. He may be apraxic and he sucks a pacifier all day and night. He seems to be very bright. What is your opinion about the pacifier?

I have seen otherwise normally-developing two-year-olds who do not talk at all become completely verbal within a few weeks after their pacifier is tossed out. I always recommend elimination of the pacifier in cases of speech delay, except in those rare cases when the child is so delayed in motor and cognitive skills that the pacifier is instrumental in developing sucking and swallowing skills.

This is not to say that excessive pacifier use is THE reason your son is behind in speech. However it may be contributing to the delay. In my opinion, a child with limited speech should NOT be allowed to suck a pacifier all day, and I recommend that the habit be eliminated. My book, How to Stop Thumbsucking addresses this issue. Also The Pacifier: Making the Decision by Charlotte Boshart may be helpful.

TECHNIQUES FOR "LONG E"

4.03.08 - I cannot get my client with Down Syndrome to produce "Long E" (as in the word bee). I have tried using a tongue blade to get his tongue back. Do you have any other suggestions?

To produce long E (/i/), the jaw must be high and the tongue must be wide, high, and tense in the back.

If you are using a tongue blade to push the tongue back, you have several problems that are working against you. First, the jaw will be too low because of the tongue blade. Thus the oral chamber will be too wide. Second, pushing the tongue back will not make it wide, nor will it help to generate the tension it needs in the back. Don't use a tongue blade. Instead:

Get the jaw high - Have the client bite down at the molars.
Get the tongue to retract and widen by smiling broadly and firmly (smile very wide; "Show me all your teeth."). Wide and tight smiling can cause the tongue to retract and widen. Biting and smiling together might get you the Long E.
If #1 and #2 do not help you, you may need to exercise the tongue itself. Have the client extend his tongue as far as it will go out (stick it out). Then have him retract it back as far as it will go. (Not curl it; retract it - pull is straight in).
If the client can't retract the tongue back toward the oropharynx, you can use resistance. Gently but firmly grab hold of the front of the tongue. Pull in an anterior direction (out the mouth). [Warning: Be careful! Do not cause pain!] Ask the client to pull the tongue back in. "I've got your tongue. Pull it back in!"]

A client with low muscle tone can take a while to generate enough tension to retract the tongue in this way. But once he can, you can begin to teach him to combine biting and retracting. You may get an Ee. You may get an R! But with the tongue pulling back, the client can begin to produce sounds and to experiment with the way it sounds to move the tongue around back there. These activities should help him learn Long E.

VERY LIMITED SPEECH

4.09.08 - I have a 3-year-old student with Joubert's syndrome. Currently we are using sign and an AAC device for communication. She can move her mouth, grunt, say "buh", and blow a whistle. She grunts more when we model the grunts back to her. Should this continue? And do you have any ideas on improving vowel phonation?

This child is not making vowels because she is not using her voice. Her grunts and productions of periodic "buh" mean that she is just beginning to get the voice to work. Her use of the whistle means that she has some voluntary use of exhalation. But she does not have full command and control of her own voice.

Producing grunts back-and-forth will be good for her. It will teach her to use the little voice she has in playful communication routines. This will act as a foundation for all the rest of her communication. But you have to do something to develop her voice.

The kazoo is the best tool for developing the voice. The kazoo only sounds when the child produces voice into it. There are lots of different kazoos available - some plastic ones are cheep and make almost no sound at all. Some plastic ones cost a few more pennies and make a beautiful resounding sound when voice is produced.

There are more "drastic" measures that can be taken to encourage voice, but see how the kazoo goes first. Get a good plastic kazoo that makes a good sound and teach her to use it. Use the kazoo for a few minutes at a time several times throughout a therapy session. Send one home, or encourage the parents to buy one, so she can practice with it here and there throughout every day. Some families like to keep the kazoo in the car for a few minutes of practice during every errand run.

Teach the child to make voice into the kazoo. Teach her to listen to her voice in it, to play with her voice with it, and to enjoy this play. Teach her to prolong her voice into it. Ultimately teach her to "sing" songs with it, to "count to ten" through it, and so forth.

HORN PROGRAMS AND ARTICULATION THERAPY

4.10.08 - I have a student I've worked with for a few years and she has several problems. I have tried everything I know, and nothing seems to help. She cannot say R, J, Sh, or Ch. She has difficulty with exhalation (i.e. she cannot blow out a candle) and therefore her speech is very quiet. She cannot even yell very loud. I've done some oral motor therapy (horn blowing hierarchy) and other things to address this, but it has not helped. Her conversational speech is so hard to understand because of these problems. Any ideas?

I hope you are using the horns to help her inhale more deeply and to exhale with more control, or to help with gross lip puckering. I hope you are not using horns and expecting your client's problems with R, J, Sh, and Ch to go away.

Blowing horns is not the be-all and end-all of oral motor treatment! Where did people get this idea?! Who is spreading this false notion?!

