Oral Placement Therapy - Down Syndrome Information Alliance

Transcription

Oral Placement Therapy
To Improve Speech Clarity and Feeding Skills
To Improve Speech Clarity and
Feeding Skills
By Sara Rosenfeld-Johnson, M.S., CCC-SLP
Author of:
Oral Placement Therapy (OPT) for Speech Clarity and Feeding,
Oral Placement Therapy (OPT) for /s/ and /z/
and Assessment and Treatment of the Jaw
TalkTools®
1852 Wallace School Road, Charleston SC, 29407
Tel: 888.529.2879 / Fax: 843.206.0590
www.talktools.com
Copyright ©2013 TalkTools® 12182013
Sara Rosenfeld-Johnson, M.S., CCC-SLP
TalkTools®, Charleston, SC
SRJ TherapiesTM, Charleston, SC
Sara Rosenfeld-Johnson, M.S., CCC-SLP, a graduate of Ithaca College and Columbia University, has more
than 40 years of experience as a speech-language pathologist. She has spent the last 35 years developing
oral placement techniques for infants, children, and adults, and has seen a high degree of success in
their therapeutic application. For this reason she is now a leading advocate for the use of oral placement
techniques in conjunction with more traditional speech therapies and is devoted to teaching other professionals
about oral placement techniques to promote speech clarity and feeding safety.
Sara is the author of Oral Placement Therapy for Speech Clarity and Feeding, Oral Placement Therapy for
Speech Clarity and Feeding, Oral Placement Therapy (OPT) for /s/ and /z/, Assessment and Treatment of the
Jaw, The HOMEWORK Book, the Drooling Program, and many other educational materials.
In 1995, Sara founded Innovative Therapists International, Inc.TM/TalkTools® as a speakers bureau and source
for oral placement therapy and therapy tools. She has held seminars throughout the United States, as well as
in Canada, Italy, Germany, New Zealand, Australia, Ireland, England, South Africa, China, Malaysia, Cyprus
Sweden, Bulgaria and Singapore. Her courses are approved for both ASHA and AOTA continuing education
units, and many are available on DVD for home study. The list of available classes includes:
“Level 1: A Three-Part Treatment Plan for Oral-Motor Therapy”
“Horns as Therapy Tools”
“Straws as Therapy Tools”
“Bubbles as Therapy Tools”
“Early Intervention: Oral Placement Therapy for Children with Down syndrome”
“Assessment and Treatment of the Jaw”
“As a Parent What Can I Do?”
Sara is an international spokesperson for speech, language and feeding disorders related to CHARGE
Syndrome and Moebius Syndrome, a member of the National Down Syndrome Congress’ Professional
Advisory Committee, and a nationally-recognized presenter on behalf of Down syndrome and Cerebral Palsy
associations. Having worked with numerous early intervention programs in Texas, New York, Connecticut,
New Jersey, Arizona and South Carolina, she is also a nationally-recognized speaker in the area of early
intervention. In addition, Sara regularly appears as a featured speaker at American Speech-Language-Hearing
Association (ASHA) conventions, on both the state and national levels.
Even while nurturing these many projects Sara has remained committed to the cause that first drew her to this
arena, so she also founded SRJ TherapiesTM, a clinic specializing in the assessment and treatment of clients
with oral-motor, speech, and feeding deficits. The clinic is located in Charleston, SC, and Sara still works with
her clients there today.
Sara is now working on a new book, Oral Placement Therapy for Adults with Muscle-Based Feeding and
Communication Disorders.
Content Disclosure: This presentation will focus on treatment methods related to the use of Oral Placement Therapy (OPT). Other similar treatment approaches will receive
limited or no coverage during this lecture.
Speaker Disclosure: Financial: Sara Rosenfeld-Johnson is an employee and patent holder of TalkTools. TalkTools is a company that manufactures tools and programs for Oral
Placement Therapy. Sara’s job is to develop, research and write directions for the use of these tools. NonFinancial: She has no relevant nonfinancial relationships to disclose.
1
Sara Rosenfeld-Johnson’s innovative tactile-sensory approach to speech therapy uses therapy tools to train
muscle movements for improved feeding safety and speech clarity. Learn how these highly motivating motor
activities can be used to improve phonation, resonation, and speech clarity. Muscles of the abdomen, velum,
jaw, lips, and tongue will be discussed within the parameters of movements necessary for speech production.
Developmentally appropriate motor movements for speech are therapeutically targeted using highly motivating
techniques appropriate for children and adults. Each activity can be implemented easily within the school and/
or home environment.
Learner Outcomes:
1. Understand the need for dissociation and grading for feeding and speech.
2. Appropriately apply at least 5 new therapy techniques.
3. Learn to use Oral Placement Therapy (OPT) techniques as a tactile cueing system in conjunction with
traditional speech therapy techniques to improve speech clarity.
4. Describe how therapeutic straw drinking can be use to improve speech clarity for /s/ and /z/.
2
What Is Oral-Motor Therapy?
ORAL PLACEMENT THERAPY to Improve Speech Clarity and Feeding Skills
Published Article
Bahr, D., & Rosenfeld-Johnson, S. (May, 2010).
Treatment of children with speech oral placement
disorders ( OPDs ): A paradigm emerges.
Communication Disorders Quarterly, 31 (3), 131-138.
Dissociation: LIPS FROM JAW
MUSCLE MOVEMENT
PHONEME EX.
Following normal speech development
1. Open
!
Closed to Open ! !
!
Open to Closed
2. !Protrude
!
Retract
3. !Lower Lip Retraction/Tension
!
Lower Lip Protrusion/Tension
(ah, uh)
(m, p, b)
(oo, oh, w, ee, ih)
(f, v)
(sh, ch, j, r, er)
3
Dissociation: TONGUE FROM JAW
PHONEME EX.
MUSCLE MOVEMENT
1. Retraction- Protrusion: Balance (Equal range of
motion)
2. Retraction- Protrusion: Imbalance
Gradual increase in retraction
Gradual decrease in protrusion
3.
