This is a repost from Dean Trout’s Little Shop of SLP, with permission from the author.

Upon reaching out to her for permission, here's what Dean wrote: "I found TalkTools to be great for oral awareness and teaching segmentation of articulators!"

Dean Trout worked for 31 years as a Speech Therapist in the public school system and for 4 years in her own speech clinic. She started 2 Gals Speech Products, LLC in 2007, spoke at several speech conferences and have been published in the ASHA Leader. Today she creates tangible things that she sells in her Etsy store as well as digital downloads in her TpT store. "For you who are new to the field of SLP, I want to give tips and tricks to make your therapy more effective. ... For you more mature SLPs I want you to feel comfortable with technology and social media." 

April 10, 2017

I have often felt baffled as to why kids cannot produce /k/ when developmentally we make posterior sounds before anterior. Think about it, a baby’s first sounds are goo-goo and ga-ga, so isn’t /k/ just a naturally developing response? It makes me go, hmmm. Luckily there are several ways to go about teaching this sound. These tips are not in any particular order, so don’t think Tip #1 is the best. All these tips have been used successfully by several of my colleagues and me.  Please remember what works with one child does not always work with another. We are simply sharing some ideas of things to try.

This tip is not EBP and I am not trying to pass it off as such.  I am just sharing an out of the box idea for when all else has failed.  In my many years of practice, I have found that the major reason a child cannot imitate a sound from our model and demonstration is simply that they don’t understand what we are telling them to do. They just don’t “get it.” It also seems that they more often than not just don’t get it when we try to show and explain how to do those sounds that are made in the back of our mouths: /k/, /g/, /r/. So to help them “get it” I try to relate the sound to something to which they are familiar. Most all of us have eaten popcorn and don’t we all, at times, get a husk caught on the back of our tongue and have to clear it out? That is what I use to help them understand what I mean by the back of the mouth or back of the tongue, etc. Every child I have had in therapy can show me with 100% accuracy where the front and back of the mouth is located on a drawing and can point to the front and back of their own mouths, but yet cannot put their own tongues there. To teach them how to find and lift the back of their tongues, we practice that horrible hacky-growly guttural sound we make when clearing out the popcorn. We do this until I feel they fully understand what I mean when I say use the back of your tongue. Once they “get it” you can shape it into a beautiful /k/ in isolation and begin your regular therapy. If they forget to get their tongue up when drilling syllables or words, just cue with “clear out the popcorn.”

If you really want to be the fun “speech teacher” why not bring some popcorn to eat in therapy? Just check for food allergies first ;)

TIP#2 Cereal

You can also get correct tongue positioning for /k/ using cereal-Cheerios or Fruit Loops. This approach is taught by Sara Rosenfeld-Johnson in her Talk Tools program. Basically, what you do is place the cereal behind the bottom front teeth and have the child place the tip of his tongue in the cereal hole and hold it there to keep the tip down while making the /k/ using the back of the tongue. This technique is explained in detail in the Talk Tools program. Here is the link to the website. http://www.talktools.com/ I highly recommend you learn how to implement this technique because it is effective. It is great for kids who front the back sounds and need the tactile cueing.

TIP #3 Tactile Cues—Holding the Tip and Blade

For years I have had kids to use their own finger to hold the tongue tip down to get the correct position for /k/ when they were substituting /t/ for/k/. Many times they will have to not just hold the tip but the tongue blade as well. You can start out with them holding only the tip down while they say /k/, but if they start making the /k/ with the blade of their tongue mid palate you will have to have them hold more of the tongue down and push the tongue further back in their mouths. This has been exceptionally effective at achieving a good /k/ sound. Many people do not like this approach, but if it works then I say use it. I have had some kids who have had to use their finger to hold their tongue down not only in isolation but through syllable and even a few into words (gasp)! However, never fear, I have never had a kid graduate from speech therapy and still have their finger in their mouth!! I never ask them to quit using their finger. They eventually get tired of using it and stop on their own. Don’t you think we sometimes worry too much about the little things?