Blowing horns and other instruments has nothing to do with the refined tongue movements needed by a client who cannot produce R, J, Sh, and Ch. Horn-blowing is only one tiny piece of treatment for respiration and phonation. A horn only wakes a client up to his respiration system. It gives him a glimpse into breathing. And a horn can wake up the lips - encouraging them to pucker.

Blowing a horn can wake up the respiratory system, however, blowing a horn does not teach a client to inhale better for speech, to speak up, to speak out, to project her voice, to speak more clearly, to speak syllables more distinctly, etc. She needs to be taught those things. She needs to be taught to elocute.

In terms of R, J, Sh, and Ch, your client needs techniques specific to getting the tongue in the right position for these phonemes. From your letter, it is clear that the over-riding issue is the need for spreading the middle and back of the tongue to make a wide groove.

What are you doing to help her learn to spread the back of her tongue for these phonemes? I have written all about this in three books:

P.S. In addition to a horn, I would use a harmonica, a whistle straw, a siren, and an inspiration-expiration spirometer. These tools help the client learn to inhale AND exhale.

TODDLER WITH AUTISM

4.11.08 - My son is 2 1/2 years old and has a great level of oral motor difficulty and has been diagnosed with autism. He has only one word that he can produce on command, and that is "mom." He tries very hard to talk and things come out a jumble. We are working on letter sounds with him as he really enjoys letters. He can make the sounds for the letters S, M, H, A, U, E. It sometimes takes him 15-20 seconds to produce the sound and he seems to move his tongue around as he tries to produce the sound. When my son was between the ages of 4-10 months is was not uncommon to hear him coughing to bring on sounds something like this "cough, cough, ah, ahhhh, ahh". I truly feel that my son really wants to speak and can't figure out how. On occasion we have heard him say "mom", "I love you", "no", "grandma", and "hello". He does this by accident and is not quite sure how to do it again. He does know some sign language. We have been told that he has really good imitative skills and joint attention. Is there any information or literature you can recommend?

This is my experience: Children with autism are highly selective about what they will say for a very long time, especially during early language acquisition.

Therefore, it is almost impossible to get them to say what we want them to say. They will say what they want to say, however. So that's what we have to go with. If your child is interested in the alphabet, teach it to him. If he wants to count numbers, and those are the words he will say, let him count away.

I have worked with many autistic children who, in the early years, would say nothing except letters, numbers, and other rote productions (e.g., prayers and songs) for a very long time. But gradually, they began to add other words.

For some, the entire world seems to revolve around the ABC's for a long time. I always have had the sense that they seem to know that the spelling of words will unlock for them the "language world" that is puzzling them. I have seen children go from naming letters over and over, to reading words over and over, to spelling words over and over, to finally speaking words over and over.

In terms of my materials, I suggest Becoming Verbal with Childhood Apraxia as a starting point. In the book, I talk bout helping the child learn to become more vocal, imitative, and verbal.

PATIENCE AND THE LATERAL LISP

4.14.08 - I have been working with a 10-year-old girl with a significant lateral lisp that affects all of her sibilant sounds. I have been focusing on establishing /s/ and /z/, but have not been able to progress very far because her ability to achieve the correct tongue position is so inconsistent. I have taught her the "Butterfly Position" to help her lift the side margins of her tongue, and am using the "Long T Method". [from Frontal Lisp, Lateral Lisp]

My client is able to obtain a midline air stream and side margin elevation using these techniques, but she cannot sustain it from one production to the next, nor can she transfer it to anything beyond a syllable or short word. Her ability to distinguish accurate from inaccurate productions is also very inconsistent. I am only able to see her twice a week and though I have been assigning her daily home practice, her parents are very minimally involved in helping her. What is your experience with children with lateral lisps like this? Is it typical for progress to take so long? Is seeing her twice a week sufficient? Might I be missing something that is preventing her from progressing?

It sounds like you are doing everything right, but you may be trying to move toooooooo fast. She may need to stay on "Ts" for many weeks, even months.

Work to habituate the motor pattern. Don't try to generalize - she won't be able to. Be patient. Build habitual motor patterns that she can control in rote practice. Work on Ts in syllables, words, phrases and sentences in every session, but consider using only 1-3 target words.

For example, the target word "hats":

Practice rote two-word phrases: "two hats, three hats, four hats..."
Practice longer rote phrases: "two big green hats, three big green hats..."
Practice rote sentences: "Mom made two hats. Mom made three hats..."
Practice longer rote sentences: "Two hats fell onto the floor. Three hats fell onto the floor..."

Help her learn to take the one motor pattern she has learned and to pack other syllables and words around it. Help her produce gradually more sophisticated utterance, but stick to the same oral motor pattern.

Be patient. You are training her to use a new motor pattern. Ask yourself this: How long does it take a child to learn a cartwheel? That's how long it may take her to learn this motor pattern. Motor learning takes time.

I see kids with frontal and/or lateral lisp once per week for 30 minutes. This is enough. It is not more therapy now that makes the difference, it is good therapy over the long haul. It takes time to change motor behaviors and motor habits.

