Ask A Therapist: You are your child's best advocate!

Posted by Deborah Grauzam on

questions

Hi,

I was recently at the NDSC conference in Denver where I heard Sara Rosenfeld-Johnson speak and saw her video about the improvements in speech that are possible among young adults with Down syndrome.

My son is 12 and today I spoke with his school SLP who told me the following:

1. Oral motor therapies are not proven. You can only improve speech with speech exercises, not other types of exercises. Therefore, she is prohibited from doing any kind of oral motor work with my son. and

2. After I pointed out that traditional speech therapy hasn't worked very well because my son hasn't made much progress since 2d or 3d grade, she said that was common among kids with Down syndrome and they reach a point where they just aren't going to progress any further in articulation.

Needless to say, I am pretty unhappy about all this. The Speech Language Pathologist also said that there is a lot of evidence to back up all of her points.

So, I was wondering if you had any papers or other evidence to shows that our kids can continue to progress in articulation AND that Oral Motor/Oral Placement therapies are effective with them.

I would be very grateful for any assistance you might be able to provide me.

Monica

Good Morning Monica!

I would be happy to answer your questions as they are numbered! This is a question I am asked over and again and I am happy to take the time to help parents such as yourself advocate for what their child needs.

1. Nothing in science is "proven" but rather what we look for is "Evidenced Based Practiced" (EBP),  which according to The American Speech and Hearing Association (ASHA) encompasses an "approach in which current, high-quality research evidence is integrated with practitioner expertise and client preferences and values into the process of making clinical decisions" ( American Speech-Language-Hearing Association. (2005).  Evidence-based practice in communication disorders [Position Statement]. Available from www.asha.org/policy). Note that research is one part and practitioner expertise is also considered. Furthermore, there are many articles and studies that suggest oral-motor activities are helpful for feeding, such as: "Effect of Tactile Stimulation on Lingual Motor Function in Pediatric Lingual Dysphagia " by Lamm, DeFelice and Cargan (2005). There is also  EBP that supports that tactile therapies and kinesthetic and proprioceptive clinical cues facilitate speech sounds such as "Efficacy of Using an Oral-Motor Approach to Remediate Distorted /r/" by Hawk (2007.) In fact Van Riper who is one of the most respected figures of articulation therapy, talks about using "therapy tools" to facilitate the placement for speech sounds. Many therapists cite the work of Gregory Lof to dispute our work at TalkTools and suggest that we are using "Non -Speech Oral Motor Exercises". This is incorrect. Phonetic placement cues that have been used in traditional speech therapy are NOT the same as NSOME. (Lof, 2009.)

At TalkTools,  we are not using "non-speech" movements, we are only using speech-like movements to facilitate improved speech clarity. For example, the mouthpiece on Horn #1 from the original horn kit facilitates the same oral placement required for /m/, /b/ and /p/. We do not blow the horn in isolation, but rather use this to superimpose oral placement skills that a client needs to help produce a bilabial sound. Pam Marshalla discusses how therapy tools are not "new" on The Oral Motor Institute Website (Marshalla, P. (2012). Horns, whistles, bite blocks, and straws: A review of tools/objects used in articulation therapy by Van Riper and other traditional therapists. Oral Motor Institute, 4(2). Available from www.oralmotorinstitute.org). This article describes how Van Riper and fourteen other authors used 86 different objects, or types of objects, to teach dissociation, direction, and grading of speech movements in articulation therapy. This approach is certainly evidenced based, and taught at hundreds of universities across the country.

2. The concept that an individual cannot make progress in therapy,  is a violation of the ethics we must follow in our profession. ASHA states : "Individuals shall not guarantee the results of any treatment or procedure, directly or by implication; however, they may make a reasonable statement of prognosis." To imply that an individual can make "no progress" is an unreasonable statement that violates this code. Down syndrome, like any diagnosis is not a static condition, it is evolving with age and environment. Many children can make progress, as well as adults, at any point in life when the right therapy is implemented.   If an individual cannot respond to traditional methods, or "look at me and say what I say" it is our ethical responsibility as speech pathologists to research , and find new ways to treat, in collaboration with other professionals such as OT and PT. Since "what we see in the body is what we see in the mouth", (Lori Overland MS, CCC-SLP), we need to remember that postural supports and fine motor deficits may influence treatment outcomes in individuals with Down syndrome; however this is by no means a reason to "give up" on therapy. I personally have worked with many clients in later stages of life who were previously unable to achieve articulation goals via traditional methods.  I have seen these same clients make amazing gains when I implemented the TalkTools "Three Part Treatment Approach" to include Feeding and Oral Placement Therapy in ADDITION to traditional methods.

Has your school based therapist even considered PROMPT therapy , which has many articles to support this technique as EBP?  Certainly traditional methods are not the only type of therapy that can be tried with your son.

In summary there will always be disagreement on treatment approaches. It is present for example, in the ongoing controversy of whether Applied Behavioral Analysis(ABA) is more appropriate for autism, than the DIR Floortime method. It is present when researchers argue whether stuttering is behavioral or neurological. In this case, yes there are studies out there that suggest Non-speech oral motor exercises are not effective for speech clarity. I would advise that you examine the test subjects in  the studies your therapist presents to you.

Did they include subjects with low tone? Down Syndrome? Co-existing tongue thrust?

