Tagged "Robyn Merkel Walsh"


A Modern Look at Van Riper's Phonetic Placement Approach

Posted by Deborah Grauzam on

by Robyn Merkel-Walsh, MA, CCC-SLP

This poster was presented at the 2016 annual ASHA Connect Convention, Poster Session #PS02.

Download the poster here  

ABSTRACT

Presentation explores 1) traditional versus phonological therapy, 2) the sensory-motor system as it relates to speech, 3) the importance of tactile and proprioception in articulation therapy, 4) shaping placement of the articulators to improve speech clarity.  

LEARNER OUTCOMES

1. Participants will be able to differentiate phonological versus traditional articulation therapy.  

2. Participants will be able to define the three stages of Van Riper’s Phonetic Placement Approach.  

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

DISCUSSION

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 (PPA) may be more useful for individuals who are not be able to achieve placement cues (Van Riper, 1978). In 1958, Van Riper stated:

"Every available device should be used to make the student understand clearly the positions of the tongue, jaw, and lips to be assumed."

Placement cues are based on the more traditional models of therapy, and rely on the concept that an individual can copy the motor plan suggested by the therapist, such as “place your tongue tip to the spot.” Therapists, however, often struggle with a population of individuals who do not respond well to “look at me and say what I say,” and those who require a tactile-kinesthetic approach to treatment (Bahr & Rosenfeld-Johnson, 2010). Individuals with dysarthria, dyspraxia and/or myofunctional disorders may make slow progress, or no progress at all, without the assistance of tactile cues. Even though therapists have heard the debate on oral motor therapy (Bowen, 2006; Lof, 2006; Lof, 2007; Lof, 2009), clinicians are still widely using the techniques because they yield positive treatment outcomes (Bahr, 2008).

Clinicians, who represent the Board of Directors for the Oral Motor Institute, have struggled with distinguishing “oral motor therapy” from the form of “Non Speech Oral Motor Exercises” (NSOME) presented by Gregory Lof (Lof, 2008). The term “Oral Placement Disorder” (OPD) was coined by Diane Bahr and Sara Rosenfeld-Johnson in 2010 (Bahr & Rosenfeld-Johnson, 2010). Children with OPD cannot imitate targeted speech sounds using auditory and visual stimuli (i.e., “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 OPD is new, the concepts surrounding the term have been discussed by a number of authors and clinicians (Bahr, 2010; Hodge, 2012; Marshalla, 2007).

There has been question, and ongoing confusion, as to what is a NSOME, versus what is an oral placement technique (OPT) (Bahr & Rosenfeld-Johnson, 2010). Oral Placement Therapy (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 program plan.

Gregory Lof’s research has even stated that the methods used in Van Riper’s Phonetic Placement Approach are not in fact considered NSOME (Lof, 2009). This is why 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).

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; Green, Moore & Reilly, 2000; Marshalla, 2007; Young and Hawk, 1955):

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); use every available device (Marshalla, 2012);

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.

TalkTools | Pam Marshalla

PHONETIC PLACEMENT THERAPY TOOLS

TalkTools | Van Riper tools

MODERN ORAL PLACEMENT THERAPY TOOLS

TalkTools | Van Riper new tools

REFERENCES

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

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

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

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.

Hodge, M. M. (2002). Non-speech oral motor treatment approaches for dysarthria: Perspectives on a controversial clinical practices. Perspectives in Neurophysiology and Neurogenic Speech Disorders, 12 (4), 22-28.

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

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

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. & 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. (2004). Ask the Expert: A response by Gregory L. Lof, PhD., CCC-SLP. The Apraxia-Kids Monthly, 5 (1).

Lof, G. L. & Watson, M. (2004). Speech-language pathologist’s use of non-speech oral-motor drills: National survey results. Poster presented at the annual meeting of the American Speech-Language-Hearing Association, Philadelphia, PA.

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

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

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

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

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

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

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Self-Limited Diets in Children with a Diagnosis of Autism Spectrum Disorders

Posted by Deborah Grauzam on

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.

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Oral Placement Therapy (OPT) vs. Non-Speech Oral Motor Exercises (NSOME): Understanding the Debate

Posted by Deborah Grauzam on

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.