Also, she should practice at home only those things that she has mastered perfectly in the therapy room.

"Practice is the key variable thought necessary for mastery of any skilled motor behavior ... Initially there is a sluggishness in the execution of motor skills because the learner is acquiring the movement. With practice, the motor skill is perfected and stabilized. Ultimately, the skill becomes a part of the learner's repertoire of skilled movements and becomes automatic for the speaker."

(Bernthal, J. E., & Bankson, N. W. (2004). Articulation and phonological disorders. Boston: Pearson, p. 295.)

ELOCUTION AND INTELLIGIBILITY

4.20.08 - I have an older client who can pass an articulation test but who is very hard to understand in connected speech. I heard you talk about "elocution" in one of your classes. Can you refer me to any written material on how to do this?

A client who can pass an articulation test but who has problems with intelligibility usually is mildly dysarthric. Thus, they have mild problems with prosody (rate, rhythm, stress, intonation, pitch, tone, volume), vowel clarity, and syllable presentation. They generally are speaking too fast for their own capability. They pass the articulation test because they can make themselves be very clear when speaking one word at a time.

Any of my classes on apraxia and dysarthria include a significant amount of information on the topic of elocution. Elocution is the process of teaching clients to speak up, speak out, pronounce carefully, orate, slow down by punching out individual syllables, over-pronounce, listen carefully to monitor one's own speech, take care in discerning if you are being clear and other's are understanding you.

This is the way "SLP" was done before the International Phonetic Alphabet came along (1877). So the writings about it are verbose 19th century treatises that are almost impossible to read. The elocutionists of the day wrote in horribly long sentences that frequently ran on for full paragraphs, and sometimes for pages. They apparently did not favor the period. They were verbose to the extreme.

Although old fashioned, elocution should be a part of all our therapies. We should be concerned with our clients' abilities to speak well first, and to pronounce individual phonemes correctly second.

This means to integrate dialogue about the process of speaking into any of the other work you are doing. Teach the client what good speech is by making general comments about what people "usually do" when they talk. For example, "When people are mad they speak louder." Or, "When we want to tell others about our situation, we usually slow down and make sure they can understand us."

Also, make specific comments about how you or the client said something or another. For example:

"I love the way you were talking about your dog. You told me about him so carefully that I could understand everything you said."
"I think I said that tooooooooo fast! I was talking as fast as a racecar. Did you understand me at all?"
"That was a very, very, very, very, very, very long sentence! You went on, and on, and on! I could not follow a single thing you said! Tell me again. But make short sentences so I can follow you!"
"Are you talking about a cow or a car? Did you say that your mom bought a new cow? I don't know why your mom would buy a cow. She lives in an apartment! If you don't take care while you are speaking, I won't understand you."

AUTISM AND MOUTHING BEHAVIOR

4.28.08 - Jessica is 26 months old and has a diagnosis of autism/PDD. She has started to respond to discrete trial instruction, however she presents with constant mouthing, licking, and biting her fingers. We have tried numerous things - chewing tubes, cold stimulation, vibration to the mouth, pressure, sweet, sour, salty, ignoring, and so forth. But the behaviors are increasing. Parents report constant licking and gnawing at furniture, books, and other household objects. Any suggestions you can give that might help would be greatly appreciated.

My clinical experience has taught me that a child on the autism spectrum usually is mouthing for a different reason than is a child with an oral motor dysfunction related to a motor speech disorder (apraxia, dysarthria). Therefore the solution is completely different.

Children with motor disabilities, like apraxia or dysarthria, may need to increase mouthing behavior in order to learn about the oral mechanism. Learning more about the mouth helps these children discover the oral movements they need for phoneme production and feeding skill.

But children on the autism spectrum often are using mouthing for a different reason. My clinical experience has taught me that these children are not using mouthing to learn about the mouth. They are mouthing to regulate their behavior. Children on the autism spectrum often use mouthing the same way they use hand flapping, finger twisting, rocking, and other forms of sensory self-regulation. These behaviors help them take control of their uncontrolled sensory responses.

As you have noticed, your inclusion of mouthing techniques appropriate for children with a motor speech disorder has not helped. In fact, it has worked in the opposite direction. It has caused an increase in the undesirable behaviors. That's what mouthing activities are designed to do. Mouthing activities are used to increase mouthing behavior for a while. They are used to get a child more interested in his mouth, to play with his mouth, to initiate more movements with his mouth, and to discover what his jaw, lips, and tongue can do. That knowledge then is carried into the process of speech or feeding therapy.

A child who is using mouthing behavior to regulate his sensory system, and who is developing oral habits like the ones you describe, however, needs a program to help him regulate, control, and eventually eliminate his oral behaviors. Adding more mouthing experiences to his routine will not help him do that, as you have discovered.

Children on the autism spectrum often need a program of behavior management designed to regulate, control, and eventually to eliminate their developing oral habits. The principles and methods of this work are the same as any used to change a child's unwanted behavior. The methods used to eliminate oral habits are the ones I would select, adopt, and experiment with were this child on my caseload.