When implementing this strategy if you are the one holding the child’s tongue via your own gloved hand, finger cot, or tongue depressor be careful of a hyper gag reflex. If you find a child with a hyper gag, you have two choices: 1) desensitize the gag reflex or 2) don’t use this approach. If the child can tolerate you inside his mouth a nice little tip is to use flavored toothpaste on a dental swab. It is just less invasive tasting.

TIP# 4 Use Gravity

Some children need a little more help learning to elevate the back of their tongue, and gravity helps! There are suggestions to have the children let their head lean over the back of their chair or have them lie on the floor. Personally, I have had no success with using the chair technique. I have had success doing therapy while the child is lying on his/her back on the floor. Initially, I just have the child lie on his back on the floor and do some deep breathing exercises to help him relax. I will sometimes lay a book on his stomach for this. They can see the book rise and fall as they breathe. After the child looks relaxed and at ease with lying on the floor, I begin therapy using the other techniques explained in this article. The one that seems to work the best is using tactile cues. I will start with a tongue blade and gently “push” the tongue tip down toward the back of the mouth. If this doesn’t work, I try having the child “cough” really hard, (similar to the clearing of the throat.) Usually, this combination of techniques works within one to two sessions, and we can go back to sitting in our chairs for therapy.

TIP#5 Getting Tongue Retraction

You cannot produce a /k/ without your tongue retracting back into the mouth. To achieve a tongue retraction response, stimulate midline of the tongue from anterior to posterior with a tongue depressor or your gloved finger. Pam Marshalla explains this very well on the websitehttps://pammarshalla.com/stimulating-tongue-back-elevation-for-k-and-g/

I suppose this sums up every tip and trick we have up our sleeves. Hopefully, this has affirmed that what you’re doing is right or maybe even got you to thinking it is ok to try something off the wall in therapy.  I am all for Evidence-Based Practice but sometimes when all else has failed you must try something unique.  It just might work for this particular student.  

I will not discuss or debate EPB, so no need to leave heated comments. 

NOTE: This article has been reprinted with permission from Diane Bahr of Ages and Stage®, LLC and Robyn Merkel Walsh.

Robyn Merkel-Walsh, MA, CCC-SLP & Diane Bahr, MS, CCC-SLP, CIMI

EVIDENCE-BASED PRACTICE (EBP) IN SPEECH-LANGUAGE PATHOLOGY

According to the American Speech, Language, and Hearing Association (ASHA, 2005) “the term evidence-based practice [EBP] refers to 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.” Note that this approach to treatment encompasses practitioner expertise and client preferences in addition to high-quality research. In June 2011, Dr. Paul Rao (ASHA’s president at the time) said, “EBP is not about identifying the one best approach – it is about deciding which among the many acceptable options is likely to work best for a particular individual.” So, we are going to talk about acceptable oral sensory-motor treatment for speech disorders.

THE TRUTH ABOUT ORAL-SENSORY MOTOR TREATMENT FOR SPEECH DISORDERS

For many years, it was rumored that oral sensory-motor treatment was ineffective for treating the sensory-motor process of speech. Therefore, the Oral Motor Institute (OMI) was formed “to publish monographs that demonstrate the evidence base of oral sensory and motor techniques for articulation, motor speech, and feeding treatment” (Oral Motor Institute, n.d.). The OMI conducted a thorough and systematic review of the claim that oral sensory-motor treatment was ineffective in the treatment of speech problems. This process included extensive journal literature review (Bahr, 2008; Bahr, 2011, Sept.; Bahr, 2011, Nov.; Bahr & Banford, 2012) and textbook review (Marshalla, 2007, 2008, & 2012) which revealed:

• There are effective oral sensory-motor treatments for speech disorders
• There is a large body of journal and textbook literature regarding oral sensory-motor treatments for speech disorders
• ASHA supports research that provides evidence on the efficacy of oral sensory-motor treatments for speech disorders
• Oral Placement Therapy (OPT) and Phonetic Placement Therapy (PPT) are forms of oral sensory-motor treatment for speech disorders
• OPT and PPT are not the same as Non-Speech Oral-Motor Exercise (NSOME)

ORAL PLACEMENT THERAPY (OPT) AND PHONETIC PLACEMENT THERAPY (PPT)

The relatively new term Oral Placement Therapy (OPT) coined by Sara Rosenfeld-Johnson (2009) seems to be an updated version of the historical term Phonetic Placement Therapy (PPT). Both OPT and PPT use touch, movement, and tools (which include hands) to help a client attain actual speech sound production. These techniques are used when “look, listen, and do as I say” methods do not work. For example, graded sizes of Bite Blocks have been effectively used to help clients establish appropriate jaw heights as they simultaneously learn to produce front vowels and various consonant sounds (Sacks, Flipsen, & Neils-Strunjas; Bahr & Rosenfeld-Johnson, 2010; Crary, 1993, p. 224). Progressive Jaw Closure Tubes have been used to teach appropriate jaw heights and lip-rounding for back vowels as clients simultaneously learn to produce these speech sounds.

Van Riper, “a founding father of modern speech-language pathology,” described the history and use of PPT in 1954:

For centuries, speech correctionists have used diagrams, applicators, and instruments to ensure appropriate tongue, jaw, and lip placement [for speech sound production].... [These] phonetic placement methods are indispensable tools in the speech correctionist's kit…. Every available device should be used to make the student understand clearly what positions of tongue, jaw, and lips are to be assumed (Van Riper, 1954, pp. 236-238).

In fact, there are many forms of PPT that have been used since the inception of speech-language pathology (Marshalla, 2007, 2012). Currently, OPT and PPT are taught by Sara Rosenfeld-Johnson (2009) and Pamela Marshalla (Marshalla, 2008). However, other forms of this type of treatment include Dynamic Temporal and Tactile Cueing (DTTC), motokinesthetics, palatometry, Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT), and ultrasound imaging (Bahr & Rosenfeld-Johnson, 2010).

OPT AND PPT ARE NOT NSOME (Non-Speech Oral-Motor Exercise)

By definition NSOME (Lof & Watson, 2008, p. 394) is “any technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities” such as unrelated cheek puffing and tongue wagging. By definition OPT and PPT use touch, movement, and tools (including hands) to attain actual speech sound production. Some OPT and PPT strategies may incorporate oral, vocal, and respiratory exercise as part of treatment (when needed), but each target is a component of actual speech production.

While confused at times in the literature and perhaps in practice, OPT/PPT and NSOME are distinct entities (Bahr & Rosenfeld-Johnson, 2010; Marshalla, 2008). In OPT and PPT, a sequenced and coordinated skill set for speech production is broken down into simpler steps and then combined into the final goal (i.e., the fine-motor function of speech). Similar approaches are used in the fields of occupational and physical therapy. This is a very different process than NSOME which addresses general muscle function (if properly applied) but not speech production.

NSOME has a place in treatment. Across the literature, there seems to be general agreement that NSOME is useful for individuals with muscle function disorders (e.g., those with Down syndrome, cerebral palsy, Parkinson’s disease, etc.) in improving overall muscle function. These individuals have muscle weakness and movement problems throughout the body, and “what you see in the body is what you get in the mouth” (Overland & Merkel-Walsh, 2013, p. 73). When NSOME is used to improve general muscle function, it must be carefully chosen and systematically applied. For example, Ruscello (2008b, p. 294) stated that “there is…a small subset of clients [with velopharyngeal insufficiency] who may improve with treatment using muscle rehabilitation procedures that are task specific to speech.”