(all sounds except th)
Retraction (stability) - Lateralization of tip
a. Midline to both sides
b. Across midline
4. Retraction - Tip Elevation/Depression
(t, d, n, l, s, z, sh, ch, j, k, g)
5. Retraction - Back of Tongue Side Spread
(stability for co-articulation, er)
4
Tongue Thrust
1. Retraction- Protrusion: Balance (Equal range of motion)
•
Gradual increase in protrusion
•
Gradual decrease in retraction
2. Retraction – Protrusion: Imbalance
•
Significantly more protrusion than retraction for
function: feeding and speech
Our Professional Title
Speech and Language Pathologist
NOT: Speech or Language Pathologist
Combination of:
(1) OPT for feeding and speech and
(2) language therapy
Oral Placement Therapy for
Speech Clarity and Feeding
1. To increase the awareness of the oral mechanism
2. To normalize oral tactile sensitivity
3. To improve the precision of volitional movements of oral
structures for speech production
4. To increase differentiation of oral movements
a. dissociation: The separation of movement, based on stability
and adequate strength, in one or more muscle groups.
b. grading: The controlled segmentation of movement through
space based upon dissociation.
c. fixing: An abnormal posture used to compensate for reduced
stability which inhibits mobility.
5
Stability / Mobility
Stability in the body will allow for maximum mobility in the mouth.
The Tactile System
1. Tactile Hyposensitivity: An under-reaction to tactile input.
2. Tactile Hypersensitivity: An over-reaction to tactile input.
3. Mixed Sensitivity: Any combination of hyper, hypo or normal
sensitivity.
4. Fluctuating Tactile Sensitivity: Responses that change over time.
_____________________________________
Tactile Defensiveness: A learned tendency to respond negatively
or emotionally to tactile input.
6
A Three-Part Treatment Plan for
Oral-Placement Therapy (OPT)
Speech
Feeding
Oral-Placement Therapies
Martha at Birth
Before and After
7
The Clinician’s Role in Teaching
Proper Infant Feeding Techniques
• The semi-upright position of the infant during breast
feeding helps eliminate the entry of milk into the
middle ear...
• These advantages, so natural to breast-feeding, are
likely to be absent from bottle feeding unless some of
the natural techniques associated with breast feeding
are adopted.
Ruth Lawrence, MD - Journal of Pediatrics 1995;126:S112-7
Why is feeding so important to an
Oral Placement Therapy program?
SPOON FEEDING: Positioning in conjunction with proper
spoon placement in the oral cavity will address the
following goals:
• Lip Closure
• Tongue Retraction
• Jaw Grading
SPOON FEEDING:
• Lateral Placement
• Front Placement
• Spoon Slurp
8
CUP DRINKING: Choosing the right cup is very important.
Thickened liquids are easer for the client to control, when
learning a new muscle movement. As the skill level
increases, the liquids can be thinned. Specific goals of cup
drinking may include:
• Lip Closure
• Tongue Tip Elevation or Depression
• Jaw Grading
STRAW DRINKING: Many children evidence poor oral movements
with spoon fed foods, despite attempts at intervention. Straw
drinking of these traditionally fed “spoon foods” may improve
functioning. Begin with a large diameter straw and a slightly
thickened liquid (e.g. nectar). As the oral functioning improves,
reduce the diameter of the straw while increasing
the thickness of the liquid (e.g. yogurt).
Specific goals may be:
Lip Rounding
• Defining Facial Musculature
• Jaw Stability
• Independent Self-Feeding
Straw Hierarchy
GOALS: Lip Protrusion, Tongue Blade Retraction/Grading
A. Honey Bear with Straw - to teach straw drinking
B. Thin Liquids (8 Straws in Hierarchy)
- Begin with either Straw #1 or #4
A THREE-PART TREATMENT PLAN FOR ORAL PLACEMENT THERAPY
9
Oral
Placement
Therapy
A Three-Part Treatment Plan for
Oral-Motor
Therapy
To Improve
Speech Clarity andMS,
Feeding
Skills
Sara Rosenfeld-Johnson,
CCC/SLP
Straw #1
Single
Sips
#5 - #8
3. Straw Drinking Hierarchy
A. Thin liquids (8 straws in hierarchy)
1. Home Program = all thin liquids, all day
2. Criteria to move to next straw = ease or under baseline
© Copyright 1993 Sara Rosenfeld-Johnson, M.S., CCC-SLP Speech-Language
Pathologist
®
Copyright ©2013 TalkTools
12182013
Rev. 04/08
37
10
Straw #1
1
2
3
4
5
6
7
8
8
SOLIDS (Cubes or Julienne): A preference for soft foods is
frequently seen with children who have oral-motor deficits.
Introduction of “chew solids” is important for al clients with weak
jaw musculature. Gradually increasing food textures, while
acknowledging each client’s taste preferences, is an integral
component of oral-motor therapy.
Goals to be addressed include:
•
•
•
•
•
Tongue Lateralization
Jaw Stability
Jaw Symmetry
Tongue Retraction
Independent Feeding
11
Oral Placement Therapies
JAW EXERCISES – BIRTH TO 3
a. Gloved Finger
b. Finger Cuff
c. Ark Probe or Z-Vibe
d. Bite-Tube Hierarchy:
Red Tube
Yellow Tube
Purple Tube
Green Tube
4
Articulation
3
Resonation
2
Phonation
1
Respiration
12
Tongue
Lips
Jaw
PHONATION: Speech is superimposed on volitionally controlled
oral airflow.
1. Bubble Blowing: Criteria for success = 10X
! GOALS: Abdominal Grading, Jaw Stability, Lip Rounding,
!
Tongue Retraction
2. Horn Blowing: Criteria for success= 25X in rapid succession
! !
without a break
GOALS: Phonation, reduce/eliminate drooling, improve speech
clarity, improve sensory awareness/reduce hypersensitivity
Duration Requirements: Horn #1: any duration; #2: 1 second duration;
#3 & 4: 1+ second duration; #5, 6, 7 & 8: 2 second duration;
#9 & 10: 2+ second duration; #11 & 12: 3 second duration.
