“The conversation for tongue tie in the speech pathology community is growing louder among some groups of speech-language pathologists (SLPs) (ASHA Leader, 2015). An ASHA literature search has suggested a correlation between tongue ties and difficulty producing lingual alveolar phonemes (Merkel-Walsh & Jahn, 2014). Furthermore, Eschler, Klein, and Overby (2010) indicated that SLPs’ diagnostic criteria, treatment, goals, and discharge criteria for ankyloglossia differ depending on comorbid behavior (i.e., SSDs or feeding/swallowing difficulty).

Recently, there is a rise in the identification of posterior tongue ties in infants who are having trouble feeding and toddlers/adolescents who are exhibiting continuous speech sound errors despite years of speech-language pathology services. Posterior ankyloglossia is characterized by a thickened frenulum (Type III) or a submucosal frenulum visualized as a flat, broad mound absent of any typical protruding frenular tissue, and restricts movement at base of tongue (Type IV) (Kutlow, 2011).”

Meaux, A., Savage, M., & Gonsoulin, C. presented the poster “Tongue Ties and Speech Sound Disorders: What Are We Overlooking?” at the 2016 Annual ASHA Convention, November 17-19 in Philadelphia, PA.

View the full poster here

Authors: Ashley Meaux, PhD, CCC-SLP, Meghan Savage, PhD, CCC-SLP, & Courtney Gonsoulin, MA, CCC-SLP

This article was initially presented at the 2016 Annual ASHA Convention, Thursday, November 17, 2016, 4:30-5:30 PM. It is available in video in full on Facebook: Part 1 / Part 2

Authors:

Robyn Merkel-Walsh MA, CCC-SLP

Lori Overland MS, CCC-SLP/C-NDT

Learner Outcomes:

1. Participants will have an improved understanding of the etiology of a self-limited.

2. Participants will be able to demonstrate understanding of a home-based diet.

3. Participants will be able to comprehend the concept of diet-shaping.

Discussion of Topic:

The CDC (2015) reports, that Autism Spectrum Disorder (ASD) impacts 1 in 68 children in the United States. In “cluster” states such as New Jersey, as many as 1 in 28 boys are affected.

Children with ASD often present with comorbid feeding issues. There is empirical evidence and an overall scientific consensus supporting an association between food selectivity and ASD (Marí-Bauset Zazpe, Mari-Sanchis, Llopis-González & Morales-Suárez-Varela, 2014). Problems with eating often occur before the actual diagnosis of ASD, and clinicians may often be alerted to the disorder when eating problems, nutritional concerns and gastrointestinal problems occur (Beckman & Cole-Clark, 2015).

Studies show that up to seventy percent of children with ASD are selective eaters and up to ninety percent have feeding problems (Volkert & M Vaz, 2010). Children with ASD are significantly more likely to refuse foods based on texture/consistency (77.4% vs 36.2%), taste/smell (49.1% vs 5.2%), mixtures (45.3% vs 25.9%), brand (15.1% vs 1.7%), and shape(11.3% vs 1.7%), (Hubbard, Anderson, Curtin, Must & Bandini,2014). Researchers at Marcus Autism Center and the Department of Pediatrics at Emory University School of Medicine conducted a comprehensive meta-analysis of published, peer-reviewed research relating to feeding problems and autism. Examination of dietary nutrients showed significantly lower intake of calcium and protein and a higher number of nutritional deficits overall among children with ASD (Korschun & Edwards, 2013). Feeding challenges in the Speech-language pathologists receive referrals for feeding issues in ASD both before and after diagnosis (Keen. 2008).

Applied Behavioral Analysis (ABA) has the most empirical research in treating ASD to date. Behavior analysis is a scientifically validated approach to understanding behavior and how it is affected by the environment (Lovaas & Smith, 1989). It has been endorsed by a number of state and federal agencies, including the U.S. Surgeon General and the New York State Department of Health (Iovannone, Dunlap, Huber, & Kincaid, 2003). Research has shown that ABA therapy is effective at increasing appropriate behaviors and decreasing inappropriate behaviors (Kodak & Piazza, 2008). Therefore, it is reasonable to believe the principles on which ABA techniques are based can help with feeding issues (Volkert & M Vaz, 2010). The problem is that behavioral therapies however, do not often take into account the complexity of the sensory-motor system or medical issues, and how they relate to self-limited diets in children with ASD. Behavioral components may be essential in a feeding program; however, they should be implemented in conjunction with a sensory-motor approach to prove the most positive outcomes.

An infant’s first “job” in life is self-regulation and modulating arousal. These hard-wired synergies impact the sensory-motor system and oral-motor development (Overland & Merkel-Walsh, 2013). Many children with autism have significant issues with arousal and self-regulation which drives behavioral responses (Barthels, 2014.) Many children with autism also have qualitative differences in motor skills, especially with posture and alignment. (Teitelbaum, 1998). These differences in motor skills may also impact the motor skills for safely handling food. Therefore, when an individual with autism is referred to a speech-language pathologist (SLP) for self-limited diet, a comprehensive feeding assessment is required, including: review of child’s medical status; gross, fine, and oral-motor development; nutritional status; and sensory processing (Arvedson & Brodsky, 2001). For example, 59 percent of autistic children who were undergoing endoscopy for GI symptoms had carbohydrate digestive abnormalities, compared with only 11 percent in unaffected children undergoing endoscopy for GI symptoms (Beckman & Cole-Clark, 2015). Issues that affect the variety in the diet may not be behavioral. Since the sensory and motor systems cannot be separated (Morris & Klein, 2000), it is very important to task analyze the child’s motor skills and how they relate to feeding before assuming that a self-limited diet is purely behavioral (Beckman & Cole-Clark, 2015; Merkel-Walsh & Overland, 2016).