My little book How to Stop Thumbsucking addresses this issue. Although it was written with the average-little-kid-who-sucks-his-thumb in mind, the principles and methods explained in the book should help you begin to formulate a different plan for your client with PDD. You need to begin to think about inhibition procedures, not facilitation procedures.

TIME OFF FROM THERAPY

05.06.08 - Do you recommend therapy breaks for preschoolers with phonological delay? For example, summer off after the year of early childhood in a public school?

I have usually found that a break from therapy (especially in the summer) is a fruitful experience for kids. Most often they come back to therapy having made considerable progress on their own. It always seemed to me that all that sunshine, gross motor activity, and new experiences helped them move along. Plus, they are free to talk as much as they want without someone prodding them all the time.

Remember, we are not teaching the client phonemes. We are teaching them how to learn phonemes. We are teaching them how to pay attention to speech, how to discriminate one phoneme from another, and how to identify a well-produced phoneme. We are also teaching them how to get their jaw, lips and tongues to make appropriate and more mature movements patterns for speech. We do this within the context of working on phonemes.

When we do all that, the client carries over our work outside of the therapy room. Thus he will continue to learn new phonemes during the time off from therapy. My experience is that most of my clients come back with even better speech after a break. How do I know they have improved? I test their speech (do a sample or a formal test) both before and after the break.

In 30 years of therapy, I never saw a client regress except under the following conditions:

The client had a medical problem or trauma during the break (e.g., ear infection, newly diagnosed medical condition, mouth injury)
The client had a neuromuscular disorder that was not handled well during the break (e.g., a client with severe cerebral palsy who was in the care of less experienced handlers during the summer)
The client had a degenerative disease that caused loss of skill over time

BECOMING VERBAL WITH AUTISM AND APRAXIA

5.23.08 - My son is 9 years old and has been diagnosed with autism and apraxia. He is non verbal and low-to-medium functioning. We are trying to determine the best methodology to help him talk more. I read a lot about your Apraxia experience but nothing about your experience with Autism. Since my son has Autism as well I was hoping if you could give me your expert opinion on what to do as I am trying to determine what is the best approach to help him. Do you recommend PROMPT?

I do not consider myself an expert on autism and therefore usually don't give advice. However, many parents with children on the autism spectrum have benefitted from my book called Becoming Verbal with Childhood Apraxia. I usually recommend it for children younger than your son.

However, if he is "low functioning", I assume that means that he is perhaps functioning like a preschool child. If so, then you might benefit from the information in there. It is about how to help kids become more interested in sound and speech, how to help them become more interactive and imitative.

I have used the methods in there for children with autism your son's age and have had good results with certain kids. They seem to be the ones who are just starting to become verbal. Enough people have benefited from the ideas that I have been asked to speak to the National Autism Conference in PA this year. You can read a little more about this book on my website.

Also, I really like PROMPT, and there are other cueing techniques, both formal and informal, that can help many children. Whether a cueing system will help your child is difficult to predict. Experimentation and time will tell.

LISPS AND MISSING FRONT TEETH

05.29.08 - I have heard you say that if kids have problems with sibilants and are missing their front teeth you prefer not to see them until their teeth come in. Could you explain your rationale?

Without front teeth true stridency cannot be produced. Stridency is produced as the midline air stream hits the front teeth and then escapes between them.

Without front teeth, a client would have to be taught a compensatory movement. He would have to produce his sibilants with the tongue-tip directing the air stream to the side teeth resulting in a lateral lisp. Or he would have to lift the tongue tip up and direct the air stream against the alveolar ridge. A fricated sound would result, but it would be a slightly distorted - broad and somewhat sloppy sound that is lacking in true stridency.

All children go through a period when the deciduous teeth fall out as the permanent teeth begin to poke through. We should wait to fix a frontal or lateral lisp until after this process has been complete. This is not a new idea. Older textbooks on articulation therapy discussed this. It was usually recommended that we wait to treat a frontal or lateral lisp until a child has gained his permanent teeth. The waiting period may only be a few weeks or months. Thus we can work on tongue placement for sibilant production in the average client either before or after the baby teeth fall out. The client should take a break while the front teeth, especially the top front teeth, are missing.

We must distinguish between helping a child gain stridency and helping a child fix a frontal or lateral lisp. We can stimulate for frication or stridency in very young children. One- and two-year-olds use the strident phonemes all the time with great success. However, we cannot expect a child to produce refined sibilant phonemes unless his baby or adult teeth are in place. Optimum mature articulation of the sibilants cannot be produced while the front teeth are missing.

A client who has front teeth that are permanently missing has to be taught to compensate for this particular structural problem. He has to be taught to produce his sibilants with the tip high so the air stream can strike the alveolar ridge, or he has to be taught a lateral lisp. In the ideal case, the client's anterior teeth would be replaced with implanted false teeth.