13
A Three-Part
Treatment
Plan for
Oral-Motor
Therapy
To Improve
Speech
Clarity
and Feeding
Skills
Sara Rosenfeld-Johnson, MS, CCC/SLP
HORN BLOWING HEIRARCHY
Phonation and Articulation
The horns presented on this &" Hierarchy form represent a technique for improving abdominal
muscle strength for prolongation of controlled exhalation. The #1 horn is the easiest to blow. The
therapist should hold the horn perpendicular to the client’s mouth. By allowing the client to hold the
horn, you may facilitate the following compensatory problems:
1. Teeth biting on the mouthpiece for jaw stability, which will inhibit jaw-lip dissociation.
2. Body extensor patterns which are associated with volitional hand-to-mouth movements in many of
our clients.
3. Bite &#
Although each horn is presented as it relates to improving &" horns are also a valuable tool for
improving articulation by increasing " creating placement and developing strength in %
muscles, and for reducing/eliminating drooling.
Working with horns facilitates increased muscle strength/muscle memory as a prerequisite to the
development of the following components of standard speech production:
1.
2.
3.
4.
Jaw grading
Jaw-lip dissociation
Jaw-tongue dissociation
Lip closure for saliva control (drooling)
5.
6.
7.
8.
Lip rounding
Tongue retraction
Back of tongue side spread
Motor planning
All horns from #9 through #12
#14 are more % to " As lip protrusion is tongue retraction
will be initiated. These horns will address tongue retraction, which is a necessary component of all
speech sound production with the exception of / 2 – " /. Use horns from #9 through #13
#12 with children
" do not necessarily have &" % but are " on the correction of an interdental lisp.
1. Flat-mouthed horns will work on lip closure to address drooling control and on phonemes that require
a) lip approximation, b) lower lip reaction and c) lower lip tension.
2. Round-mouthed horns will work on lip rounding phonemes.
3. The harder the client is required to blow using lip protrusion with tension, the more tongue retraction
you will obtain.
4. Superimposed jaw stability and assisted lip closure may be used for horn #1 & #2, but may not be
used for the remainder of the horns in the hierarchy.
5. When a client relies on lip retraction to blow a horn, it may be a compensatory pattern to establish
jaw stability. Go to a lower level on the hierarchy until the client can blow with abdominal
constriction and lip closure, rounding or protrusion. Inhibit all compensatory body postures.
6. Remember to remove the horn after each blow and to use only one horn at a time. At no time should
you be using more than 1 horn during any therapy session.
Disinfecting Statement:
Most TalkTools® products are reusable and should be thoroughly cleaned or sterilized between uses. If
this is a concern, please contact your local Center for Disease Control for further guidance.
© Copyright 1993 Sara Rosenfeld-Johnson, M.S., CCC-SLP Speech-Language Pathologist
Rev. 04/08
24
14
- Drooling control
2. Lip Closure:
Bilabial sounds / m - b - p /
- Lower lip / f - v - r /
2.
3.
HORN BLOWING HIERARCHY
HORN
BLOWING
HIERARCHY
HORN
BLOWING
HIERARCHY
1.
4.
1.
1.
2.
5.
2.
2.
7.
Jaw, Open Mouth Sounds:
4. Low
Lip Closure:
4. Lip
4. Closure:
Lip
Closure:
(vowels)
/ ah - eh
- ih
Bilabial
sounds
/m
- b- -uh
p/
Bilabial
sounds
/lip
m /-/fbm
Bilabial
sounds
- Lower
- -v-p-b/r -/ p /
- Lower
lip / flip
-control
v/ -f -r v/ - r /
Lower
8. Lip
Closure:
--Drooling
- Drooling
control
- Drooling
control
Bilabial
sounds
/m-b-p/
5. Lip Closure:
5. Lip
5. Closure:
Lip
Closure:
Bilabial
sounds / m - b - p /
Bilabial
sounds
/lip
m /-/fbm
Bilabial
sounds
- Lower
- -v-p-b/r -/ p /
Lower
lip / flip
v/ -f -r v/ - rRetraction:
Lower
/
9. Lip- Protrusion
/-control
Tongue
--Drooling
-/ w
Drooling
control
Drooling
control
- oo - ʃ - tʃ -  - s - z - t - d - ε - r /
8.
5.
5.
9.
6. Second Level Lip Rounding:
6. Second
Level
Lip Rounding:
6. Second
Level
Lip Rounding:
- Prerequisite
for lip rounding sounds / w - oo - ʃ - tʃ -  /
Prerequisite
lipforrounding
sounds
/ w - /oo
ʃ - tʃ- ʃ- -tʃ /-  /
Prerequisite
lip Retraction:
rounding
sounds
w - oo
10. Lip Protrusion for
/ Tongue
/ w Jaw,
- oo -Open
ʃ - tʃ - Mouth
 - s -Sounds:
z-t-d-ε-r/
7. Low
7. Low
Jaw,
Open
Mouth
7. Low
Jaw,
Mouth
Sounds:
Gradedairflow
(vowels)
/Open
ah
- eh
- Sounds:
ih - uh
/
(vowels)
/ ah -/ ah
eh - eh
ih --uh
(vowels)
ih -/ uh /
6.
6.
6.
10.
7.
7. 7.
8. Lip Closure:
8. Lip
8. Closure:
Lip
Closure:
11.
Lip
Protrusion
Retraction with Release:
Bilabial
sounds/ /Rapid
m - b -Tongue
p/
Bilabial
sounds
/fbm
/Bilabial
w -sounds
oo
- ʃ - /lip
tʃm- /-
Lower
- -v--p-kb/r--/gp-/ r /
- Lower
lip / flip
- v/ -f -r v/ - r /
- Lower
8.
8. 11.
8.
12.
LipProtrusion
Protrusion/ /Tongue
TongueRetraction:
Retraction:
9. Lip
9. Lip
9. Protrusion
Lip
/ wProtrusion
- oo - ʃ/ -Tongue
tʃ /- Tongue
 -Retraction:
s - zRetraction:
-t-d-ε-r/
/ w Gradedairflow
- /oo
ʃ - tʃ- ʃ- -tʃ -- 
s - -z s- -t -z d- t- -ε d- r- /ε - r /
w - oo
12.
9.
9.
9.
Oral-Motor
Goals
Oral-Motor
Goals
4.
Lip Closure:
1.
Phonation
andand
Articulation
Phonation
Articulation
5.