Sensory processing issues can also contribute to feeding disorders (Twachtman-Reilly, Amaral, & Zebrowski, 2008). Sensory processing refers to the ability to receive messages from the senses, interpret and organize the information in order to turn it in to an appropriate motor or behavioral response. Not all children with sensory processing disorders have autism but more than ¾ or as many as 90% of children with a diagnosis of autism have some degree of sensory processing disorder (Schoen, Miller, Brett-Green & Nielsen, 2009). Children with sensory regulation disorder may not be able to organize themselves for feeding. Those with oral sensory issues may not feel the food in their mouths, or they may be overly sensitive to the feeling of the food in their mouths. They may not feel hunger or satiation. Sensory defensiveness produces a neurochemical reaction of fear that quickly becomes a hardwired automatic response. The nervous system triggers a “fright-flight-fight” response even if it is irrational (Merkel-Walsh & Overland, 2016). In addition, once a behavior is inadvertently reinforced, the behavior will reoccur (Brophy, 2013). Children with autism are at a higher risk for these problems, because many children with autism engage in ritualistic behaviors. Seemingly well-meaning parents and therapists may not realize that by reacting to food refusals they are actually increasing the chance for this behavior to reoccur (Brophy, 2013; Merkel-Walsh & Overland, 2016).

In clinical practice the speech-language pathologist needs to look at how the child with ASD reacts to touch of the extremities, the face, and oral cavity as well as oral habits such as teeth grinding, mouthing objects and eating items other than foods. A diet analysis is needed to assess if the child has intolerances to certain tastes, temperatures and textures. This will establish the child’s home base and provide a starting point for diet expansion. The therapist must look at the underlying oral sensory-motor skills to support safe, effective nutritive feeding (Merkel-Walsh & Overland, 2016).

In conclusion, children with ASD are prone to self-limited diets. In order for a speech and language pathologist to thoroughly assess and treat this disorder, the therapist must be in tune to the sensory-motor system and design a treatment plan based on the home base, and systematically and sequentially via diet- shaping.

References:

Arvedson, J. C. & Brodksy, L. (2001). Pediatric swallowing and feeding: Assessment and management (2nd Ed.). Albany, NY: Singular.

Barthels, K. (2014). There is always a reason for behavior: is it sensory or is it behavior? (Live presentation), New York, NY.

Beckman, D. & Cole-Clark, M. (2015). Diet texture transition for individuals with autism. American Speech Language Hearing Association, Denver, CO. Retrievable: http://www.beckmanoralmotor.com/media/Diet-Texture-Progression-for-Individuals-with-Autism-ASHA.pptx

Brophy, N. (2013). Behavior plan implementation in the classroom. (Power point slides), Ridgefield, NJ.

Center for Disease Control (2015). Autism Spectrum Disorders (ASDs). Retrieved from http://www.cdc.gov/ncbddd/autism/data.html

Fisher, A. G., Murray, E. A., & Bundy, A. C. (1991). Sensory integration: Theory and practice. Philadelphia, PA: F. A. Davis.

Gisel, E. G. (1994). Oral-motor skills following sensorimotor intervention in the moderately eating impaired child with cerebral palsy. Dysphagia, 9, 180-192.

Hubbard, K.L., Anderson, S.E., Curtin, C. Must, A. & Bandini, L.G. (2014). A comparison of food refusal related to characteristics of food in children with autism spectrum disorder and typically developing children, Journal of the Academy of Nutrition and Dietetics, Vol.114 (12), pp.1981-1987.

Iovannone, R. et al. (2003). Effective educational practices for students with autism spectrum disorder. Focus on autism and other developmental disabilities, 10883576,18,3.

Keen, D.V. (2008). Childhood autism, feeding problems and failure to thrive in early infancy, European Child & Adolescent Psychiatry, Vol.17 (4), pp.209-216.

Korschun, H., & Edwards, C. (2013.) Retrieved from http://www.news.emory.edu/stories/2013/02/autism_nutritional_deficits/

Kodak, T. & Piazza, C.C. (2008). Assessment and behavioral treatment of feeding and sleeping disorders in children with autism spectrum disorder. Behavior Modification, 33: 520-536.

Lovaas, O. I. & Smith, T. (1989). A comprehensive behavioral theory of autistic children: Paradigm for research and treatment. Journal of Behavioral Therapy and Experimental Psychiatry, 20, 17-29

Marí-Bauset, S., Zazpe, I., Mari-Sanchis, A., Llopis-González, A. & Morales-Suárez-Varela, M. (2014). Food selectivity in autism spectrum disorders, Journal of Child Neurology, 2014, Vol.29 (11), pp.1554-1561.

Merkel-Walsh, R. & Overland, L.L. (2016). Self-limited diets in children with a diagnosis of autism spectrum disorder. Oral Motor Institute. Vol 5, Monograph 7. Retrieved from: http://www.oralmotorinstitute.org/mons/v5n1_walsh.html

Morris, S. E., & Klein, M. D. (2000). Pre-feeding skills: A comprehensive resource for mealtime development. San Antonio, TX: Therapy Skill Builders.

Overland, L.F. & Merkel-Walsh, R. (2013). A sensory-motor approach to feeding. Charleston, SC. TalkTools.