TalkTools | ASHA Poster 2015

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.TalkTools | ASHA Poster 2015 picture 1
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 /.TalkTools | ASHA Poster 2015 picture 2
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.TalkTools | ASHA Poster 2015 picture 2

 

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.

ASHA Poster 2015 graph

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.

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Autism Spectrum Disorders: Clinical Parameters of Oral Placement Therapy (OPT)

Posted by Deborah Grauzam on

Authors: Robyn Merkel-Walsh M.A., CCC-SLPSara Rosenfeld-Johnson M.S., CCC-SLP

Foreword:

This article, in the original form, was published in Advance Magazine for Speech Pathologists. The article has been expanded upon and revised with current Evidenced Based Practice.

Abstract:

Autism is a developmental disability that affects, often severely, a person's ability to communicate and socially interact with others. Autism Spectrum Disorder (ASD) impacts 1 of 68 children in the United States (CDC, 2015). In “cluster” states such as New Jersey, as many as 1 in 28 boys are affected. Autism Spectrum Disorders (ASD) is an umbrella term to include related disorders such as Asperger's Syndrome, Pervasive Developmental Disorder (PDD) and Kanner's Syndrome. The intensity of symptoms varies widely; however, all people on the spectrum display impairments in communication, social relationships and patterned behaviors. What is not as clearly understood, is the comorbidity of Oral Placement Disorder (OPD). There is  acknowledgement that, at least in a subpopulation of children with autism, communicative deficits may instead stem from more basic motor and oral motor issues (Belmonte, Saxena-Chandhok , Cherian, Muneer,  George & Karanth, 2013). Therefore, it is important for therapists to evaluate and treat not only the communication deficits with the ASD population, but also the oral sensory-motor deficits that many of these children present with.   

Introduction:

Most individuals with autism are diagnosed by the age of three or younger, and the primary complaint is delayed language skills and/or the regression of language use (Wiggins, Baio & Rice, 2006). For example, parents often report that their child was able to say some words, but suddenly they stopped speaking and became socially withdrawn. At the same time, they began engaging in repetitive behaviors, their play skills regressed, and parents reported poor eye contact and limited socialization with others (CDC, 2015).

When a child is diagnosed with ASD, most likely, a Speech-Language Pathologist (SLP) will be called upon for an evaluation. It is imperative for therapists to look at not only receptive and expressive language, but oral motor skills, oral sensory-motor issues, feeding and motor planning in order to obtain global information that may be impacting the child's ability to communicate. Dr. Barry Prizant, a leader in the field of ASD, has indicated that there is increasing evidence that lack of speech and/or gestures in children with autism may be related to issues other than social-cognitive abilities. Prizant argues that clinical evidence suggests that motor speech impairments can be a significant factor inhibiting the development of speech in children with ASD (Prizant, Wetherby,  Rubin & Laurent, 2010).

Assessment:

In clinical practice, the Speech-Language Pathologist needs to look at several areas in order to devise a treatment plan. This includes 1) sensory processing 2) structure and tone 3) pre-feeding skills 4) feeding skills 5) motor planning and 6) speech sound production.

Sensory processing is important to assess, as it relates to feeding and speech in children with ASD. Acceptance of touch to the face and oral cavity, as well as oral habits such as teeth grinding, mouthing objects and eating items other than foods (PICA) are critical to assess. Some children with ASD are over-responsive to sensory stimuli while others may be under-responsive. An over-responsive child may react to sounds in the kitchen and be distracted during meals, while an under-responsive child may seek pressure in the mouth by chewing on non-edible items (Overland & Merkel-Walsh, 2014).

Structure and tone must be assessed to rule out any comorbid factors that may be impeding feeding and speech. Children with autism may also present with issues such as: dysarthria, Orofacial Myofunctional Disorders, dental malocclusions, or Ankyloglossia. Low-tone occurs in approximately thirty percent of children with ASD (Bailey, 2013). Global hypotonia also occurs with ASD (NAN, 2015). Char Boshart (2015) has carefully designed an Ebook which outlines how to assess oral structures.

Pre-feeding skills are the underlying oral sensory-motor skills that are necessary for safe, effective, nutritive feeding (Overland & Merkel-Walsh, 2013). Morris & Klein (2010) and Overland & Merkel-Walsh, have written texts describing pre-feeding skills with careful detail.