2. Lip Closure:
2. Lip
2. Closure:
Lip
Closure:
Bilabial
Bilabial
/lip
m/-f/ b-mv- -p-br/ -/ p /
Bilabial
sounds
-sounds
Lower
- Lower
lip / flip
-control
v/ -f -r v/ - r /
Lower
--Drooling
3. First Level Lip Rounding:
3. First
Level
Lip
Rounding:
3. Second
First
Lip
Rounding:
6.
Level
Lip
-Level
Lower
lip
/ f Rounding:
-v-r/
- Lower
lip / flip
- v/ -f for
Lower
-r v/ lip
- r /rounding sounds / w - oo - ʃ - tʃ - 
--Prerequisite
/
/
- Prerequisite
for lipforrounding
sounds
/ w - /oo
ʃ - tʃ- ʃ- -tʃ/-  /
- Prerequisite
lip rounding
sounds
w - oo
7.
4.
4.
5.
Oral
Placement
Goals
Oral-Motor
Goals
1. Lip
1. Closure:
Lip
Closure:
Bilabial
Bilabial
/lip
m/-f/ b-mv- -p-br/ -/ p /
Bilabial
sounds
-sounds
Lower
- Lower
lip
/
f
v/ -f -r v/ - r /
Lower
lip
- Drooling -control
- Drooling
control
- Drooling
control
3.
3. 6.
3.
4.
3. First Level Lip Rounding:
Phonation
- Prerequisite for lip rounding sounds / w
- oo - ʃ - tʃ -and
 / Articulation
Note:Thehornhierarchyhasbeenreconfiguredtoreflectrecentclinicaldata.ThishierarchywastestedandvalidatedbyQuestEngineeringSolutions(Billerica,MA.).Fora
10.
10. Lip Protrusion / Tongue Retraction:
10.
10. Lip
10.
10. Protrusion
Lip
copyof“TestReport#Q08024”pleasecontactTalkToolsTherapy.
/ wProtrusion
- oo - ʃ /- Tongue
tʃ - /Tongue
- sRetraction:
- z -Retraction:
t-d-ε-r/
/ w Gradedairflow
- /oo
ʃ - tʃ- ʃ- -tʃ -- 
s - -z s- -t -z d- t- -ε d- r- /ε - r /
w - oo
Gradedairflow
Gradedairflow
11. Lip Protrusion / Rapid Tongue Retraction with Release:
11. Lip
Tongue
withwith
Release:
11. Protrusion
Lip
Rapid
Release:
/ wProtrusion
- oo - ʃ /- Rapid
tʃ - /
- k -Tongue
g - rRetraction
/ Retraction
/ w - /oo
ʃ - tʃ- ʃ- -tʃ - -
k - -gk- -r g/ - r /
w - oo
11.
11. 11.
12.
12. 12.
www.talktools.net
3420 N. Dodge Blvd., Suite 148
MDSS
12. Lip Protrusion / Tongue Retraction:
Tucson, AZ 12.
85716
Lip
/- Tongue
Retraction:
12. Protrusion
Lip
Protrusion
/Tongue
Retraction:
Burckhardtstr.
1
EC
REP
/
w
oo
ʃ
tʃ
s
z
t
d
ε-r/
Phone: 888-529-2879/Local: 520-795-8544
/ w Gradedairflow
- /oo
ʃ - tʃ- ʃ- -tʃ -- 
s - -z s- -t -z d- t- -ε d- 30163
r- /ε - r / Hannover,
w - oo
Fax: 520-795-8559 [email protected]
Gradedairflow
Gradedairflow
Germany
This
hierarchy was tested and validated by Quest Engineering Solutions (Billerica, MA.). For a copy of “Test Report #Q08024” please contact TalkTools Therapy
WARNING: Therapy tools should not be used without therapist or parent supervision.
Copyright ©1993 TalkTools® / Innovative Therapists International
3420 N. Dodge Blvd., Suite 148
MDSS
34203420
N. Dodge
Blvd.,
Suite
148 148
N. Dodge
Suite
Tucson,
AZBlvd.,
85716
MDSS
MDSS
®
Copyright
©2013 TalkToolsEC
12182013REP
Burckhardtstr.
1
Tucson,
AZ
85716
Tucson,
AZ
85716
Phone: 888-529-2879/Local: 520-795-8544 EC EC REPREPBurckhardtstr.
1 1
Burckhardtstr.
30163
Hannover,
Phone:
888-529-2879/Local:
520-795-8544
Phone:
888-529-2879/Local:
520-795-8544
Fax:
520-795-8559
[email protected]
15
Germany
ARTICULATION: Jaw Activities
1. Feeding Program - Chew on back molars
2. Non-Food Jaw Activities
1
2
3
4
5
6
7
HIGH
MEDIUM
LOW
8
Jaw Grading Bite Blocks
Three sequential exercises for each Bite Block height:
1. Bite Block
2. Twin Bite Block
3. Bite Block for Jaw Stability
16
ToTreatment
Improve Speech
and Feeding
A Three-Part
Plan forClarity
Oral-Motor
TherapySkills
Sara Rosenfeld-Johnson, MS, CCC/SLP
1. How to Evaluate Jaw Stability:
A. Bite Block Exercise: (Bite Block #2 – Bite Block #7)
1. Place a single Bite Block #2 on the surface of the lower back molars on the left side, extending from the
front of the mouth.
2. Instruct the client to bite and hold
3. While maintaining the bite, pull forward with isometric resistance (inhibit all compensatory posturing).
4. Hold the isometric pull for 15 seconds.
5. Repeat on the right side.
Criteria for Success: 15 seconds per side, 1 time. (Diagnostic)
Bite-Hold Picture
B. Twin Bite Block Exercise: (Bite Block #2 through Bite Block #7)
1. Place a single Bite Block #2 on the surface of the lower back molars on each side, extending from the
front of the mouth.