Schoen, S., Miller, L.J., Brett-Green, B.A. & Nielsen, D.M. (2009). Physiological and behavioral differences in sensory processing: a comparison of children with autistic spectrum disorder and sensory modulation disorders, Frontiers in Integrative Neuroscience, Vol. 3, Article 29, 1-11

Teitelbaum, P., Teitelbaum, O., Nye, J., Fryman, J.& Mauer, R. (1998). Movement analysis in infancy may be useful for early diagnosis of autism. Psychology, 95:23, 13982-13987

Twachtman-Reilly, J., Amaral, S.C. & Zebrowski, P. P. (2008). Addressing feeding disorders in children on the autistic spectrum in school based settings: Physiological and behavioral issues. Language Speech and Hearing Services in Schools, 39, 261-272.

Volkert, V.M. & M Vaz, P.C. (2010). Recent studies on feeding problems in children with autism. Journal of Applied Behavioral Analysis, 43 (1), 155-159.

The Oral Motor Institute has recently published a new monograph by TalkTools® Instructors Robyn Merkel-Walsh MA, CCC-SLP and Lori L. Overland MS, CCC-SLP/NDT-C.

"SELF-LIMITED DIETS IN CHILDREN WITH A DIAGNOSIS OF AUTISM SPECTRUM DISORDERS"

ABSTRACT

The CDC (2014) reports, that Autism Spectrum Disorder (ASD) impacts 1 in 68 children in the United States. They also indicate that in “cluster” states such as New Jersey, as many as 1 in 28 boys are affected. Children with ASD often present with comorbid feeding issues. Studies show that up to seventy percent of children with ASD are selective eaters and up to ninety percent have feeding problems (Volkert & M Vaz, 2010). Researchers at Marcus Autism Center and the Department of Pediatrics at Emory University School of Medicine conducted a comprehensive meta-analysis of all published, peer-reviewed research relating to feeding problems and autism. Examination of dietary nutrients showed significantly lower intake of calcium and protein and a higher number of nutritional deficits overall among children with autism (Korschun & Edwards, 2013).

Researchers are exploring the possible causes of ASD, but thus far there are many theories regarding this complex disorder, ranging from genetics to autoimmune dysregulation (Merkel-Walsh, 2012). There is also debate regarding methods of treatment for children with autism. Applied Behavioral Analysis (ABA) has the most empirical research to date. Behavior analysis is a scientifically validated approach to understanding behavior and how it is affected by the environment (Autism Speaks, 2014). It has been endorsed by a number of state and federal agencies, including the U.S. Surgeon General and the New York State Department of Health. (Iovannone, Dunlap, Huber, & Kincaid , 2003). Research has shown that ABA therapy is effective at increasing appropriate behaviors and decreasing inappropriate behaviors (Kodak & Piazza, 2008). Therefore, it is reasonable to believe the principles on which ABA techniques are based can help with feeding issues (Volkert & M Vaz, 2010). The problem is that behavioral therapies however, do not often take into account the complexity of the sensory-motor system or medical issues, and how they relate to self-limited diets in children with ASD.

PURPOSE

This article explores 1) the sensory-motor system as it relates to feeding, 2) the importance of a thorough assessment; 3) biomedical treatment approaches for children with ASD, 4) Applied Behavioral Analysis (ABA) and its’ relevance when treating sensory-motor based feeding disorders in children with ASD.

METHOD

Numerous texts, journal articles, print articles, internet articles and clinical presentations were reviewed in order to collect information on the etiology, treatment and outcomes of feeding therapy for self-limited diets with children on the autism spectrum, who have comorbid feeding issues. The authors explored current research in speech - language pathology, biomedical and holistic medicine, nutrition, and Applied Behavioral Analysis (ABA). The authors also looked at case studies and the factors that may have influenced the diets of three children with ASD, who seemingly had behavioral issues, but when assessed presented with structural, medical and /or sensory-motor issues.

RESULTS

The authors found that self-limited diets are often not purely behavioral in nature, and there is a future need for more peer reviewed research on this topic.

[...]

Read the full monograph here.

------------------------------------

Robyn Merkel-Walsh, MA, CCC-SLP has specialized for over 21 years in Oral Placement and myofunctional disorders in children. She is employed by the Ridgefield Board of Education, runs a private practice in Ridgefield, NJ, is the board chair of the Oral Motor Institute, and is a member of the TalkTools® speakers bureau.

Meet her in Washington, DC May 14, 2016, in Syracuse, NY June 4, 2016, in Minneapolis, MN July 8-10, 2016. See our full Event Calendar here.

Lori Overland, MS, CCC-SLP is a speech and language pathologist with more than 35 years of professional experience. She specializes in dealing with the unique needs of infants, toddlers, pre-schoolers and school-aged children with oral sensory-motor, feeding and oral placement/speech disorders. In addition to her private practice, Lori is a member of the TalkTools® speakers bureau.

Good news! The American Academy of Private Practice in Speech Pathology and Audiology (AAPPSPA) has accepted a position statement TalkTools® Instructor Robyn Merkel-Walsh proposed on Oral Motor Therapy.

American Academy of Private Practice in Speech Pathology and Audiology (AAPPSPA) Position Statement - Oral-motor Therapy

Originally posted on AAPPSPA website.

By Robyn Merkel-Walsh, MA, CCC-SLP

Foreword:

In order to investigate Evidenced Based Practice in regards to oral-motor therapy, an AAPPSPA committee was formed. This Position Statement was written with input and editing from: Susan Arnold MS, CCC-SLP , Kaye Baumgardner MS, CCC-SLP/COM, Mary Billings MS, CCC-SLP/COM, Amanda Chastain MA, CCC-SLP, COM and Denise Dougherty MA, CCC-SLP.