In Oral-motor Techniques in Articulation and Phonological Therapy, I discuss a "Hierarchy of Thinking" I use when it comes to treating speech production problems. I explain that we "fix the structural, habitual and medical fixables" before we tackle the articulation problem. Missing teeth would fall into the category of a structural problem that can be fixed, either through waiting for natural change or by initiating dental or orthodontic procedures.

INHIBITING LIP INTERFERENCE DURING PHONEME LEARNING

06.01.08 - How do you get a client to stop puckering, pursing, retracting, and tensing the lips when learning R?

To get rid of lip interference when working on R (or any other sound) you need a way to hold the lips back. The child can use his fingers or a Lip Retractor.

Fingers: Have the client use his own fingers to pull back the lips. Have the client place one or two fingers inside his mouth at the corners of the lips. Then ask him to pull the corners of the mouth back laterally. (You know what this is. All kids do this sometimes when they stick out the tongue.)
Lip Retractor: The Lip Retractor is a plastic orthodontic tool that is used to hold the lips back out of the way when photos are taken of the teeth before braces are put in. I talk about it in several of my books.

With the lips out of the way have the client practice R using whatever methods of tongue placement you prefer. Tell him, "Your lips cannot do the work. Only the tongue can do the work." Teach the client to hear the correct sound he can make without his lips. Over time, fade his dependence upon the lip pull back procedure. Eventually teach him to use a slight amount of lip rounding to produce a great R.

OROFACIAL MYOLOGY

06.23.08 - How can I find out about orofacial myofuctional therapy?

Go to the website for the International Association of Orofacial Myology. According to their website, "The IAOM provides information about Orofacial Myological disorders including: tongue thrust, improper mouth posture and incorrect swallowing patterns."

THE R CRISIS

06.31.08 - My 12-year-old son cannot say R, however I am not so sure if that is the only problem. Many people do not understand him, a great crisis for him as he starts junior high this fall. He talks very fast. We tried a home program, but I really don't know what I'm doing. Help!

Your letter points directly to the articulation crisis occurring in this country: Many SLP's are graduating from universities with absolutely no idea how to fix an R distortion. Let me use this question to discuss four topics: diagnosis, home programming, university requirements, professional development, and equal access to therapy.

First, a thorough diagnosis of expressive speech needs to be made. Many of these long-term R kids are not simply R kids. The distortion of R may be the only error that reveals itself on a test, but these kids often demonstrate additional significant problems in conversational speech. Often they talk too fast, distort vowels, use an incomplete set of vowels, shorten diphthongs, drop syllables, delete final consonants, reduce clusters, and have nasal resonance problems. It is these other factors that reduce intelligibility. Therapy needs to address the R and all the other issues.

Second, the notion that a home program will solve these issues is, in my opinion, ridiculous. The child requires the attention of a professional speech-language pathologist who knows what he or she is doing in regard to expressive speech therapy.

Third, universities need to step up in this regard. Every SLP who graduates from school with a master's degree in speech-language should have exposure to articulation therapy. They should graduate knowing the basics of working with R, L, and the lisps at the very minimum.

Fourth, SLP's who do not know how to fix a distorted R effectively need to hook up with at least one therapist who does. Take a half-day and go watch this therapist in action. You will learn more in one hour than you would in any other way. Therapists who do know how to do this work need to offer themselves as mentors to the less experienced therapists.

Finally, it is my professional opinion that children with distorted R phonemes, and other so-called "mild" articulation errors have as much right to treatment as children with severe speech-language impairment. Why we are treating articulation errors as less important is beyond me. These children are our future leaders in education, science, medicine, politics, economics and more. They need clear well-developed speech! If we do not help them with their speech nobody will.

ORAL MOTOR TREATMENT AND NS-OME

07.10.08 - Once again I shall take a run at the question of what oral motor treatment is, and what are the differences between oral motor treatment and non-speech oral-motor exercises. This answer ensued from an email dialogue I was having with someone very concerned that SLP's have begun to use non-speech oral-motor exercises INSTEAD of methods to facilitate sound and word productions. I tried to explain how this is wrong.

ALL methods to improve speech are "oral" techniques, and they are "movement" techniques. Thus they are "oral motor" techniques. Or as Dr. Suzanne Evans Morris puts it, "oral sensory motor techniques." This is true even for the simplest of sounds. Oral motor treatment, as I have been defining it since 1978, is the process of facilitating improved jaw, lip, and tongue movement for speech. This is a simple idea.

For example:

When you ask a child to open his mouth to say "Ah", you are asking for an oral movement.
When you ask a child to put his lips together, you are asking for an oral movement.
When you use the Association Method, you are using an old oral movement to teach a new oral movement.
When you use a PROMPT or a Motokinesthetic technique, you are training new oral movement by using a cue.
When you use a tongue blade to prop the jaw in place while the client is attempting to move the tongue, you are teaching a new oral movement.
When you ask a child to lift his tongue to the alveolar ridge to produce T, D, N, or L, you are asking for an oral movement.
When you use a straw to teach a client to blow air through a central groove for S, you are teaching him a new oral movement.

