This presentation is going to be held at the Texas Speech-Language & Hearing Association 2017 Annual Convention, Thursday. Feb. 23, noon-1:30 p.m.

Author: Renee Roy Hill, MS, CCC-SLP

Abstract:

Discuss treatment of clients diagnosed with apraxia of speech and related motor speech disorders. Explore 1) Childhood Apraxia of Speech 2) Related Motor Speech Disorders 3) Van Riper’s Phonetic Placement Approach 4) the importance of tactile and proprioception in shaping speech movements for speech, 5) shaping placement of the articulators using tools.

Learning outcomes: 

1. Participants will be able to list at least three characteristics of Childhood Apraxia of Speech and Dysarthria.
2. Participants will be able to list at least two goals of a tactile treatment approach.
3. Participants will be able to implement three phonetic placement methods.

Summary: 

Children with motor based speech disorders such as Dysarthria and Childhood Apraxia of Speech (CAS) present with a speech sound disorder in which precision and consistency of movements underlying speech are impaired. CAS may impact both non-speech and speech movements. CAS may also coexist with disorders of muscle strength and tone such as dysarthria. As infants and toddlers, children with CAS may have limited babbling, limited expression, but seemingly typical receptive skills. Older children with CAS may have poor oral imitation skills, erratic speech sound errors, and lack of a verse phonemic repertoire (Kaufman 2013).  Unfortunately, there is no specific, validated list of diagnostic features of CAS which differentiates this disorder from other types of speech sound disorders (ASHA, 2007), however the research is emerging. 

This presentation will attempt to identify key diagnostic features of both CAS and Dysarthria and discuss when Oral Placement Therapy (OPT) may be beneficial.  While it is always the goal to work on verbal output and speech production, some children with CAS have such severe motor planning issues, or co-morbid muscle based issues that they are non-verbal, or have very limited verbal output. Tactile cueing techniques such as PROMPT (Grigos,2010), or The Kaufman Speech Praxis Therapy (Kaufman, 2007) may prove positive results for some children; however others may need even more work on the sensory-motor system to gain foundational skills necessary for speech (Kaufman, 2007). Kaufman suggests that in order for these therapies to be successful, the child must be able to imitate, sit and attend, and execute gross motor movements on command. In addition, oral motor weakness should not be the primary disorder. For these children, sensory integration, oral motor stretching and toning and speech sound shaping may be needed (Kaufman 2007). There is no question that working on oral-motor skills should not be done is isolation of speech production when dealing with apraxia (Marshalla, 2000), but rather as Oral Placement Therapy (OPT) which is a term suggested by Bahr and Rosenfeld Johnson (2010.)

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 (Bahr 2001, Crary 1993, Hayden 2004, Marshalla 2004, Rosenfeld Johnson 1999, 2009, Young and Hawk 1955):   

• Facilitate speech movement with the assistance of a therapy tool (ex. horn, tongue depressor) or a tactile-kinesthetic facilitation technique (ex. PROMPT facial cue);
• Facilitate speech movement without the therapy tool and/or tactile-kinesthetic technique (cue fading);
• Immediately transition movement into speech with and without therapy tools and/or tactile-kinesthetic techniques.

For children with motor speech disorders, this sequence can be helpful if the child cannot form the necessary placement of the articulators to produce sounds. Repetition and reinforcement is helpful based on motor learning theory (Hammer, 2007; Mysak 1971.) To improve speech, one must work on speech (Jakielski, 2007); however one must consider those children who have very limited verbal output (Merkel-Walsh, 2012).

The concept of “bridging” which is movement to speech based on muscle memory is an effective therapy technique (Roy-Hill, 2013). For example if a child has limited lip rounding to produce a /w/ , blowing bubbles can be used to reinforce lip rounding through tactile cueing, and as soon as movement is noted the tool is faded (Van Riper 1958) and speech sound drills can begin.

Clinicians must use evidenced based practice (EBP) to determine therapeutic treatment (ASHA, 2005). It is important to remember that EBP is not only limited to double blind studies, but 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 (ASHA, 2007). Client progress and clinical data are important factors when determining treatment, and certainly the Phonetic Placement Approach (Van Riper , 1957) has been widely documented in the field of speech pathology. In addition, sensory-motor and oral tactile teaching techniques have clinical data to support their use (Bathel, 2007; Bahr & Rosenfeld-Johnson, 2010). Through muscle and motor based placement skills , therapists can effectively improve speech clarity in children who present with CAS. 

References:

American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech [Technical report] available from www.asha.org/policy

Bahr, D., Rosenfeld-Johnson, S. (2010). Treatment of Children With Speech Oral Placement Disorders (OPDs): A Paradigm Emerges. Communication Disorders Quarterly, XX(X), 108.

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.

Roy-Hill, R. (2013). A Sensory-Motor Approach to Apraxia of Speech and Related Motor Speech Disorders [Live presentation].

Van Riper, C. (1958, 1954, 1947) Speech Correction: Principles and Methods. Englewood Cliffs: Prentice-Hall.

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.

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 & Sara Rosenfeld-Johnson, MS, CCC-SLP This poster was presented at the 2015 annual ASHA Convention, Session #9333, Poster Board #602.

