Tagged "tactile approach"

#tbt: My Best Tips For Eliciting The K Sound

Posted by Deborah Grauzam on

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

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

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

April 10, 2017

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

TIP #1 Cue with “Clear out the Popcorn”

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

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

TIP#2 Cereal

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

TIP #3 Tactile Cues—Holding the Tip and Blade

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

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

TIP# 4 Use Gravity

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

TIP#5 Getting Tongue Retraction

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

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

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

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Brain Stem Stroke: A Case Study

Posted by Deborah Grauzam on

This case study was originally posted in Advance for Speech & Hearing on November 14, 2016. Retrieved from http://www.advanceweb.com/

Author: Gabrielle Zimmer, MS, CCC-SLP

Brain Stem Stroke: A Case Study

Rebuilding communication one subsystem at a time.

Where do you start when a client understands everything that is said but has no way to communicate back to you? He cannot speak, gesture or write. How can you improve his quality of life?

As speech-language pathologists in the outpatient department at Kessler Institute for Rehabilitation, we frequently encounter challenging situations and provide treatment for medically complex adults who have suffered acquired and traumatic brain injuries (TBIs). To maximize each client’s potential, collaboration with an interdisciplinary team, including physicians, therapists and other specialists, is crucial. The implementation of a variety of treatment approaches based on the individual needs of the client is also critical.

An example of a complex case in which collaboration was necessary is the case of Ben, a 38-year-old male who began feeling right upper extremity twitching and slurred speech. This evolved and progressed and an MRI revealed a severe brainstem stroke. Ben was ultimately diagnosed with Locked-In Syndrome. He was unable to move any part of his body, although his receptive and expressive language and cognition remained entirely intact. He remembers hearing and understanding all that was being said at his bedside, but he was unable to express himself in any way with the exception of eye blinking. Ben recounted his inability to make requests such as to turn on the fan, feed him ice chips or scratch an itch.

Familiar Voice

Ben completed acute inpatient rehabilitation at Kessler and progressed to a state in which he could move his neck and to a small degree his mouth, lips and tongue. By using the eye gaze access feature of a high technology augmentative and alternative communication (AAC) speech generating device, Ben was able to demonstrate to his family members for the first time since his stroke that “he was in there.” This allowed him to communicate his wants and needs, ask questions and express concerns. He was an excellent candidate for an AAC device, but strived to speak in his own voice. Ben achieved his swallowing goals and was beginning to target phonation when he was discharged from inpatient therapy and transitioned to my care in the outpatient department.

When Ben started outpatient therapy, he had significantly reduced breath support, severely reduced tongue, lip, cheek and jaw movement, and was aphonic and unintelligible. He had difficulty changing his facial expressions to convey emotion and was unable to manage his saliva. He required 24/7 supervision and assistance and was unable to verbally communicate his basic wants and needs. Initially, I trialed traditional approaches to improve articulatory movement as well as voice exercises but quickly felt like we were hitting a wall. I felt it was necessary to break down and target each speech subsystem to maximize his abilities.

Tactile Approach

I sought an evaluation from an otolaryngologist who specializes in voice disorders to examine the integrity of his vocal cord movement which proved to be within normal limits. The difficulty appeared to be with the coordination of inhalation and exhalation for productive voicing as well as a resonance disorder due to limited velar movement. Volitional diaphragmatic breathing was challenging and most of his air was lost through his nasal cavity.

Knowing that his vocal cords were functioning properly was promising for the goal of achieving consistent voicing going forward. We used a spirometer for visual feedback and to target consistent volitional inhalation and exhalation for speech. Additionally, we consulted with a prosthodontist to further examine Ben’s palatal movement and to assess his candidacy for prosthesis. Ben was deemed a viable candidate and use of the palatal lift helped improve voicing and increased his volume. Now that voicing was becoming more consistent and breath support was improving, our goals shifted to articulatory movement and intelligibility.