A thorough feeding assessment is a team approach. In addition to the SLP, the feeding team may include the child’s pediatrician, nutritionist, gastroenterologist and/or otolaryngologist. It is important to determine if feeding challenges are organic or behavioral. Feeding disorders in children with ASD are often judged to be behavioral, when there may be medical and/or sensory-motor underpinnings. Most children with self-limited diets have feeding challenges that are multidimensional and are not purely behavioral (Roche, Eicher, Martorana, Berkowitz, Petronchak, Dziob & Vitello, 2011). Children with ASD often have sensory processing issues which impact feeding, but they may also have oral sensory-motor challenges that are related to deficits in pre-feeding skills. An SLP who diagnoses a feeding disorder in ASD must be sure to rule out any related medical etiology such as reflux or food allergies.

Motor planning disorders can also be comorbid with an ASD diagnosis. Childhood Apraxia of Speech (CAS), according to The American Speech-Language-Hearing Association, is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody (ASHA, 2007). In assessing a child with ASD, an SLP must determine if CAS could be a factor in a child being non-verbal. Experts in CAS, such as David Hammer and Deborah Hayden, have done extensive work in the diagnosis of CAS, and standardized measures such as The Kaufman Speech Praxis Test are available to clinicians to diagnose this disorder.

Finally, speech clarity is an important part of the assessment. There are standardized measures available, such as the Goldman-Fristoe Test of Articulation-2; however when assessing a child with ASD, standardized measures may prove challenging. There may also be children who cannot be tested because they are non-verbal. Therapists should not assume that cognition is severely impaired in a non-verbal child with ASD, because there may be coexisting oral-motor issues (Merkel-Walsh, 2014). This is why the aforementioned assessment tools are so important.

Treatment:

After a thorough assessment, the SLP can create a treatment plan that will incorporate: 1) oral sensory-motor based activities 2) feeding therapy 3) Oral Placement Therapy (OPT) and 4) speech sound production.

Oral sensory-motor based activities involve activities designed to regulate the sensory system, help stabilize postural stability, orient towards the midline and establish pre-feeding skills. Massage, vibration, and tactile stimulation methods are often used to stimulate oral postures, improve stability, and improve strength and dissociation (Morris & Klein, 2000). Deborah Beckman has a systematic approach to providing oral sensory-motor therapy called the Beckman Oro-facial Deep Tissue Release©. The protocol uses mechanical muscle responses, which are not mediated cognitively, to baseline the response to pressure and movement, range of movement, variety of movement, strength of movement and control of movement for the lips, cheeks, jaw, and tongue (Beckman, 2014). Therapeutic tools may also assist with sensory-motor and pre-feeding skills. For example, a Jiggler tool can be used to superimpose lip closure, the placement skill needed for bilabial sounds and spoon feeding. Massaging the lateral margins of the tongue can provoke lateralization which is important for safely handling a small bolus (Overland & Merkel-Walsh, 2013).

Therapeutic feeding techniques are necessary for those individuals who require supports to ensure a safe, effective, nutritive feeding (Overland, 2010). Therapeutic feeding involves postural supports, adaptive utensils and cups, placement of the food and supplemental techniques to assist in handling a bolus. It also involves careful consideration of food choices, especially with children on the autism spectrum. Establishing a home base diet is critical in diet-shaping and diet expansion (Overland & Merkel Walsh, 2013). Therapeutic feeding also considers nutrition needs and diet restrictions.

Oral Placement Therapy is a tactile approach to therapy for those individuals who cannot respond to look and me and say what I say. 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). Merkel-Walsh and Roy-Hill (2014) presented this concept at the ASHA Convention:

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.

Speech sound production should always proceed oral sensory-motor and OPT tasks. Speech tasks may involve repetition of target words, and may involve tactile cueing such as the PROMPT method (Prompts for Restructuring Oral Musculature Phonetic Targets). PROMPT has been found useful for children with ASD, (Rogers, Hayden, Hepburn, S., Charlifue-Smith, Hall & Hayes, A. 2006). PROMPT is a positive treatment method, as it provides cues for placement for children who cannot easily imitate oral placements for sound production. PROMPT can be used  in conjunction with language goals.