I have listed some studies and articles below to respond to your request to do so.  The list actually includes some of the studies that therapists often use to dispute oral motor therapy so you are educated and free to form your own opinions. Remember that what we teach at TalkTools has nothing to do with non-speech movements, so that in itself invalidates the studies that are used to oppose our methods.

Unfortunately, it is highly unlikely that the therapist in question will change her opinions on treatment approaches.  Because of this I would suggest that you request a change in therapist from your school so they are able to provide someone with specific training in muscle based speech sound disorders.  Quite often, I perform independent evaluations for school districts that face this same problem. Good luck and thank you for your interest in Oral Placement Therapy.

Robyn Merkel-Walsh MA, CCC-SLP

REFERENCES:

Bahr, D. (in press). Healthy baby, healthy mouth: What every parent and professional should know about feeding, speech, and mouth development. Las Vegas: Sensory Resources, LLC.

Bahr, D. (2008, November). The oral motor debate: Where do we go from here? Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Chicago, IL. (Full handout at http://www.asha.org/Events/convention/handouts/2008/2054_Bahr_Diane/)

Bahr, D. C. (2001). Oral motor assessment and treatment: Ages and stages. Boston: Allyn and Bacon.

Banotai, A. (2007, September).  Reviewing the evidence:  Gregory Lof’s critical take on oral-motor therapy.  Advance for Speech-Language Pathologists & Audiologists, 7-9.

Bowen, C. (2006). What is the evidence for oral motor therapy? Acquiring Knowledge in Speech, Language, and Hearing, 7, 144-147.

Clark, H. (2005, June 14). Clinical decision making and oral motor treatments.  The ASHA Leader, 8-9, 34-35.

Crary, M. A. (1993). Developmental motor speech disorders. San Diego: Singular.

Dorais, A. (2009, May/June). Palatometry: An approach for treating articulation problems. Word of Mouth, 20 (5). 1-4.

DeThorne, L. S., Johnson, C. J., Walder, L., & Mahurin-Smith, J. (2009, May).  When “Simon Says” doesn’t work: Alternatives to imitation for facilitating early speech development. American Journal of Speech-Language Pathology, 18(2), 133-145.

Flaherty, K., & Bloom, R. (2007, November). Current practices & oral motor treatment.  Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Boston, MA.

Fletcher, S. (2008, November). Palatometry principles and practice.  Session presented at the annual meeting of the American Speech-Language-Hearing Association, Chicago, IL.

Green, J. R., Moore, C. A., Ruark, J. L., Rodda, P. R., Morvee, W. T., & VanWitzenburg, M. J. (1997).  Development of chewing in children from 12 to 48 months: Longitudinal study of EMG patterns. Journal of Neurophysiology, 77, 2704-2716.

Insalaco, D., Mann-Kahris, S., Bush, C., & Steger, M. (2004, November). Equivocal results of oral motor treatment on a child’s articulation.  Poster presented at the annual meeting of the American Speech-Language-Hearing Association, Philadelphia, PA.

Kent, R. D. (1999). Motor control: Neurophysiology and functional development. In A. J. Caruso and E. A. Strand (Eds.),Clinical management of motor speech disorders in children, (pp. 29-71). New York: Thieme Medical Publishers.

Kent, R. D. (2008, July). Theory in the balance. Perspectives on Speech Science and Orofacial Disorders, 18, 15-21.

Lass, N., Pannbacker, M., Carroll, A., & Fox, J. (2006, November). Speech-language pathologists’ use of oral motor treatment. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Miami, FL.

Lof, Gregory (2009) . Nonspeech Oral Motor Exercises: An Update on the Controversy, American Speech-Language-Hearing Association Convention. New Orleans, LA.

Lof, G. L., & Watson, M. (2008, July). A nationwide survey of nonspeech oral motor exercise use:  Implications for evidence-based practice. Language, Speech, and Hearing Services in Schools, 39, 392-407.

Maas, E., Robin, D. A., Austermann Hula, S. N., Freedman, S. E., Wulf, G., Ballard, K., & Schmidt, R. A. (2008). Principles of motor learning in treatment of motor speech disorders. American Journal of Speech-Language Pathology, 17(3), 277-298.

Marshalla, P. (2004). Oral-Motor techniques in articulation & phonological therapy. Mill Creek, WA: Marshalla Speech and Language.

Marshalla, P. (2007). Oral motor techniques are not new. Oral motor institute, 1(1). Available from www.oralmotorinstitute.org.

Meek, M. M. (1994). Motokinesthetic Approach. Albuquerque, NM: Clinician’s View. (3 videos)

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Pannbacker, M., & Lass, N. (2004, November). Ethical issues in oral motor treatment. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Philadelphia, PA.

Polmanteer, K., & Fields, D. (2002, November).  Effectiveness of oral motor techniques in articulation and phonology treatment.  Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Atlanta, GA.

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American Speech-Language-Hearing Association ASHA poster ASHA presentation Ask a Therapist Down syndrome EBP Evidence based practice Gregory Lof NSOME oral motor exercises Oral Motor Therapy Oral Placement Therapy parent advocacy Robyn Merkel-Walsh

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Comments


  • Hi Robyn,
    This is an excellent explanation. I am sharing on my Facebook page as I have this question posed to me by other therapist in my community. Thank you!
    Tracey

    Tracey Siebold on
  • You are very welcome. I have expanded this with Diane Bahr on the Ages and Stages Blog we will post it soon !

    Robyn Merkel-Walsh on

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