Abstract:

The American Academy of Private Practice in Speech Pathology and Audiology (AAPPSPA) is a non-profit organization of speech and language pathologists (SLP) and audiologists who work in the private sector. Members of AAPPSPA foster the highest ideals and principles of private practice in speech pathology and audiology (AAPPSPA, 2015). Due to the continued controversy surrounding oral-motor therapy, the AAPPSPA board found it necessary to investigate this topic and forge a position statement. This position statement explores 1) defining Non-Speech Oral-Motor Exercises (NSOME), 2) defining Oral Placement Therapy (OPT), 3) understanding the difference between NSOME and OPT, 4) clinical implications for Evidenced Based Practice (EBP).

Discussion:

By analyzing AAPPSPA discussions, it is noted that many therapists in our organization supplement phonological and traditional models with oral-motor activities to help the patient achieve placement cues, especially for those individuals with muscle-based and motor-based diagnoses. Discussions involving NSOME, Myofunctional therapy, feeding and OPT can be frequently found in list-serve discussions. It was also noted, that not all AAPPSPA members were in support of oral-motor therapy due to lack of EBP; therefore this topic required further review. Clinicians who are a member of AAPPSPA must use EBP to decide if they want to reject the use of oral-motor and OPT based on the evidence, or look into the most appropriate treatment parameters based on the recipient of the treatment, and the diagnosis (Clark, 2005).

The ongoing question is whether or not oral-motor therapy is evidenced based. EBP according to the American Speech and Hearing Association is the integration of best research evidence with clinical expertise and patient values (ASHA, 2005). There is a misconception that EBP is limited to double-blind studies when in fact EBP is very centered on valuing feedback from the individual receiving treatment, and the clinical data collected in therapy. Not every method in the field of speech pathology has a large sampled, double blind study. For example, there is no proof that using a mirror aides in articulation therapy, but many therapists and patients report the value of mirror use when learning to imitate speech sounds. In addition, a single study can prove, that another study is not valuable. No single study has proven that oral-motor, OPT or Myofunctional therapy is an invalid or unethical therapy method.

Over the past decade, there has been an ongoing debate, through secondary research studies between those who do not support the use of Non-Speech Oral-motor Exercises (NSOME) (Bowen, 2005; Bowen , 2013; Lof, 2006; Lof, 2007; Lof, 2009 ), and those who support the use of Oral Placement Therapy (OPT) (Bathel, 2007; Bahr, 2008; Bahr & Johnson, 2010; Marshalla, 2007). Neither camp has large sampled double-blind studies to support their case; however, both sides of the debate have supported their hypothesis via secondary research such as literature review and surveys (Lof & Watson, 2005; Bahr, 2011.)

Oral-motor therapy is an umbrella term that leads to confusion (Bahr & Rosenfeld-Johnson, 2010.) Pre-feeding exercises, NSOME, Myofunctional therapy, strengthening exercises, swallowing exercises, oral imitation tasks and the use of oral speech tools were all being associated with the term oral-motor therapy (Marshalla, 2007). Thus far, there is no debate in the field of speech-language pathology that oral-motor exercises can prove positive results on disorders of feeding.

The term oral-motor therapy is in fact the appropriate term to describe exercises to strengthen the musculature, and regulate sensory-motor dysfunction for individuals who present with oral phase feeding disorders. This may include but is not limited to: dysarthria, Moebius syndrome, Down syndrome, Cerebral palsy, and Orofacial Myofunctional Disorders (OMD). SLPs involved in the treatment of oral-phase feeding disorders, have evidenced based support from sources such as: The International Journal of Orofacial Myology and the ASHA SIG13 committee publication Perspectives on Swallowing and Swallowing Disorders (Dysphagia). Numerous research articles have been dedicated to the use of oral-motor therapy in respect to the oral phase of feeding. In particular the relevance of oral sensory-motor function has been documented in the literature (Overland, 2010).

Over thirty-five years ago, the International Association of Orofacial Myology (IAOM) was formed, and has addressed the need for regulated educational opportunities and standardized college level credentialing of therapists to treat Orofacial Myofunctional Disorders (OMD) (Snow, 2015). Experts in Myofunctional therapy understand the connection between the airway, dentition and tongue posture, swallowing, and speech clarity. The Myofunctional Clinic of Bellevue has compiled an excellent list of EBP to support the use of Myofunctional therapy with a variety of individuals (Bellevue, 2015). Gommerman & Hodge produced a study analyzing the effectiveness of Myofunctional therapy and sibilant production and found that articulation therapy was achievable in only four therapy sessions after a tongue-thrust disorder was remediated in Myofunctional therapy (Gommerman & Hodge, 1995).

Clinicians, who represent the Board of Directors for the Oral-Motor Institute, have struggled with distinguishing oral-motor therapy, from the form of NSOME presented by Dr. Gregory Lof (Lof, 2008). The controversy in the field was causing much confusion; therefore, the term Oral Placement Disorder was coined by Diane Bahr and Sara Rosenfeld-Johnson in 2010 (Bahr & Rosenfeld-Johnson, 2010). The two practicing clinicians wanted to define that the therapeutic techniques being used to support speech sound productions were not the same types of activities that were suggested in the current literature, such as puffing air in the cheeks or tongue wagging (Lof, 2008). There is some misconception that speech-language pathologists (SLPs) who work on oral-motor issues, are not working on speech, and this is not the case (Merkel-Walsh & Bahr, 2014).