Clinical Parameters:

Once a plan is established and an OPT plan is created, therapists are often challenged by service delivery models, since individuals with ASD often present with challenging behaviors including: self- stimulatory behaviors (e.g. hand flapping or spinning), aggression, non-compliance, work avoidance and inability to attend to task. Since there are many theories on service delivery models in autism, therapists must decide which model best suits their treatment style, and which models are based on research and evidence based. With some background on oral-motor therapy and OPT, therapists know that the child must be seated appropriately in order to gain stability and appropriate positioning for the therapy to be successful. This often presents as a challenge with this population; however with help from ASD experts, it is quite easy to incorporate oral motor and OPT techniques into a therapy plan.

Greenspan, Wetherby and Prizant are advocates of language developing through play schemas in the natural setting. Floor time, modeling and hands-on life experiences are critical in this “child centered” model. Typical natural settings include the home, the park and the grocery store. This approach follows the child's "lead", the direction the child wants to go. The adult engages the child in pleasurable activities with reciprocal play and communicative exchange, so that the activity in itself is reinforcement for the child. The therapist judges what the child wants to do based on non-verbal and verbal cues. This is the basis of the SCERTS model. “SC” - Social Communication – the development of spontaneous, functional communication, emotional expression, and secure and trusting relationships with children and adults; “ER” - Emotional Regulation - the development of the ability to maintain a well-regulated emotional state to cope with everyday stress, and to be most available for learning and interacting; “TS” – Transactional Support – the development and implementation of supports to help partners respond to the child’s needs and interests, modify and adapt the environment, and provide tools to enhance learning (e.g., picture communication, written schedules, and sensory supports). Specific plans are also developed to provide educational and emotional support to families and to foster teamwork among professionals (Prizant, Wetherby, Rubin & Laurent, 2007).

Though the SCERTS is a wonderful model for therapy, the challenge in using this approach with oral sensory-motor and OPT  programs is that the therapy is definitely led by the therapist, the client does not select the activities or tools, because the therapist knows what activities are required to improve a certain muscle-memory based skill (Merkel-Walsh, 2014). The treating SLP must balance the structure needed for OPT programs with a model that fosters a reciprocal communication exchange.

Applied Behavioral Analysis (ABA) is a method of behavioral intervention developed by Ivan Lovaas PhD and Tristan Smith PhD. It consists of teaching skills by breaking them down into small steps, while rewarding the correct responses. It is data driven and quite intensive. ABA is often associated with Discrete Trial Teaching (DTT) which uses the instruction-prompt-response-reward method to help people on the spectrum complete complex tasks. The ABA method has the most empirical research to date to show progress in children on the autism spectrum (CAN, 2005). This approach is better suited to oral-motor therapy, since OPT activities are broken down into small specific steps and have preset mastery levels, such a Bite Blocks, which have a 15 second criteria for mastery. OPT tasks can easily be written into short term objectives (STO) which are the basis of program books for ABA programs. OPT progress can be easily charted and graphed to track progress.

LG Rethink Graph

Graph provided by www.rethinkfirst.com.

Therapists do not have to choose between these two models; both principles can be applied if therapy sessions are carefully planned. A challenge in following the child-centered approach is that OPT programs have pre-established hierarchies and set requirements for mastery or success; however, one must consider that therapy must be rewarding in order for the child to engage. Children on the spectrum will need consistent, highly-motivating tangible reinforcers to engage in OPT. In addition, the sessions need to be language oriented as the main goal is oral communication.

With these principles in mind, here are general parameters in structuring Oral Placement Therapy with children presenting with ASD:

• Create a calming environment ensuring that lighting and sound have been considered in relation to sensory processing issues. Meta-music, a lava lamp, or concentration tapes can all help make the session more calming and rewarding. Consult with an Occupational Therapist if a child with ASD presents with very intense sensory dysregulation.

• Select an appropriate setting that encourages 90 degree angles in the hips, knees and ankles. Make sure the feet are on the floor or flat on an elevated surface, such as the foot rest of a high chair. You may use dycem on the chair so the child does not slide, or may need additional weighted items, such as a rice bag across the lap or a weighted vest, to give additional sensory input. If this is not possible due to out of seat behavior, a Behaviorist will need to intervene prior to therapy sessions and help the SLP with a behavior plan and/or use of alternative seating such as a bean bag chair, swing and or a ball pit.