Ruscello (2008a, p. 386) also said, “It should be noted that childhood speech disorders caused by neuromuscular deficits…need to be treated accordingly.” In their survey, Lof and Watson (2008, p. 396) found that speech-language pathologists primarily used NSOMEs with children who exhibited motor speech disorders. With the exception of Childhood Apraxia of Speech, children with motor speech disorders usually have generalized muscle function problems.

While McCauley, Strand, Lof, Schooling, and Frymark (2009, p. 343) found “insufficient evidence to support or refute the use of OMEs [oral motor exercises] to produce effects on speech,” researcher Christopher Moore and his colleagues have repeatedly demonstrated (via electromyography) that the neural mechanisms and subsequent motor plans/gestures for speech and non-speech activities are different from one another (Bahr & Banford, 2012). Therefore, NSOME alone is unlikely to improve speech unless it is used with actual speech production techniques. This concept is consistent with OPT and PPT which work on actual speech production through task analysis and successive approximations when properly applied.

THE IMPORTANCE OF WORKING WITH A TRAINED PROFESSIONAL

When selecting appropriate speech treatment for an individual, it is important to be educated about the treatment whether you are a family member or a professional. The treatment needs to be evidence-based, and the therapist supplying the treatment must be properly trained.

Family members can look for professionals specifically trained in OPT and PPT. While it would be ideal if these techniques were taught at the undergraduate and graduate levels, most of this training occurs at the post-graduate level (Bahr & Banford, 2012). So, family members can look for speech-language pathologists trained in DTTC, motokinesthetics, OPT, PPT, PROMPT, ultrasound imaging for speech, palatometry, and similar “hands-on” treatments.

In thinking back to Dr. Rao’s 2011 statement: “EBP is not about identifying the one best approach – it is about deciding which among the many acceptable options is likely to work best for a particular individual.” Both OPT and PPT are viable options for speech treatment when properly implemented. Forms of PPT been used since the inception of speech-language pathology practice.

REFERENCES

American Speech-Language-Hearing Association. (2005). Evidence-based practice in communication disorders [Position Statement]. Available from www.asha.org.

Bahr, D. (2008, Jan.). A topical bibliography on oral motor assessment and treatment. Oral Motor Institute, 2(1). Available from www.oralmotorinstitute.org.

Bahr, D. (2011, Sept.). The oral motor debate - Part I: Understanding the problem. Oral Motor Institute, 3(1). Available from www.oralmotorinstitute.org.

Bahr, D. (2011, Nov.). The oral motor debate – Part II: Exploring terminology and practice patterns. Oral Motor Institute, 3(2). Available from www.oralmotorinstitute.org.

Bahr, D., & Banford, R. J. (2012, Jan.). The oral motor debate – Part III: Exploring research and training needs/ideas. Oral Motor Institute, 4(1). Available from www.oralmotorinstitute.org.

Bahr, D., & Rosenfeld-Johnson, S. (2010, Feb.). Treatment of children with speech oral placement disorders (OPDs): A paradigm emerges. Communication Disorders Quarterly, 31, 131-138.

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

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

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

Marshalla, P. (2008, Apr.). Oral motor treatment vs. non-speech oral motor exercises. Oral Motor Institute, 2(2). Available from www.oralmotorinstitute.org.

Marshalla, P. (2012, Apr.). Horns, whistles, bite blocks, and straws: A review of tools/objects used in articulation therapy by Van Riper and other traditional therapists. Oral Motor Institute, 4(2). Available from www.oralmotorinstitute.org.

McCauley, R. J., Strand, E., Lof, G. L., Schooling, T., & Frymark, T. (2009, Nov.). Evidence-Based systematic review: Effects of nonspeech oral motor exercise on speech. American Journal of Speech-Language Pathology, 18(4), 343-360.

Oral Motor Institute (n.d.). Home page: Mission statement. Available from www.oralmotorinstitute.org.