OPT, which is a form of tactile intervention, is used to create the standard placement for the targeted speech sound and is then immediately transitioned into direct work on that targeted speech sound (Marshalla, 2007). The major difference between NSOME and OPT noted, was that NSOME are movements which are not related to speech sounds, while OPT therapy only includes speech-like movements (Bahr & Rosenfeld-Johnson, 2010). OPT follows the principles of Van Riper’s Phonetic Placement Therapy (PPT), and uses tactile cueing to help individuals who cannot respond to visual-verbal treatment cues (Marshalla, 2008). Children with Oral Placement Disorders (OPD) cannot imitate targeted speech sounds using auditory and visual stimuli (ex. look, listen, and say what I say). They also cannot follow specific instructions to produce targeted speech sounds (e.g. put your lips together and say /m/). Although the term Oral Placement Disorder is new, the concepts surrounding the term have been discussed by a number of authors and clinicians (Green, Moore & Reilly, 2000; Pannbacker & Lass, 2002; Polmanteer & Fields, 2002; Pruett-Hayes, 2005).

Despite this clarification in 2010, there have been continued questions, and persistent confusion, as to what constitutes a NSOME, versus what is an OPT technique (Bahr & Rosenfeld-Johnson 2010). OPT is a tactile teaching technique used for children and adults with Oral Placement Disorders (e.g., dysarthria), who cannot learn standard speech sound production using auditory and visual teaching methods alone. OPT facilitates the pre-requisite skills in muscle control to develop dissociation and grading in the muscles of the abdomen, velum, jaw, lips and tongue for clients who cannot approximate the standard speech sounds using the instructions. If the client can produce standard speech using adequate placement and duration using only auditory and visual cueing, OPT would not be included in that client’s treatment plan (Merkel-Walsh, 2014).

OPT is a modern extension of Phonetic Placement Therapy (Van Riper, 1954) and The Feedback Model (Mysak, 1971). It is based on a very common sequence (Young and Hawk, 1955; Van Riper, 1978). Gregory Lof’s research has stated that the methods used in Van Riper’s Phonetic Placement Approach, are not in fact considered NSOME (Lof, 2009). Merkel-Walsh and RoyHill (2014) presented this concept at the ASHA Convention:

1) Facilitate speech movement with the assistance of a therapy tool (ex. horn, tongue depressor) or a tactile-kinesthetic facilitation technique (ex. PROMPT facial cue);

2) Facilitate speech movement without the therapy tool and/or tactile-kinesthetic technique (cue fading);

3) Immediately transition movement into speech with and without therapy tools and/or tactile-kinesthetic techniques.

Conclusion:

Based on literature review and analysis of current articles, journal entries, podcasts, texts and monographs, it is determined that it is important to explore current clinical techniques to determine what activities are considered ethical and meaningful to an individual seeking private based speech pathology services. Being both sides of the debate have equal evidence by way of primary and secondary research, it should therefore be AAPPSPA’s position that:

1) Oral-motor therapy is an acceptable treatment method for those individuals who present with disorders of strength and tone, oral-phase feeding deficits and/or Orofacial Myofunctional Disorders. This may include the oral-phase of feeding, oral resting posture, drooling, and overall appearance of the oral-facial musculature. Oral-motor therapy encompasses activities that target the improvement of strength, tone, dissociation and grading of the oral musculature and usually involves regulation of the oral sensorymotor system (Overland, 2010). Oral-motor therapy for strength, tone and the oral-phase of feeding and been accepted in the field without debate.

2) Oral Placement Therapy, a form on Phonetic Placement Therapy, is an acceptable form of treatment methodology for those individuals who do not progress from purely traditional or phonological methodology. The individuals may also present with disorders of muscle strength and tone (OPD), and cannot respond accurately to look at me and say what I say. This therapy utilizes the implementation of therapy tools, in order to provide tactile cues to shape oral placements into speech sound production (Bahr & Rosenfeld-Johnson, 2010; Marshalla, 2007). Once the individual can imitate the sound(s) through traditional methods, direct work on speech sound production should be implemented.

3) The combination of oral-motor therapy and Oral Placement Therapy may be presented concurrently. An individual may present with a comorbid diagnosis (e.g., low tone and an Orofacial Myofunctional Disorder) that requires implementation of both oral-motor and Oral Placement Therapy simultaneously.

4) Myofunctional therapy is an acceptable form of therapy for those patients who present with Orofacial Myofunctional Disorders. These patients may also present with articulation errors that do not resolve with traditional models of therapy. The connection between tongue placement, swallowing, dental alignment and sibilant production has been thoroughly supported by the International Association of Orofacial Myology. Clinical evidence has been documented repeatedly by active Orofacial Myologists to indicate direct correlation between remediation of Orofacial Myofunctional Disorders and persistent speech sound disorders.

References:

American Academy of Private Practice in Speech Pathology and Audiology (AAPPSPA). 2015. Retrieved from : http://www.aappspa.org/.

American Speech-Language-Hearing Association. (2005). Evidence-Based Practice in Communication Disorders [Position Statement]. Available from www.asha.org/policy.

Bathel, J. A. (2007). Current research in the field of oral-motor, muscle-based therapies: response to: Logic, theory and evidence against the use of non-speech oral-motor exercises to change speech sound productions by Gregory Lof. TalkTools, Charleston, SC.

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. Bahr, D., Rosenfeld-Johnson, S. (2010). Treatment of children with speech oral placement disorders (OPDs): a paradigm emerges. Communication Disorders Quarterly, XX(X), 108.

Bahr, D. (2011) . The oral-motor debate part I: understanding the problem. The Oral-Motor Institute. Available from www.oralmotorinstitute.org.