• Create a picture schedule booklet for the client or schedule board from start to end with every activity and built in breaks for gross and sensory-motor play. Ensure that you are using favorite items, sound activities toys, music, and sensory based activities for free play on breaks. This builds in Greenspan's philosophies while keeping within the structured parameters of an ABA format.

• In coordination with an ABA Therapist/Behaviorist, create a token board with a set reward for positive work. For example, 5 pennies can result in a pretzel or squish toy. It also helps to take a photo of the child engaged in the target behavior, such as sitting in a chair with "quiet hands.” Verbalize the target behavior consistently and avoid talking about the negative behavior such as "no spitting" or "stop that." Use positive verbal cues such as, "good sitting with hands down.”

• When using food reinforcers, coordinate this with feeding therapy. For example, a specific placement of a strip to the molars, as where the food is placed in the mouth impacts the skills used to break it down. Use a highly desirable drink, such as fruit juice, with a target straw from the TalkTools® Hierarchy.

• A therapy protocol should always incorporate sensory activities (Sensory Bean Bags, vibration, massage, ZVibe),  jaw activities (Bite Blocks, Jaw Exerciser, Chewy Tube etc.), respiration and phonation activities (Horns, bubbles) and additional OPT activities as needed (Lip Press, etc.). The session should always include sound drills, word imitation (verbal ims) and/or play with targeted words embedded within the structured activity.

• For many kids with ASD, the speech therapist will be involved with sensory-based food tasting programs which can be presented in a discreet trial teaching (DTT) model. First, the child needs to tolerate the new food in their proximity, then touch it, smell it, tolerate it near the mouth, kiss it/tongue touch, hold it in the mouth, chew it and swallow. These steps need to be broken down into small tasks that are highly reinforced.

• Create an OPT book with specific therapy and chart notes, so that the work is done at home and at school/clinic. The therapist must train the parent, or in some cases the babysitter or ABA therapist, so that the exercises are done daily. This is not to say that an ABA therapist should be performing speech therapy, but rather facilitate progress by practicing specifically assigned homework. In some cases, challenging behaviors are much easier for a ABA therapist than for the parent. In addition, parents can videotape sessions to follow at home. Video modeling is a very common procedure in ABA programs.

• Since the main goal is expressive communication, it is imperative that the therapist recognizes the clients strengths in terms of jaw-lip-tongue dissociation and planes of movement as taught by Debra Hayden's PROMPT System Hierarchy, Nancy Kaufman’s “Kaufman Praxis Level 1” and Lori Overland's/Sara Rosenfeld-Johnson's oral motor developmental norms references. This will help the speech therapist select the first words for drill and repetition in order to translate muscle-motor memory into speech production. For example, if the child's lip closure is a goal, and he/she is working on TalkTools® horn level 1, simple CV, VCV, VC words with picture cards should be used to elicit productions such as: me, bee, apple (ae-po), up and so forth. The words should be practiced in every session with the help of facial cues (PROMPT), and lip reading cues to 80% mastery. When this occurs, the therapist can then fade cues and move to higher level targets such as CVC forms.

• To evoke new productions spontaneously, David Hammer, an expert in the field of apraxia, recommends use of repetitive games and toys within each session. For example, if target words are in/out use a simple activity, such as small animals that go in and out of a paper towel tube, and repeat this each session so that the client can predict what utterances are expected. Prediction of outcome reduces anxiety and also follows along with Dr. Edythe Strand's research on the need for repetition in order to solidify a motor plan.

Conclusion:

In summary,  OPT for children with ASD is an essential part of their speech therapy program in addition to pragmatics, language, sensory integration and total communication. While engaging children with ASD may be challenging, if speech therapists follow the lead of experts in the field of autism, OPT is actually quite easy to deliver as long as the therapist combines the principles of behavior modification with natural language development. Since OPT hierarchies are very task oriented and data driven, (e.g., each TalkTools® horn has a pre-established criteria for mastery), therapists can present activities in specific sequences with consistent positive reinforcers which is in line with the experts suggestions for systematically teaching target behaviors in an ABA format, while the SCERTS approach opens pathways for carryover and language acquisition with improved speech clarity.