Initially, Ben attempted to mouth single letters and words for lip reading. With such poor movement of his cheeks, lips and tongue, success was inconsistent and extremely frustrating for both Ben and his family. A tactile approach was deemed necessary for this case. I implemented two excellent therapeutic interventions – the Beckman Oral Motor Protocol and oral placement therapy with Talk Tools. The Beckman Oral Motor Protocol provided assisted movement to activate muscle contraction and movement against resistance to build strength and increased control of movement for the lips, cheeks, jaw, and tongue.

This was done in conjunction with a variety of hierarchical oral placement therapy techniques with Talk Tools, such as the jaw grading bite block, bubble blowing, horn blowing, velar grading and straw hierarchies, among others.

Improved Articulatory Movement

The initial tactile-kinesthetic feedback was crucial and contributed to improved articulatory movement. All oral placement tasks were paired with functional speech tasks. Ben began to increase intelligibility starting at the single word level, progressed to the basic phrase level and subsequently advanced to the sentence level. In addition, although Ben was tolerating a regular solid diet with thin liquids, he had self-established habitual patterns to compensate for his limited tongue and lip movement. The treatment approaches that were initially sought to improve his articulatory movement for speech simultaneously improved his feeding and swallowing function as well.

Ben progressed from an aphonic state to demonstrating increasingly controlled respiration for consistent phonation at the conversation level. Focus shifted to improve volume, pitch and vocal quality. His articulatory movement was severely limited, and he improved to the point where he produced intelligible sentences. Carryover was targeted outside of the speech therapy treatment room with collaboration between his physical and occupational therapists. He targeted speech goals to maintain phonation and intelligibility in different positions such as standing upright, lying on his back and during facilitated movement.

This same person who initially relied on an AAC device was now able to gradually participate in conversation using his own voice and his personality emerged. I began to learn about Ben’s interests, such as his skill at trivia, opinions on television shows and sarcastic sense of humor. He achieved major milestones, which included his abilities to participate and self-advocate in doctors’ appointments, hold conversations with his wife out to dinner and contribute to group conversation. His independence increased and required less caregiver support as he could call for help if needed.

Maximizing Abilities

In a complex case like Ben, utilizing a variety of treatment approaches was crucial to his progress and success. It is important to create individualized treatment programs that are comprehensive and functional for the client. The key to maximizing the client’s abilities is maintenance of well-rounded continuing education, implementation of strong evidence-based practice, collaboration within an interdisciplinary rehabilitation team and daily completion of a home exercise program for carryover outside of the therapy setting. This is in combination with time and dedication from the client and their support system. Ben said it best, “You can sit back and wait for a miracle, or you can make one happen. Let’s make a miracle!”


1: Beckman, D.A., (1994, Rev. 2010). Beckman Oral Motor Assessment and Intervention. Published by Beckman & Associates, Inc., 620 N Wymore Rd, Suite 230, Maitland, Florida 32751-4253. www.beckmanoralmotor.com

2: Rosenfeld-Johnson, S. (2014). A Therapist Guide to Rehabilitative Feeding and Speech Techniques for Teens and Adults: TalkTools, Charleston, SC.
Gabrielle Zimmer, MS, CCC-SLP is a speech-language pathologist and clinical specialist at Kessler Institute for Rehabilitation in West Orange, New Jersey.

Top-ranked by U.S.News & World Report for the 23rd consecutive year, Kessler Institute is the only rehabilitation hospital in New Jersey to be named to the prestigious list of “America’s Best Hospitals” and is the leading center of its kind in the East.

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Diet-Shaping for Self-Limited Diets in Children With a Diagnosis of Autism Spectrum Disorder

Posted by Deborah Grauzam on

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


Robyn Merkel-Walsh MA, CCC-SLP

Lori Overland MS, CCC-SLP/C-NDT

Learner Outcomes:

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

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

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

Discussion of Topic:

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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