Bowen, C. (2005). What is the evidence for oral-motor therapy? Acquiring Knowledge in Speech, Language and Hearing, Speech Pathology, 7, 3, 144-147.

Bowen, C. (2013). Controversial practices and intervention for children with speech sound disorders. Retrieved from: http://www.speech-language-therapy.com/pdf/nsome2013.pdf

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

Gommerman, S. & Hodge, M.M. (1995). Effects of oral Myofunctional therapy on swallowing and sibilant production. International Journal of Orofacial Myology, 21:9-22.

Green, R., Moore, C. A., Reilly, K.J. (2000). The sequential development of jaw and lip control for speech. Journal of Speech, Language and Hearing Research, 45, 66-79.

Klein, E.S. (1996). Phonological/traditional approaches to articulation therapy: a retrospective group comparison. Language, Speech, and Hearing Services in Schools, 27, 314-323.

Lof, G. L., & Watson, M. (2005). Survey of universities ‘teaching: oral-motor exercises and other procedures. Poster presented at the annual meeting of the American Speech Language-Hearing Association, San Diego, CA.

Lof, G.L. (2006). Logic, theory and evidence against the use of non-speech oral-motor exercises to change speech sound productions. Invited presentation at the ASHA Annual Convention, Miami, FL. Nov. 17.

Lof, G.L. (2007). Reasons why non-speech oral-motor exercises should not be used for speech sound disorders. Presentation at the ASHA Annual Convention, Boston, MA. Nov. 17.

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

Lof, G.L. (2009). Nonspeech oral-motor exercises: an update on the controversy. Presentation at ASHA Annual Convention, New Orleans, LA

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

Merkel-Walsh, R. (2015). Conversations in speech pathology. Retrieved from: http://www.conversationsinspeech.com/.

Merkel-Walsh, R. (2014). Oral Placement to speech: transitioning muscle-memory into speech sound production. TalkTools. Charleston, SC.

Merkel-Walsh,R. & Roy-Hill, R. (2014). Using tactile techniques to improve speech clarity in children with childhood apraxia of speech. ASHA Annual Convention, Orlando, FL.

Merkel-Walsh, R. & Bahr, D. (2014). What evidenced based sensory-motor treatments are effective for speech disorders? Retrieved from: http://www.agesandstages.net/qadetail.php?id=31.

Mysak, E. (1971). Speech pathology and feedback therapy. Charles C. Thompson Publisher.

Overland, L. (2010). A sensory-motor approach to feeding. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 20, 3, 60-64.

Pannbacker, M., & Lass, N. (2002). The use of oral-motor therapy in speech-language pathology. Poster session presented at the annual meeting of the American Speech Language-Hearing Association, Atlanta, GA.

Polmanteer, K., & Fields, D. (2002). 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

Pruett-Hayes, S. (2005). Comparison of two treatments: Oral-motor and traditional articulation treatment. Poster session presented at the annual meeting of the American Speech Language-Hearing Association, San Diego, CA.

Snow, M. (2015, March 13). International Association of Orofacial Myology. Retrieved from IAOM: http://www.iaom.com/history.html

Van Riper, C. (1978). Speech Correction: Principles and Methods (6th Edition). Englewood Cliffs: Prentice-Hall.

Young, E. H., & Hawk, S. S. (1955). Moto-kinesthetic speech training. Stanford, CA: Stanford University Press.

By: Robyn Merkel-Walsh MA, CCC-SLP

Presentation of the Problem:

Individuals with Down syndrome are at risk for what is known as Orofacial Myofunctional Disorders or OMD. OMD can impact the oral phase of feeding, oral resting postures and oral placement skills for speech clarity. OMD issues require tactile therapies which include Myofunctional and Oral Placement Therapy (OPT). Myofunctional therapy and OPT are not the same as non-speech oral motor exercises. The purpose of this article is to differentiate the difference between non-speech movements and speech–like movements in treatment for individuals with Down syndrome, and to explore various types of tactile therapies that may help facilitate progress.

What Kind of Therapy Are We Talking About and Is It Evidenced Based?:

The ongoing question in the field of speech pathology is whether or not Oral Motor Therapy is evidenced based. Evidence Based Practice (EBP) according to the American Speech and Hearing Association is "the integration of best research evidence with clinical expertise and patient values" (ASHA, 2005). There is a misconception that EBP is limited to double-blind studies when in fact EBP is very centered on valuing feedback from the individual receiving treatment, and the clinical data collected in therapy. Not every method in the field of speech pathology has a large sampled, double blind study. For example, there is no proof that mirror aides in articulation therapy, but many therapists and patients report the value of mirror use when learning to imitate speech sounds. In addition, no one study can prove that another study is not valuable. No one study has proven that oral-motor, OPT or Myofunctional therapy is an invalid or unethical therapy method.

Another problem is that Oral Motor Therapy is a very general term that leads to confusion. Pre-feeding exercises, non-speech oral motor exercises, myofunctional therapy, strengthening exercises, swallowing exercises, oral imitation tasks and the use of oral speech tools were all being associated with the term Oral Motor Therapy. Though many therapists and parents see the clinical success of these therapies, there is still controversy in the field about the efficacy of these therapies. This is why in 2010 Diane Bahr and Sara Rosenfeld-Johnson wrote a landmark article in Communications Quarterly, outlining the difference between non-speech oral motor exercises (NSOME) and OPT. The major difference noted, was that NSOME are movements which are not related to speech sounds, while OPT therapy only includes speech-like movements (Bahr  & Rosenfeld-Johnson, 2010). OPT follows the principles of Van Riper’s Phonetic Placement Therapy (PPT), and uses tactile cueing to help individuals who cannot respond to visual-verbal treatment cues (Marshalla, 2008).  The use of therapy tools in speech pathology is certainly not new according to Pam Marshalla (2012) , and therapists admit that even after hearing that oral-motor exercises may not have research to support their use, they still use them in practice  (Bahr, 2011).