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

Rao, P. R. (2011, Jun. 7). Evidence-Based practice: The coin of the realm in CSD. The ASHA Leader, 16(7), 7.

Rosenfeld-Johnson, S. (2009). Oral placement therapy for speech clarity and feeding (rev. 4^th ed.). Tucson, AZ: Innovative Therapists International.

Ruscello, D. M. (2008a). Nonspeech oral motor treatment issues related to children with developmental speech sound disorders. Language, Speech, and Hearing Services in Schools, 39, 381-391.

Ruscello, D. M. (2008b). An examination of nonspeech oral motor exercises for children with velopharyngeal inadequacy. Seminars in Speech and Language, 29, 294-303.

Sacks, S., Flipsen, P., & Neils-Strunjas, J. (2013, Oct.). Effectiveness of systematic articulation program accessing computers (SATPAC) approach to remediate dentalized and interdental /s, z/: A preliminary study. Perceptual and Motor Skills, 117(2). 559-577.

Van Riper, C. (1954). Speech correction: Principles and methods. Englewood Cliffs: Prentice-Hall.

AUTHORS

Robyn Merkel-Walsh is a speech pathologist who is employed by the Ridgefield Board of Education, TalkTools, as well as her own practice. Robyn is an international lecturer who specializes in muscle and motor based speech disorders, feeding, and orofacial-myofunctional disorders. She is the co-author of A Sensory Motor Approach to Feeding (2013) and the Oral Placement to Speech Kit (2011). She is the author of the 2002 SMILE (SysteMatic Intervention for Lingual Elevation) program and has published many popular articles.

Diane Bahr is co-owner of Ages and Stages®, LLC (Resources for Feeding, Speech, and Mouth Function) and the author of Oral Motor Assessment and Treatment: Ages and Stages (2001) and Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development (2010). She has taught at both the undergraduate and graduate levels and is currently an international speaker on the topics of feeding, motor speech, and mouth function. She has also written extensively on these topics.

Both authors are experienced master clinicians and Board Members for the all-volunteer Oral Motor Institute study group.

• The Groden Centre, USA
• Division of Psychology, Nottingham Trent University, United Kingdom
• Center for the Study of Human Development, Brown University, USA
• The Com DEALL Trust, India

Authors: Matthew K. Belmonte, Tanushree Saxena-Chandhok, Ruth Cherian, Reema Muneer, Lisa George and Prathibha Karanth

Abstract

"Absence of communicative speech in autism has been presumed to reflect a fundamental deficit in the use of language, but at least in a subpopulation may instead stem from motor and oral motor issues. Clinical reports of disparity between receptive vs. expressive speech/language abilities reinforce this hypothesis. Our early-intervention clinic develops skills prerequisite to learning and communication, including sitting, attending, and pointing or reference, in children below 6 years of age. In a cohort of 31 children, gross and fine motor skills and activities of daily living as well as receptive and expressive speech were assessed at intake and after 6 and 10 months of intervention. Oral motor skills were evaluated separately within the first 5 months of the child's enrolment in the intervention programme and again at 10 months of intervention. Assessment used a clinician-rated structured report, normed against samples of 360 (for motor and speech skills) and 90 (for oral motor skills) typically developing children matched for age, cultural environment and socio-economic status. In the full sample, oral and other motor skills correlated with receptive and expressive language both in terms of pre-intervention measures and in terms of learning rates during the intervention. A motor-impaired group comprising a third of the sample was discriminated by an uneven profile of skills with oral motor and expressive language deficits out of proportion to the receptive language deficit. This group learnt language more slowly, and ended intervention lagging in oral motor skills. In individuals incapable of the degree of motor sequencing and timing necessary for speech movements, receptive language may outstrip expressive speech. Our data suggest that autistic motor difficulties could range from more basic skills such as pointing to more refined skills such as articulation, and need to be assessed and addressed across this entire range in each individual."

Read the full article HERE