2. While maintaining the bite, pull forward with isometric resistance (inhibit all compensatory posturing).
Criteria for Success: 15 seconds, 1 time. (Diagnostic)
C. Bite Block for Jaw Stability Exercise: (Bite Block #2 through Bite Block #7)
1. Place a single Bite Block #2 on the surface of the lower teeth extending across midline.
2. Maintaining the bite, pull forward with isometric resistance (inhibit all compensatory posturing).
Criteria for Success: 15 seconds, 1 time. (Diagnostic)
Repeat the same sequence of exercises: A. Bite Block Exercise, B. Twin Bite Block Exercise, and C. Bite
Block for Jaw Stability Exercise, using Bite Blocks #3 through #7 as the Criteria for Success is achieved.
NOTE: The diagnostic assessment is completed as soon as the Criteria for Success is not met at any step
in the sequence.
17
Rev. 04/08
28
Dissociation: TONGUE FROM JAW
PHONEME EX.
MUSCLE MOVEMENT
1. Retraction- Protrusion: Balance (Equal range of
motion)
2. Retraction- Protrusion: Imbalance
Gradual increase in retraction
Gradual decrease in protrusion
3.
(all sounds except th)
Retraction (stability) - Lateralization of tip
a. Midline to both sides
b. Across midline
4. Retraction - Tip Elevation/Depression
(t, d, n, l, s, z, sh, ch, j, k, g)
5. Retraction - Back of Tongue Side Spread
(stability for co-articulation, er)
BLADE RETRACTION
! Lip Protrusion=Tongue Retraction
! Straw Drinking Hierarchy
Tongue Lateralization: TalkTools® Tongue-Tip Lateralization Tool
Prerequisite: Complete all 3 exercises using Bite Block #2 - #5
Midline to Left
! Midline to Right
! Across Midline
Position A
Position B
Position C
Criteria for success: Repeat the appropriate unit 5 times
TONGUE TIP ELEVATION AND/OR DEPRESSION:
TalkTools® Tongue-Tip Elevation/Depression Tool
Prerequisite: Complete all 3 exercises using Bite Blocks #2 - #7
Tongue- Tip Elevation Up
! Tongue- Tip Depression Down
Text
! Up and Down
Criteria for success: Repeat the appropriate unit 5 times
18
8
1
2
3
4
5
6
7
8
Phoneme Associations
PRODUCTION OF /S/ AND /Z/
1. Place tip of tongue depressor between closed front teeth
2. Repeat “Up and Down” 5x
3. Say “ts” – freeze your articulators
4. “Where is your tongue tip?”
5. Teach /s/ and /z/ in that position
What is the Diagnosis?
RACHEL: AGE 10 YEARS
LATERAL PRODUCTION OF: /S/, /Z/, /!/, /t!/and /d!
1. Speech therapy for 4 years
2. Did not know how to make the /s/ or /z/sounds when she started
3. Deficits: Asymmetrical Jaw Weakness, Reduced mobility in the lips, Tongue
Protrusion
4. Initial Program Plan:
Straw #4
Spoon Slurp
Bite-Tube Hierarchy
Bubble Bear
Horn #7
Jaw Grading Bite Block #4
Button Pull
Tongue Depressor for Lip Closure
Reference: Rosenfeld-Johnson, 2009: Oral Placement Therapy for /s/ and /z/, TalkTools
19
Ready for Production
RACHEL: AGE 11 YEARS
LATERAL PRODUCTION OF:
/S/, /Z/, /!/, /t!/and /d!/
1. Nine months after Oral Placement Therapy was started
2. Rachel was seen 2 times per month - homework was practiced a minimum
of 3 times per week
3. OPT Program Plan Completed:
Straw #8, Straw D with pudding texture
Bite-Tube Hierarchy - 10 aligned bites on both sides
Bubble Bear - 4 feet, 10 times
Horn #12, 25 times at 3 second duration
Jaw Grading Bite Block #7 - Symmetrical Jaw Skills
Tongue-Tip Lateralization Tool
Tongue-Tip Elevation/Depression Tool
What is the Diagnosis?
DEVORAH: AGE 36 YEARS
INTERDENTAL PRODUCTION OF: /L/, /S/ AND /Z/
1. Speech therapy on and off from age 3 through age 18
2. Did not know how to make the /s/ or /z/sounds when she started
3. Deficits: Asymmetrical Jaw Weakness, Reduced Mobility in the Lips, Tongue
Protrusion, Limited Abdominal Grading (clavicular)
4. Initial Program Plan:
Straw #1
Spoon Slurp
Bite-Tube Hierarchy
Bubble Tube
Horn #1
Jaw Grading Bite Block #2
Final Speech Therapy Session
DEVORAH: AGE 36 YEARS
INTERDENTAL PRODUCTION OF: /L/, /S/ AND /Z/
1. Seven months after Oral Placement Therapy was started
2. Devorah was seen 2 times per month - homework was practiced a minimum
of 3 times per week
3. OPT Program Plan Completed:
Straw #8, Straw D with pudding texture
Bite-Tube Hierarchy - 10 aligned bites on both sides
Bubble Bear - 4 feet, 10 times
Horn #12, 25 times at 3 second duration
Jaw Grading Bite Block #7 - Symmetrical Jaw Skills
Tongue-Tip Lateralization Tool
Tongue-Tip Elevation/Depression Tool
20
Straw Drinking Hierarchy
Horn Blowing Hierarchy- Horns # 3, 6, 7, 9, & 10
OO-EE
Button Pull
Cheerio for Lower Lip Retraction
Protrusion/
Retr action
Lower Lip Retr action
r, vocalic /r/
f, v
m, r, vocalic /r/, t, d, L, n, s,
z, 1(sh), b, k, f, g, t1, d8, p, v,
n, #, , 4, #i, , o, I, a, i, ae
(up), #i (aim),
(the), O (own), I (his), a (father),
* Phonetic chart for vowels: # (egg),
Back of Tongue Side
Spread
r, vocalic /r/, 1(sh), t1, d8, nz, 4,
#i, I, i, u
(off), i (eat), u (to), ae (ask)
Horn Blowing Hierarchy- Horn # 14 only
Straw Drinking Hierarchy- Straw # 8 and cocktail straw
Horn Blowing Hierarchy- Horns # 9, 10, 11, 12, 13, & 14 all sounds with the exception
Bubble Blowing Hierarchy
of " and 2
Straw Drinking Hierarchy
Candle Blowing Hierarchy
Golf Ball Air Hockey
prerequisite: tongue tip elevaTongue Tip Later alization Tongue Tip Lateralization Tool
Across Midline
Bite Touch
tion and depression sounds
Tongue Tip Elevation/Depression Tool
Tongue Tip Elevation
t, d, L, n, s, z, t1, d8
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Cheerio
_ _ _ _ for
_ _Tongue
_ _ _ _Tip
_ _Elevation