Over thirty-five years ago, The International Association of Orofacial Myology (IAOM) was formed, and has addressed the need for regulated educational opportunities and standardized college level credentialing of therapists to treat OMD (Snow, 2015). Experts in myofunctional therapy understand the connection between the airway, dentition, and tongue posture, swallowing and speech clarity. The Myofunctional Clinic of Bellevue has compiled an excellent list of EBP  to support the use of myofunctional therapy with a variety of individuals (Bellevue, 2015). Gommerman & Hodge produced a study analyzing the effectiveness of myofunctional therapy and sibilant production and found that articulation therapy was achievable in only four therapy sessions after a tongue-thrust disorder was remediated in myofunctional therapy (Gommerman & Hodge, 1995).

Oral-motor therapy has never been debated in cases of oral phase dysphagia or for tongue-thrust disorders; therefore it seems questionable that some experts in the field continuously debate the ethics and efficacy of these practices, especially in the Down syndrome populations, where we can predict issues with OMD. For example, Caroline Bowen has a publication on her website indicating that NSOME are unnecessary for children with Down syndrome (Bowen, 2015). The rationale is that to gain speech, speech must be worked on. There is some misconception that speech-language pathologists (SLPs) who work on OMD issues are not working on speech, and this is not the case (Merkel-Walsh & Bahr,  2014).

The Importance Of Treating Orofacial Myofunctional Disorders in Down Syndrome:

When a baby is born with Down syndrome, there are some factors we assume to be true about craniofacial development, feeding and swallowing. In 1997, Sara Rosenfeld-Johnson identified the myths of Down syndrome. This included: a high narrow palatal vault, (Myth #1), tongue protrusion (#2), mild to moderate conductive hearing loss (#3), chronic upper respiratory infections (#4), mouth breathing (#5), habitual open mouth posture (#6), and finally, the impression that the child's tongue is too big for its mouth (#7) (Rosenfeld-Johnson, 1997). The reason Sara referred to these issues as myths, is because clinical evidence suggests that these issues can be prevented and/or improved by therapeutic intervention. For example, Sara Rosenfeld-Johnson presented case studies at the American Speech and Hearing Association annual convention, highlighting improvements in an adult patient with Down syndrome with one month of OPT (Rosenfeld-Johnson,  2014).

Despite the myths, clinicians are often faced with a variety of orofacial myofunctional challenges when treating individuals with Down syndrome. This includes but is not limited to: poor speech intelligibility, tongue thrusting, bruxing / teeth grinding, oral-phase feeding deficits and inappropriate oral habits (Bahr , 2001). It is important to treat these issues in conjunction with language-based speech therapy.

Since there is some confusion regarding terminology, it is important to understand various types of OMD therapies.  We can categorize therapeutic interventions into four categories:

• Pre-feeding/Oral Sensory-Motor Therapy: These are exercises introduced to improve jaw, lip, and tongue movements as a prerequisite for safe, effective nutritive feedings. A pre-feeding plan is always one step ahead of a feeding plan. For example, if the goal is spoon feeding, the infant is receiving the primary source of nutrition from the breast and/or bottle, while the therapist works on the sensory-motor skills needed for spoon feeding  (Overland & Merkel-Walsh, 2013). It is important to understand the oral-motor developmental hierarchy and age related normative data when designing a pre-feeding treatment plan.
• Feeding Therapy : Therapeutic feeding may focus on the oral phase of feeding, and/or the pharyngeal phase of feeding. Feeding therapy involves manipulation of the placement of food in the mouth, designing the tastes, temperatures and tastes to work with, and is always considerate of safety. Feeding therapy often involves the choice of therapeutic feeding equipment, including adaptive seating, as well as therapeutic spoons, cups, forks, and straws (Overland & Merkel-Walsh, 2013).
• Oral Placement Therapy: OPT does not include NSOME. OPT is a specific therapy which involves tactile cueing in order to facilitate the articulatory postures required for precise speech sound production. OPT follows the principles of Van Riper’s Phonetic Placement Therapy in which: a therapist facilitates an oral posture with a therapy tool, drills this posture through repetition, and slowly fades out the tactile cue once the individual can produce the sound accurately (Bahr D. & Rosenfeld-Johnson, 2010).
• Myofunctional Therapy: Joy Moeller, a dental hygenist who specializes in myofunctional disorders, defines this therapy as a program used to correct the improper function of the tongue and facial muscles used at rest, for chewing and for swallowing (Moeller, 2008). Myofunctional therapy is essentially a combination of pre-feeding, feeding, and OPT. Dentists, lactation consultants, otolaryngologists, dental hygienists and SLPs treat myofunctional disorders. Myofunctional therapy often involves a hierarchy of exercises, which helps an individual simultaneously correct oral-rest posture, oral habits (e.g. thumb sucking) swallowing and speech sound production (Merkel, 2002).

