Tagged "Sara Rosenfeld-Johnson"


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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Orofacial Myofunctional Disorders in Individuals with a Diagnosis of Down Syndrome

Posted by Deborah Grauzam on

By: Robyn Merkel-Walsh MA, CCC-SLP

Presentation of the Problem:

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

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

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

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

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

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

The Importance Of Treating Orofacial Myofunctional Disorders in Down Syndrome:

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

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

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

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

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

           

          PROBLEM

          Activity

          Tactile Intervention

          Low jaw posture and tongue protrusion during oral rest posture

          Therapist can work on facilitation of lip closure by placing a Jiggler tool in between the lips to facilitate lip closure. (Overland & Merkel-Walsh, 2013).

          stabalize

          Pre-feeding
          Reversed swallowing pattern/tongue thrust

          Therapist engages client in therapeutic straw drinking   to facilitate jaw stability, lip rounding and tongue retraction. (Rosenfeld-Johnson S.  2009).

          TalkTools | Straw 8

          Feeding Myofunctional
          Teeth grinding

          Therapist uses appropriate biting activities, chewing, appropriate mouthing activities, and massage techniques (Bahr, 2001). Therapist implements a gum chewing program to facilitate an appropriate replacement for teeth grinding (Rosenfeld-Johnson, 2009).

          TalkTools | Bean bags

          Pre-feeding Feeding Myofunctional
          Interdental lisp Therapist implements activities to superimpose lip closure with tongue retraction in order to improve strength and dissociation of the musculature, such as therapeutic horn and bubble blowing (Rosenfeld-Johnson, 2009; Merkel, 2002). The tools will be faded when the oral placement skill is achieved and the individual can produce the target sound without the use of the tactile cue/tool.boy bubble OPT Myofunctional

           

          Conclusions:

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

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

           

          Bibliography

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

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

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

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

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

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

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

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

          Marshalla, P. (2012). Horns, whistles, bite blocks, and straws: A review of tools/objects used in articulation therapy by Van Riper and other traditional therapists. . Retrieved from oralmotorinstitute.org: www.oralmotorinstitute.org/mons/v4n2_marshalla.html

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

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

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

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

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

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

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

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

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

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          What Evidence-Based, Oral Sensory-Motor Treatments are Effective for Speech Disorders?

          Posted by Deborah Grauzam on

          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. 4th 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.

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