____________________________________
Tongue Tip Elevation/Depression Tool
Tongue Tip Depression
s, z, k, g
Cheerio for Tongue Tip Depression
Retr action
v
Tongue
Sponge-Balsam-Tongue Depressor
Single-Sip Cup Drinking
Horn Blowing Hierarchy- Horns # 1, 2, 3, 4, 5, & 8
Tongue Depressor for Lip Closure
Open to Closed
Closed to Open
Tongue Depressor with Pennies
Jaw Grading Bite Blocks using # 6 and # 7
Jaw Bite Tube Set
low
Lower Lip Protrusion/
Tension
t, d, L, n, s, z, b, k, d, g, ", 2,
p, n, #, , #F, , a, ae
Jaw Bite Tube Set
medium
e
© Copyright 1993 Renee Roy-Hill, M.S., CCC-SLP Speech Language Pathologist
c
Lips
m, r, vocalic /r/, s, n, z, 1 (sh),
b, f, t1(ch), d8 (j), p, 3, ', F, R
vocalic /r/, t, L, d, "(th),
2(th), #, , ,
k, g, n, a, ae
Jaw Bite Tube Set
v
v
high
Speech Sounds
e
e
C e S
jaw
Oral
Placement
Therapy
Or
al-Motor
Ther
apy
OralMovements
Placement Therapy
(OPT) To
Improve
SpeechSpeech
Clarity and
Feeding Skills
Necessary
for
Standard
Production
79
21
(Rev. 10/01/08)
Skills
Communication Disorders Quarterly OnlineFirst, published on February 8, 2010
as doi:10.1177/1525740109350217
To Improve
Speech Clarity and Feeding
Treatment of Children With Speech
Oral Placement Disorders (OPDs):
A Paradigm Emerges
Communication Disorders Quarterly
XX(X) 1–8
© 2010 Hammill Institute on Disabilities
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1525740109350217
http://cdq.sagepub.com
Diane Bahr1 and Sara Rosenfeld-Johnson2
Abstract
Epidemiological research was used to develop the Speech Disorders Classification System (SDCS). The SDCS is an important
speech diagnostic paradigm in the field of speech-language pathology. This paradigm could be expanded and refined to also
address treatment while meeting the standards of evidence-based practice. The article assists that process by initiating a
clinical exchange of ideas on the topic of speech treatment. It explores: (a) the treatment of children with speech oral
placement disorders (OPD; a new term suggested by the authors), (b) the various types of speech oral placement therapy
(OPT) used to treat OPD, (c) the relationships of OPT to current motor learning theories and oral motor treatment, as
well as (c) the critical need for appropriately designed, systematic research on OPT.
Keywords
speech treatment, speech disorders, motor learning, oral motor treatment, evidence-based practice
The Speech Disorders Classification System (SDCS;
Shriberg, 1993, 1994; Shriberg, Austin, Lewis, McSweeny, &
Wilson, 1997) contains a number of subcategories under the
subtopic of speech delay. The subtopic of speech delay falls
under the overall category of developmental phonological
disorders in the SDCS. According to this system, speech
delay can result from
v
v
v
v
v
Definition of Speech
Oral Placement Disorders
Oral placement disorder (OPD) is a new term suggested by
the authors. Children with speech OPDs may have typical or
atypical oral structures. The key to the definition of OPD lies
in the child’s ability or inability to imitate auditory-visual
stimuli and follow verbal oral placement instructions.
an unknown, possibly genetic, origin,
otitis media with effusion,
childhood apraxia of speech,
developmental psychosocial impairment, or
craniofacial and sensory-motor impairment in
special populations.
These classifications are important diagnostic categories. However, it is unlikely that children within these
SDCS diagnostic subcategories fit into homogeneous
treatment groups. It is more likely that treatments will
vary within each subgroup based on individual needs.
This article proposes ideas to further refine and possibly
expand the SDCS system to account for this variability. It
is hypothesized that at least two treatment subgroups
(i.e., children with oral placement disorders and those
without) will be found within each SDCS subcategory
listed here.
Suggested definition: 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, 2001, in press; DeThorne, Johnson,
Walder, & Mahurin-Smith, 2009; Hammer, 2007; Hayden,
1
Ages and Stages, LLC, Las Vegas, NV
TalkTools Therapies, Tucson, AZ
2
Corresponding Author:
Diane Bahr, Ages and Stages, LLC, 11390 Patores Street, Las Vegas, NV 89141
Email: [email protected]
22
2
Communication Disorders Quarterly XX(X)
2004, 2006; Kaufman, 2005; Marshalla, 2004; Meek, 1994;
Ridley, 2008; Rosenfeld-Johnson, 1999, 2009; Strand,
Stoeckel, & Baas, 2006).
Oral placement disorder does not apply to children with
speech delay who can imitate targeted speech sounds using
auditory-visual stimuli and can follow specific verbal
instructions to produce targeted speech sounds. Yet, some
speech-language pathologists (SLPs) use methods developed for these children to treat children with OPDs.
Treatment of Speech OPDs
When a child with an OPD is treated using auditory-visual
imitation and verbal instruction alone, clinical improvements in speech production and intelligibility may be
extremely limited and progress may be slow. Occupational
therapy (OT) and physical therapy (PT) colleagues facilitate movement patterns using the tactile and proprioceptive
sensory systems. Because speech is a fine-motor, tactileproprioceptive act, a number of SLPs also facilitate speech
movements and placements in children with OPD via
tactile-proprioceptive input (Bahr, 2001, in press; Hammer,
2007; Hayden, 2004, 2006; Kaufman, 2005; Marshalla,
2004; Meek, 1994; Ridley, 2008; Rosenfeld-Johnson, 1999,
2009; Strand, et al., 2006).