Speech IS movement. Therefore, ALL articulation methods are oral movement techniques.

THUS, it behooves SLP's to understand movement - how it is organized, how it develops, how it breaks down, and how to remediate it. This info does not just come from the speech literature. It also comes from the OT/PT literature.

Difference from NS-OME: When you ask a child wag his tongue back-and-forth (a NON-speech oral motor exercise) you are NOT teaching new movement. You are simply having the child exercise the movements he already has. As has been amply pointed out, this does not help speech. Those of us in the "oral motor camp" already know this. We have known it for 30 years. We do not teach nor do we advocate non-speech oral-motor exercises. There is no point to them.

When we talk about oral motor treatment, we are not talking about exercising already-existing movements. We are talking about helping the client create new movements. We are using MOTOR techniques to facilitate the emergence of tongue movement that is absent or poorly organized or uncontrolled. The methods are the same, whether you are talking about the movements for speech, feeding, dysphagia, orofacial myology, or motor speech therapy. If you read all this literature - or if you carefully read my latest monograph on the OMI - you will come to realize that the same methods have been advocated in all this literature - in feeding, in speech, in dysphagia, orofacial myology and motor speech therapy. And in NDT, SI, and other motor therapies as well.

Darley et al¹ classified apraxia and dysarthria as motor speech disorders. The most current text on childhood motor speech disorders, written by some of the most highly respected authors in the field, recommends that we engage in speech therapy that relies heavily upon "principles of motor learning"². Duffy³ says the same thing. Thus SLP's are being asked to understand movement as it has been studied by movement specialists (OT's/PT's).

That is all we are saying. Oral motor methods borrow ideas from OT and PT and use them to facilitate movement for speech. These are methods like inhibition of abnormal oral movements, facilitation of more advanced oral movements, stabilization of oral movements, facilitation of improved muscle tone in the oral mechanism, separation of oral movements, integration of the two sides of the oral mechanism, normalization of oral-tactile sensitivity so that new oral movements can be explored, and so forth. These methods are fundamental to movement therapies. SLP's can add these ideas to the many we already have in order to help clients create new movements that are absent.

Am I advocating non-speech oral-motor exercises? NO!

Should non-speech oral-motor exercises be used instead of speech therapy? NO!

Am I advocating that oral motor treatment be used instead of traditional articulation or phonological therapy? NO!!

Techniques to facilitate improved oral movements should be used within the program of articulation and phonological therapy to help create new speech movements when the methods prove to be necessary.

A real dilemma: I believe that the problem is not in the oral motor treatment.

I believe the problem is that many SLP's today are graduating from the universities without basic knowledge about how to do articulation therapy. This is the problem, not the oral motor techniques. Without a firm foundation in how to do good old-fashioned articulation therapy, many young therapists have begun to think that oral motor treatment IS articulation therapy. This is not true.

In the 1970's and 1980's, when we first started talking about these methods, no one had a problem with them because all SLP's knew how to do articulation therapy. They were able to take these new ideas and put them into their articulation programs. But today, with so much focus on language and literacy, multiculturalism, and so forth, there seems to be no time to teach graduate students how to do articulation therapy. Yet, articulation therapy is the heart of almost every SLP's caseload!

Methods to facilitate improved oral movements are to be used within the program of articulation or phonology. Therapists should not use oral motor techniques alone. They will do you no good. You must work on speech first, in the middle, and last. Do that first, and then determine from your results which of your clients need more help with oral movement.

References

Darley, F. L., & Aronson, A. E., & Brown, J. R. (1975) Motor speech disorders. Philadelphia: W. B. Saunders.
Yorkson, K. M., & Beukelman, D. R., & Strand, E. A., & Bell, K. R. (1999). Management of motor speech disorders in children and adults, P. 552-553. Austin: Pro-Ed.
Duffy, J. R. (1995) Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis: Mosby.

EBP - CHOPPING DOWN TREES TO SAVE THE FOREST

07.19.08 - I have heard you say that you have a real problem with Evidence-Based Practice (EBP). Why would you be opposed to something that so clearly will help and protect our clients?

I am not against using EBP. I am for EBP.

However, I am concerned about several recent results of the EBP philosophy. I am especially opposed to three new ideas:

I am against throwing out everything we have learned through a century of trial-and-error speech-language therapy just because we have no laboratory proof in the modern sense. As Dollaghan (2007) has pointed out, evidence comes from the lab, from the clinic, and from the client.
I am against disposing of the SLP's freedom to experiment in therapy in order to discover new ways to go about doing things. It is through this freedom that a profession grows. Without this freedom, a profession dies.
I am against restricting our treatment to only certain methods when those methods might not be appropriate for the client. This harms clients and limits their potential.