INTRODUCTION

Presentation explores 1) defining Non-Speech Oral Motor Exercises, 2) defining Oral Placement Therapy, 3) understanding the difference between NSOME and OPT, 4) clinical implications for Evidenced Based Practice.

Two widely used models of articulation therapy include the traditional and phonological models (Bowen, 2005). While studies suggest that the phonological model may prove more positive results than the traditional model (Klein, 1996), Van Riper’s Phonetic Placement Approach may be more useful for individuals who are not be able to achieve placement cues (Van Riper, 1978). Many therapists supplement phonological and traditional models with oral motor activities to help achieve placement cues, especially for those individuals with muscle-based and motor-based diagnoses (Marshalla, 2007). 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) and those who support the use of Oral Placement Therapy (OPT). Neither camp has large sampled double-blind studies to support their case; however, both sides of the debate have supported their hypothesis via literature review and surveys (Bahr & Rosenfeld-Johnson, 2010; Lof & Watson, 2005).  

LEARNER OUTCOMES

1. Participants will be able to differentiate a NSOME from an OPT technique.

2. Participants will be able to define the three stages of a phonetic placement cue.

3. Participants will be able to use at least three oral placement cues in order to facilitate speech movements.  

DISCUSSION

NSOME are movements which are not related to speech sounds, while OPT therapy only includes speech-like movements. 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. Children with Oral Placement Disorder (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 (Bahr & Rosenfeld-Johnson, 2010). OPT facilitates the muscle placement to produce the targeted standard speech sound. If the client can produce standard speech using adequate placement and endurance using only auditory and visual cueing, OPT would not be included in that client’s treatment plan.

OPT is a modern extension of Phonetic Placement Therapy (PPT) as taught by Van Riper (1978) and follows The Feedback Model by Mysak (1971). It is based on a very common sequence:

1. Facilitate speech movement with the assistance of a therapy tool (ex. horn, tongue depressor);

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.  

NSOME	OPT
As quoted from Dr. Gregory Lof in 2006:"No speech sound requires the tongue tip to be elevated toward the nose; no sound is produced by puffing out the cheeks; no sound is produced in the same way as blowing is produced. Oral movements that are irrelevant to speech movements will not be effective as speech therapy techniques."	Puffing air in cheeks during blowing is not used in OPT.Abdominal grading for phonatory control, jaw stability and jaw-lip-tongue dissociation are important for speech sound production.The use of a therapeutic horn can help shape the articulators into the placements required for the bilabial sounds /m, b, p/. That tool is quickly faded once the individual has the muscle-memory skill to produce the correct oral placement without the tool in the mouth.
As quoted from Dr. Gregory Lof in 2003:"There is no relevance to the end product of speaking by using an exercise of tongue wagging, because there are no speech sounds that require tongue wagging."	This movement is not related to speech so should not be used in speech therapy sessions. Tongue wagging is not used in OPT.Stimulation of the lateral margins of the tongue with vibration, elicits elongation of the tongue and can assist in creating the tongue tip tension needed to elevate the tip to the incisive papillae for / n, t, d, l /.
As quoted from Dr. Gregory Lof in 2009:"NSOME encourages gross and exaggerated range of motion, not small, coordinated movements that are required for talking."	OPT only works on small, coordinated movements that are similar to speech.Blowing a bubble with appropriate placement of the articulators assists with lip rounding using the correct jaw posture for the high jaw vowels /w/, /u/ and /o/. We immediately practice those sounds without the therapy tool as per Van Riper’s PPT.

Clinical data supports the relationship between OPT and speech clarity. The graph below reflects data collected from sessions with a 6 year old male with labial paresis. Lip closure on a flat-mouthed horn and bilabial production progress were monitored. When lip closure on the horn improved so did bilabial production. In sessions where lip closure was not as positive bilabial clarity decreased.

CONCLUSION

Dr. 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). It is important to explore current clinical techniques to determine what activities are considered unrelated to speech production, as opposed to those activities that in fact are an extension of Phonetic Placement Therapy (Marshalla, 2007). If therapists understand the current debate, and that a NSOME is not the same as OPT; there would be less confusion amongst professionals in regard to evidence based practices when working towards improved speech clarity. Clinicians must use EBP to decide if they want to reject the use of a therapy technique based on the evidence, and look into the most appropriate treatment parameters based on the recipient of the treatment, and the diagnosis (ASHA, 2005). This new understanding of how OPT is used to create the standard placement for speech production would then encourage university-based researchers to explore why practicing SLPs report they use this therapy with good results. The next step would be large sample, double blind studies that would definitively address the use of OPT for clients with muscle-based speech clarity disorders.

REFERENCES

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

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

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

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. (2003). Oral motor exercises and treatment outcomes. SIG 1 Perspectives on Language Learning and Education, Vol. 10, 7-11.

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. (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.

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

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.

Recently, TalkTools® Presenter Robyn Merkel-Walsh, MA, CCC-SLP joined Jeff Stepen, MS, CCC-SLP on his podcast, Conversations in Speech Pathology. In the podcast, Robyn discusses common misconceptions about Oral Placement Therapy (OPT). Click below to listen to the podcast.

We encourage everyone to add their thoughts for discussion in the comments section on the Conversations in Speech Pathology page.