Using the work of OTs and PTs as a model, SLPs first
evaluate the movement and placement of mouth structures
for speech production. It is more difficult to observe intraoral than extraoral movements and placements. However,
instrumentation such as ultrasound imaging (Sonies, 1998;
Ridley, Sonies, Hamlet, & Cohen, 1990, 1991) and palatometry (Fletcher, 2008) will hopefully become increasingly available for this process. Currently, the SLP must
infer intraoral movements from a thorough oral mechanism
examination (including palpation of the oral structures) and
an evaluation of speech production patterns (e.g., fronting,
backing, etc.).
Once the SLP identifies and understands the oral movements
used in a child’s speech production, tactile-proprioceptive
techniques for speech articulator placement can be used.
These techniques are found in the work of Diane Bahr (2001,
in press), David W. Hammer (2007), Deborah Hayden
(2004, 2006), Nancy Kaufman (2005), Pamela Marshalla
(2004), Merry Meek (1994), Donna Ridley (2008), Sara
Rosenfeld-Johnson (1999, 2009), Edythe Strand (Strand,
et al., 2006), and others. The methods represent a paradigm
of tactile-proprioceptive treatment, different from traditional
auditory-visual approaches. This can be termed oral placement therapy (OPT, Rosenfeld-Johnson, 2009) because
tactile-proprioceptive oral placement techniques are used to
directly facilitate speech sound production.
Phonetic placement therapy (PPT), as discussed by Van
Riper in 1954 (pp. 236–238), has been used historically to
improve speech production. Traditional articulation
and phonology treatments use auditory-visual cueing and
verbal instruction for phonetic placement. OPT uses
proprioceptive-tactile input to attain phonetic placement.
Oral placement therapy is combined with other approaches
in this paradigm. For example, Diane Bahr (in press) and
Nancy Kaufman (2005) also use bottom-up speech approaches
(e.g., moving from vowel, consonant-vowel, vowel-consonant,
to more complex speech productions) in conjunction with OPT.
David W. Hammer (2007) and Deborah Hayden (Hayden &
Square, 1994) use hierarchical speech approaches (i.e., building speech from sounds a child can produce) along with OPT.
Other therapists combine OPT with more traditional articulatory approaches (i.e., building the use of a targeted speech
sound from isolation to carry-over in conversation). Carryover to standard speech sound production is obtained through
repetition and practice incorporated into daily homework
assignments in all types of treatment.
The following sequence is seen in many forms of OPT
(Bahr, 2001, in press; Crary, 1993, p. 224; Hayden, 2004,
2006; Marshalla, 2004, 2007; Meek, 1994; RosenfeldJohnson, 1999, 2009; Young & Hawk, 1955):
1.
2.
3.
Facilitate speech movement with assistance
of a therapy tool (e.g., bite block) and/or other
tactile-proprioceptive facilitation technique (i.e.,
manipulation of oral structure by therapist);
facilitate speech movement without therapy tool
and/or other tactile-proprioceptive technique; and
immediately transition movement into speech
with and without therapy tool and/or other tactileproprioceptive facilitation technique.
(Note: This will be different based on the individual
child. Some children can handle speech work along with
sensory-motor facilitation. Other children may need the
speech production added once the appropriate movement is
established. Information on motor learning theories can
assist the SLP in understanding how this may work.)
When a child receives speech OPD remediation, the following sequence may be seen:
1.
2.
3.
The child is first assessed to evaluate if he or she
can produce speech sound(s) in isolation using
auditory-visual cueing and/or verbal instruction.
If the child can produce the targeted speech
sound(s), then tactile-proprioceptive placement
work is not needed and typical speech production work can begin.
If the child cannot attain targeted speech
sound(s) with auditory-visual input, a thorough
assessment of oral sensory and motor function
for speech is required.
23
3
Bahr and Rosenfeld-Johnson
4.
Once abnormal oral placement patterns are identified, a hierarchy of tactile-proprioceptive therapeutic activities is used to teach targeted movements
needed for speech. This is hypothesized to teach the
“feel” of speech while developing motor plans or
gestures for speech. The section on motor learning
theories explains these processes. Oral placement
is practiced until the child performs the movement
and speech sound without a therapy tool and/or
other facilitation technique. Tactile-proprioceptive
treatment techniques are hypothesized (in schema
theory) to establish muscle memory/motor plans
so the child can retrieve the oral placement for
speech sound production. As soon as placement is
attained, it is immediately transitioned into speech.
Hayden (2006), Strand, Stoeckel, and Bass (2006),
as well as DeThorne et al. (2009) have written
about the use of tactile-proprioceptive treatment
techniques to facilitate speech production in recent
journal literature.
If a traditional articulation treatment approach is used,
the speech sound is taught in isolation and then expanded to
syllables, words, phrases, sentences, and so on. However,
phonological process, bottom-up (e.g., V, CV, VC, CVC,
etc.), or other speech treatment approaches may also be
combined with OPT.
The goal of OPT is to transition appropriate oral movements into speech during the same therapy session. For
example, if a child cannot produce the /m/ sound with
auditory-visual cueing and/or verbal instruction, then a thin
bite block or tongue depressor may be placed on the inner
borders of the lips to attain the appropriate oral movement
and speech sound. Once the sound is attained it can be moved
immediately into speech work. Another way to facilitate the
/m/ sound would be through Prompts for Restructuring Oral
Muscular Phonetic Targets (PROMPT) or Moto-kinesthetic,
hands-on speech facilitation approaches where the therapist
brings the child’s lips together manually.
Speech Oral Placement Therapy (OPT)
and Motor Learning Theories
Oral placement therapy may be congruent with current yet
somewhat opposing theories of motor learning (i.e.,
dynamic systems theory and schema theory). Kent (2008)
discusses the differences between these theories in his
recent article entitled “Theory in the Balance.” According
to Kent, dynamic systems theory has not been widely
applied in speech-language pathology. Most OPTs appear
to be based on the schema theory and motor programming.
However, Edythe Strand’s (Strand, et al., 2006) Dynamic
Temporal and Tactile Cueing (DTTC) and Deborah
Hayden’s (2004, 2006) Prompts for Restructuring Oral
Muscular Phonetic Targets approaches appear to have been
developed from dynamic systems theory. Both theories may
have some value in the discussion of OPT.