Almost every textbook that I have ever read in our profession - and I have read hundreds - ends with a discussion about "what this all means" for the SLP. And in just about every one of these books there is a statement like the following: "SLP's must use their common sense, their clinical judgment, and their personal clinical experienced to adjust and modify these methods to suit the needs of their clients."

That's it. That's what Speech-Language Pathology is all about. SLP is the process of applying scientific ideas to concerns of a specific client. SLP is not a cookbook of procedures. We do not do step 1, followed by step 2, and so forth. We take science and apply it. Usually this means altering it to fit the immediate needs of our patients. We are professionals who design and implement programs. We are not technicians who follow procedures of someone else's design.

And what about the trees? In the current zeal to make sure that everything we do has evidence behind it, there are those in the profession who seem willing to dismiss literally millions of hours of clinical evidence that have evolved out of the history of our profession. They think this will save the profession. In essence they are saying, "In order to save this forest, let's cut down all the trees!"

Well I would prefer not to cut down the trees to save the forest. I would prefer to preserve every tree, to allow the trees to regenerate themselves naturally, and to allow new trees to be planted among them.

Reference

Dollaghan, C. A. (2007) The handbook for evidence-based practice in communication disorders. Baltimore: Paul H. Brooks.

STIMULATING LIP MOVEMENT

07.27.08 - What can I do from a muscle-based perspective to engage the upper lip?

There have been many methods of stimulating lip movement in the articulation, motor speech, oral motor, feeding, dysphagia, and orofacial myofunctional literature. The following sources are my favorite ones for activities to facilitate lip mobility. [Presented alphabetically]

Dworkin, J. P. (1991). Motor speech disorders: A treatment guide. St. Louis: Mosby.
Garliner, D. (1981) Myofunctional therapy. Coral Gables: Institute for Myofunctional Therapy.
Marshalla, P. J. (1992). Oral motor techniques in articulation and phonological therapy. Mill Creek: Marshalla Speech and Language.
Morris, S. E., & Klein, M. D. (2000, 1987). Pre-feeding skills: A comprehensive resource for mealtime development, 2nd addition. Austin: Pro-Ed.
Rosenfeld-Johnson, S. (2001) Oral-motor exercises for speech clarity. Tucson: Talk Tools.

TEACHING SH

08.04.08 - Do you have any techniques for teaching Sh for a client who can do a correct S?

There are several easy things that usually work well if the client already can do an S.

Use a Sequence: Have him make an S, and then slide into a whispered (voiceless) Y. Then have him do the same thing with the lips rounded. The sound of Sh often will be heard during the transition between the two sounds if the client can slow down and make the transition slowly. Teach him to hear the Sh that is embedded in there.
Use the Association Method with E. When you use the Association Method, you use the movements and positions of one phoneme to teach those of another. The tongue position for E is basically the same as that needed for Sh. If your client can say E, then do the sequence a-d below. Help the client listen very carefully to tweak the acoustic quality in order that he gets the best Sh possible. Make sure to do each step discretely. Have him:
1. Say an exaggerated E. (Smile very broadly)
2. Whisper this E. (The sound that results with not sound like Sh. It will sound like a whispered E.)
3. Now round the lips as you whisper this E. (An Sh sound might come right then. If not, go to step 4.)
4. Say E, whisper E, round the lips with the whispered E, and elevate the jaw slightly. (A better sounding Sh should come in.) Tweak the acoustic quality.
Use a specific oral motor technique: Have the client bite down on the back lateral margins of the tongue, push up the tongue sides against the upper molars (the "Butterfly Position"), smile broadly, and blow gently. A gross Sh should emerge if he can maintain a central groove while biting down. Then have him hold this position and round the lips. A good Sh should be heard. Then tweak the acoustic quality.

For more I have written on the sibilants, please see Frontal Lisp, Lateral Lisp.

COUNSELING PARENTS ABOUT ARTICULATION DEFICIT

08.20.08 - What do you tell parents when they ask what caused their child's articulation disorder?

First I draw whatever conclusions I can from the child's medical and physical history. For example, I explain how the child's errors might be related to his positive history of ear infections, oral injury, structural deficit, neuromuscular disorder, sensorimotor dysfunction, and so forth.

Second, I draw conclusions from information I have about the client's cognitive level. For example if the client is four-years-old, but he processes information like a one-year-old, then I help the parents understand that his articulation will be like that of a one-year-old. I help them understand what this means in terms of our expectations about speech sound development.

Third, I draw conclusions from his social, emotional, educational, and language history if there are any significant findings. For example, a child who is adopted from another country where he was in a less-than-optimum orphanage may have significant speech-language issues to overcome during the first few years after adoption.

Finally, if there are no obvious potential causes, I tell the parents that we may never know the cause of the articulation deficit

SOUND-ACTIVATED TOYS

08.21.08 - I was listening to your audio tape called Apraxia Uncovered and heard you say that voice-activated toys are great for getting children to vocalize. Where can I find these?