Individuals with Down syndrome often may require all four types of tactile therapies, since they may often present with feeding and speech issues. The problem remains, that many universities are not teaching these methods to clinicians, and families are struggling to find the services (Pierce & Taylor, 2002). In order to understand how these therapies can facilitate improvement, let’s look at some orofacial myofunctional issues associated with Down syndrome:

 

PROBLEM	Activity	Tactile Intervention
Low jaw posture and tongue protrusion during oral rest posture	Therapist can work on facilitation of lip closure by placing a Jiggler tool in between the lips to facilitate lip closure. (Overland & Merkel-Walsh, 2013).	Pre-feeding
Reversed swallowing pattern/tongue thrust	Therapist engages client in therapeutic straw drinking   to facilitate jaw stability, lip rounding and tongue retraction. (Rosenfeld-Johnson S.  2009).	Feeding Myofunctional
Teeth grinding	Therapist uses appropriate biting activities, chewing, appropriate mouthing activities, and massage techniques (Bahr, 2001). Therapist implements a gum chewing program to facilitate an appropriate replacement for teeth grinding (Rosenfeld-Johnson, 2009).	Pre-feeding Feeding Myofunctional
Interdental lisp	Therapist implements activities to superimpose lip closure with tongue retraction in order to improve strength and dissociation of the musculature, such as therapeutic horn and bubble blowing (Rosenfeld-Johnson, 2009; Merkel, 2002). The tools will be faded when the oral placement skill is achieved and the individual can produce the target sound without the use of the tactile cue/tool.	OPT Myofunctional

 

Conclusions:

Individuals with Down syndrome may present with orofacial myofunctional challenges. While some therapists argue that non-speech oral motor exercises are not appropriate for these individuals, experts in tactile therapies have worked diligently to differentiate NSOME from OPT. Evidenced Based Practice is not limited to double blind studies and includes client feedback and therapeutic outcomes. Experts in OMD have provided evidence over the years to support the use of tactile therapies, and the relationship between swallowing and speech. Practicing clinicians are providing more case studies in the research base and most importantly, individuals who have engaged in OPT have positive reports of progress. There is no doubt that more studies need to be performed, and experts in OPT are hopeful to have more support from universities to perform larger group studies.

Robyn Merkel-Walsh MA, CCC-SLP is a speech-language pathologist with over 20 years’ experience devoted to oral motor, feeding and OPT. She works full time for the Ridgefield Board of Education, in addition to her private practice and affiliation as a lecturer for TalkTools®. Robyn is the Acting Chair of the Oral Motor Institute and has recently presented a poster session at the ASHA convention. You may contact Robyn at robynslp95@aol.com.    

 

Bibliography

ASHA (2005). Evidence-based practice in communication disorders [Position Statement]. Retrieved from asha.org: http://www.asha.org/policy/PS2005-00221/

Bahr, D. & Rosenfeld-Johnson (2010). Treatment of Children With Speech Oral Placement Disorders (OPDs): A Paradigm Emerges. Communications Quarterly, vol. 31 no. 3 131-138 .

Bahr, D. (2001). Nobody Evert Told Me (or my mother) That ! Arlington, TX: Sensory World.

Bahr, D. (2011, September). The Oral Motor Institute. Retrieved from The Oral-Motor Debate Part I: Understanding the Problem: www.oralmotorinstitute.org/mons/v3n1_bahr.html

Bellevue, M. C. (2015, March ). Studies showing efficacy of orofacial myofunctional therapy. Retrieved from Myofunctional Clinic of Bellvue: http://myofunctional.com/internal/resources.html

Bowen, C. (2015, January 13). Controversial Practices in Children's Speech Sound Disorders - Oral Motor Exercises, Dietary Supplements, Auditory Integration Training . Retrieved from Speech-Language Therapy.com: http://www.speech-language-therapy.com/index.php?option=com_content&view=article&id=28:controversy&catid=11:admin&Itemid=122http://

Gommerman, S.  & Hodge, M.M.  (1995). Effects of oral myofunctional therapy on swallowing and sibliant production. International Journal of Orofacial Myology, 21:9-22.

Marshalla, P. (2008, April). Oral Motor TReatment VS. Non-Speech Oral Motor Exercises:Historical Clinical Evidence of "Twenty-two Fundamental Methods". Retrieved from The Oral Motor Institute.: www.oralmotorinstitute.org/mons/v2n2_marshalla.html

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. . Retrieved from oralmotorinstitute.org: www.oralmotorinstitute.org/mons/v4n2_marshalla.html

Merkel, R. (2002). Systematic Intervention for Lingual Elevation . Tucson, AZ: TalkTools.

Merkel-Walsh, R. & Bahr, D.  (2014). Ages & Stages. Retrieved from What evidence-based, oral sensory-motor treatments are effective for speech disorders?: http://www.agesandstages.net/qadetail.php?id=31

Moeller, J. (2008). What is myofunctional therapy ? Retrieved from myofunctional-therapy.com: http://www.myofunctional-therapy.com/what-is-myofunctional-therapy.html

Overland, L. & Merkel-Walsh (2013). A Sensory -Motor Approach to Feeding. Charleston, SC: Talk Tools.

Pierce, R. & Taylor, P. (2002). Rationale for including orofacial myofunctional therapy in university training programs. International Journal of Orofacial Myology., 24-34.

Rosenfeld-Johnson, S. (1997). The Oral-Motor Myths of Down Syndrome. Advance Magazine for Speech-Language Pathologists.

Rosenfeld-Johnson, S. (2009). Oral Placement Therapy for Speech Clarity and Feeding. Charleston, SC: TalkTools.

Rosenfeld-Johnson, S. (2014). Using Tactile Cues to improve speech clarity in the adult rehabilitative setting. ASHA Convention. Orlando , FL: TalkTools. Retrieved from Talk Tools.

Snow, M. (2015, March 13). International Association of Orofacial Myology. Retrieved from IAOM: http://www.iaom.com/history.html