Click here to learn more about the course Robyn Merkel-Walsh teaches on Autism & OPT



Robyn_color_lowRobyn Merkel-Walsh MA, CCC-SLP is a speech pathologist with over 20 years of experience in both the Ridgefield Public Schools, and in her private practice located in Bergen County, NJ. She is the author of The Smile Program, A Sensory Motor Approach to Feeding, and other educational materials. Robyn is a certified TalkTools Instructor on Tongue Thrust, Autism and Oral Placement Therapy. Robyn is the acting chair of the Oral Motor Institute. She can be reached at robynslp95@aol.com.

   

Sara R JSara Rosenfeld-Johnson MS, CCC-SLP is the founder of Innovative Therapists International, and TalkTools® based in Charleston, South Carolina. She is the author of Oral Placement Therapy (OPT) for Speech Clarity and Feeding, The HOMEWORK Book, Assessment and Treatment of the Jaw, OPT for /s/ and /z/ as well as many other education materials.  Sara specializes in assessment and treatment of motor speech and feeding disorders.  She is a national and international speaker on the topic of Oral Placement Therapy.  She can be reached at srjohnson@talktools.com.

Thanks to Rethink for providing the graph above. 

REFERENCES

American Speech and Hearing Association (ASHA), (2007). Positions statement: childhood apraxia of speech. Retrieved from:  asha.org: http://www.asha.org/policy/PS2007-00277/.

Bailey, E. (2013). 7 characteristics and traits of  autism spectrum disorders. Health Guide. Retrieved from: http://www.healthcentral.com/autism

Beckman, D. (2014). About Beckman oral motor intervention. Retrieved from: http://www.beckmanoralmotor.com/about.php.

Belmonte, M.K., Saxena-Chandhok, T., Cherian, R., Muneer, R., George, L. & Karanth P. (2013). Oral motor deficits in speech impaired children with autism. Frontiers in Integrative Neuroscience; 7:47.

Boshart, C. (2015). Oral facial illustrations and reference guide. Ebook.

Cure Autism Now (CAN), (2005). Applied behavioral analysis and other skills-based therapies, https://www.autismspeaks.org/site-wide/cure-autism-now

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

Center for Disease Control (CDC), (2015).  Autism Spectrum Disorder signs and symptoms. Retrieved from: http://www.cdc.gov/ncbddd/autism/signs.html.

Merkel-Walsh, R. (2014). Solving the puzzle of autism: using tactile therapy techniques. Live presentation. Charleston, SC: TalkTools®.

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

Merkel-Walsh, R. & Overland, L.L. (in press). Diet-shaping: a useful technique for children on the autism spectrum. Retrieved from The Oral Motor Institute: http://www.oralmotorinstitute.org.

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

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

National Autism Network (NAN), (2015). C0-occuring Conditions. Retrieved from: http://nationalautismnetwork.com

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

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

Prizant, B. M., Wetherby, A. M., Rubin, E., Laurent, A. C., (2010). The SCERTS Model. In K. Siri and T. Lyons (ed), Cutting-Edge therapies for autism: New York, NY: Skyhorse Publishing.

Prizant, Wetherby, Rubin & Laurent, (2007). The SCERTS model. Retrieved from: http://www.scerts.com/index.php?option=com_content&view=article&id=2&Itemid=2.

Roche, W.T. , Eicher, P., Martorana, P., Berkowitz, M., Petronchak, J. Dzioba, J. & Vitello, L. (2011). An oral, motor, medical, and behavioral approach to pediatric feeding and swallowing disorders: an interdisciplinary model. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 20, 3, 65-74.

Rogers, S. J., Hayden, D. Hepburn, S., Charlifue-Smith, R., Hall, T., & Hayes, A. (2006). Teaching young nonverbal children with autism useful speech: A pilot study of the Denver Model and PROMPT interventions. Journal of Autism and Developmental Disorders, 36(8), 1007–1024.

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

Wiggins L, Baio J., Rice C. (2006). Examination of the time between first evaluation and first autism spectrum diagnosis in a population-based sample. Journal of Developmental Behavior Pediatrics; 27:S79.

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

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Podcast: A Case for Oral Placement Therapy

Posted by Deborah Grauzam on

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.

  TalkTools_Robyn Merkel-Walsh_Podcast
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