I know of no speech company that is selling these toys now, but I searched online and found many for sale at various venues. Some are overpriced, but if you take the time to look around online, I am sure you will find at least one at a reasonable price. Search by the specific name or by "sound activated toys." Here are several to get you started:

Pete the Repeat Parrot: This very obnoxious parrot repeats back twice the short utterances you say to him. The sound quality of the parrot's voice is not great, but it also flaps its wing when it talks. It's a great toy to motivate a child to speak in order to get the parrot to activate. That is, as long as it doesn't scare him!
The Green Machine Frog Band: This is my absolute favorite. These five little frogs are so cute and they bob to sound, either music or voice. Hold a tube from the child's mouth to the receiver for absolute perfection in voice-movement activation.
Dino Band: Just like the frog band. Use the phrase "Dino Band Sound Activated" when you search.
Sound Activated Wind Chime: I haven't used these, but it looks very interesting.
New Toys: Several toys I have not seen personally but which look potentially great are at this website.

DIAGNOSIS OF APRAXIA

08.29.08 - Is it necessary to get a diagnosis of apraxia with a young child who does not talk, or can we just proceed with therapy?

The answer to that depends upon the rules and regulations of your treatment center or school, and whether or not insurance providers are involved. But in my opinion, as far as the actual therapy is concerned, you do not need a diagnosis to start. Just start. Time in treatment will tell you increasingly more about his abilities, and apraxia will be ruled in or ruled out.

THE ESSENCE OF THERAPY WITH LITTLE KIDS

08.30.08 - Our son is three and was non-verbal. Our SLP seems really good at helping him learn to talk. But he is very hard to understand. What can we do?

The essence of speech therapy for little children is to learn about words and sounds. We need to focus on both when working with young children. Many of today's younger therapists put all their focus on building vocabulary, and they spend very little time focused on the actual production of sounds. Do both. But don't focus on his ability to learn one phoneme or another. Stimulate him to produce a huge variety of sounds including:

Animal and Environmental Sounds - Dog bark, cat meow, cow moo, siren, tire screech, etc.
Vowels - Eee, Ooo, Ahhh, Ohhh, Uhhh, etc.
Eating Sounds - Mmmm, Nnnnn, Num-num-num, etc.
Non-speech Sounds - Laugh, cry, squeal, shout, snort, whisper, etc.
Babbling - Babbababa, mamamamama, gogogogogo, etc.
Raspberries - Made with the lips, with the tongue, with the back of the tongue
Hissing Sounds - Ssss (snake), Shhh (shush), Ch-Ch (Chew-chew train), Zzzz (bee), etc.
Alphabet - Teach him to sing the song. He will mumble at first. The individual letter names will become clearer with time.
Songs - Sing all the time. Sing kids songs and adult songs. Sing in the shower, sing in the car, and sing your way through household chores.
Words - Exaggerate words for him to hear and teach him to do the same. When modeling words, slow down, pause before the word, speak clearly, and exaggerate the pronunciation. Encourage him to do the same.
Play with words he can say - Say them loud and soft, high and low, happy and sad, long and short, angry and pleased, etc.

The first few chapters of my book Becoming Verbal with Childhood Apraxia is all about this.

CAS AND SELF-ESTEEM

09.08.08 - Is it wise to talk to a preschool child with childhood apraxia about their disorder?

I never tell little kids that they have a disorder. I let them know that they are speaking very well, that they are still learning, and that I am thrilled that they are speaking as well as they are. Often I imitate back to the child what he said and how he said it, then I model for him how to say it better. Consider this little dialogue:

Child: (Naming an alligator) "Day-bo."
Therapist: (Pleased) "Day-bo! You said, 'alligator!'"
Child: "Uh-nuh day-bo."
Therapist: "Another day-bo! You found another alligator. That is a big word. A-Li-Gay-Tor." (Emphasizing each syllable)
Child: "A-Gay-Bo."
Therapist: "Good. 'A-Li-Gay-Tor.' You are learning how to say, 'A-Li-Gay-Tor.'"
Child: "A-Gay-Bo."
Therapist: "A-Gay-Bo." Perfect. 'A-Li-Gay-Tor.'"

In this little exchange, the therapist has given the client several messages:

I am listening hard to everything you are saying
I am pleased that you are talking to me
You said a great word
I accept the way you said that word
Here’s how to say it better
You said it better!
You eventually will say it the best way because you are still learning

CHILDHOOD APRAXIA AND DYSARTHRIA: FREQUENCY OF THERAPY

09.11.08 - How often should a young child (2-4 years of age) with apraxia or dysarthria receive speech-language therapy services?

I have a baseline that all my clients with motor speech disorders have to meet. They must attend once per week for one hour at a minimum. Twice per week is very nice. Three times per week is a complete luxury. More than that is unnecessary because these children do not change very fast.

Children with motor speech disorders take a long time to change. I have found that "more therapy right now" is not the answer. "Good therapy over the long haul" is a much better solution. Please keep in mind that this is only my clinical opinion.

Pam Marshalla, MA, CCC-SLP