Dynamic systems theory (Kent, 1999, p. 60–62) is based
on “motor gestures,” which are “abstract representations of
movement.” Sensory processing and motor output are inextricably connected to form synergies that are said to be
“softly assembled to create stable but flexible units of
action.” A particular synergy is related to a specific movement goal but may accomplish different motor tasks. Kent
provides this example: In “oral motor control . . . a synergy
based on lip and jaw muscles can be useful in eating and
drinking but also in forming the bilabial sounds of speech”
(p. 62). The difference between these tasks is in the assembly and tuning of the movements. The child must know
which gestures to use, then assemble and tune the gestures
for speech. Gestures for speech are tuned and assembled
differently than gestures for eating, drinking, or other mouth
activities. Oral placement therapy assists the child in developing, assembling, and tuning the oral motor gestures
needed for targeted speech sounds. This is qualitatively different from the idea of motor planning for speech
production.
Maas et al. (2008, p. 279–280) discuss schema theory
(i.e., the work of Schmidt, 1975, 2003, and Schmidt & Lee,
2005). They say, “schema theory . . . assumes that production of rapid discrete movements involves units of action
(motor programs) that are retrieved from memory and then
adapted to a particular situation.” Motor programs are said
to be generalized by capturing the unchanging aspects of a
movement. A single generalized motor program (GMP)
may govern a general class of movements that is graded for
the demands of a particular task. Oral placement therapy
appears to help establish oral motor plans that cannot be
established by traditional auditory-visual cueing and verbal
directions. It uses the concept of the GMP to place those
motor plans directly into speech production.
The basic tenants of OPT also align with the research of
Moore and his colleagues (Green et al., 1997; Moore &
Ruark, 1996; Moore, Smith, & Ringel, 1988; Ruark &
Moore, 1997). Their research revealed that motor coordination for speech production is likely controlled by different
neural mechanisms than motor coordination for eating,
drinking, and other nonspeech tasks, particularly beyond 2
years of age. Oral placement therapy facilitates movements
used in speech production only and supports the idea that
eating, drinking, speaking, and other oral activities have
distinct motor plans.
Oral Placement Therapy in Relationship
to Oral Motor Treatment
Until now, there was no term for OPT, so it was frequently
filed under the heading of oral motor treatment. Not all
24
4
therapy under this umbrella term is the same. Treatments
targeting specific movements for speech sound production
have unfortunately been categorized with treatments not
targeting specific speech sound production. This can be better understood by reviewing Bahr’s research regarding the
misunderstanding and confusion surrounding the term oral
motor treatment.
Bahr (2008) found some of the first references to the term
“oral motor” in 1980s peer-reviewed journal literature describing feeding and motor speech behaviors (e.g., Alexander,
1987; Morris, 1989). However, some recent authors and presenters (Banotai, 2007; Bowen, 2005; Clark, 2005; Flaherty
& Bloom, 2007; Insalaco, Mann-Kahris, Bush, & Steger,
2004; Lass, Pannbacker, Carroll, & Fox, 2006; Pannbacker
& Lass, 2002, 2003, 2004; Polmanteer & Fields, 2002;
Pruett-Hayes, 2005; Ruscello, 2005; Williams, Stephens, &
Connery, 2006) appear to narrowly define and equate the term
oral motor treatment with nonspeech oral motor exercise and
treatment (NSOME/NSOMT). It is important to note that the
majority of these articles and presentations did not appear in
peer-reviewed journals.
The recent narrow use of the term oral motor treatment
has apparently caused significant misunderstanding and
confusion within the field of speech-language pathology.
According to Bahr (2008), 74% of 500 SLPs surveyed said
they had heard the general statement “oral motor treatment
does not work” from colleagues, professors/instructors,
and other sources. Bahr then looked at how these same
therapists defined oral motor treatment. Approximately
70% of SLPs considered feeding/oral phase swallowing,
motor speech, oral awareness/discrimination, and oral
activities/exercises as part of oral motor treatment. With
74% of therapists hearing the general statement “oral motor
treatment does not work,” and approximately 70% of therapists defining oral motor treatment as feeding/oral phase
swallowing, motor speech, oral awareness/discrimination,
and oral activities/exercises, the confusion and misunderstanding in the field of speech-language pathology regarding the term oral motor treatment is understandable.
Oral placement therapy for speech is a form of oral
motor treatment, but it only targets movements used in
speech sounds. It can be used with both children and adults
who cannot imitate targeted speech sounds (RosenfeldJohnson, 2008). OPT for speech does not include activities
unrelated to speech sound production such as “tongue wagging” and “cheek puffing” (Lof & Watson, 2008). The concepts of OPT are consistent with information in articles by
authors discussing NSOME/NSOMT (e.g., recent articles
found in Language Speech and Hearing Services in Schools,
39, July 2008). Only speech movements are targeted in
OPT. Movements dissimilar to speech are not used in OPT
to facilitate speech. Therefore, OPT for speech is not
NSOME/NSOMT.
A number of forms of OPT are listed in Table 1. The
approaches seem to have some important common characteristics. Most of them appear to involve task analysis that is
systematically and hierarchically applied. Only movements
needed for identified speech sounds are targeted. These
movements are facilitated in a repeated manner, so appropriate speech movements can be generalized throughout the
processes of co-articulated speech. Most of the listed
approaches involve hands-on, tactile-proprioceptive facilitation techniques. However, two of the approaches (i.e., palatometry and ultrasound imaging) reflect instrumentation
currently unavailable to most SLPs.
Implications for the Field of SpeechLanguage Pathology
This article is meant to stimulate a clinical exchange among
SLPs regarding the appropriate treatment of children with
speech delay. It describes a treatment group (i.e., children
with OPD) not defined in past literature. It also explores the
variety of current treatments for children with OPD (i.e.,
OPT). The authors suggest the expansion and refinement of
the SDCS to address treatment categories because children
fitting current SDCS diagnostic categories do not appear to
form homogenous treatment groups. The relationships of
OPT to current motor learning theories and oral motor treatment are described, so that SLPs can use this information as
part of a clinical exchange. It is important for SLPs to
understand that OPT is a form of oral motor treatment;
however, it is not NSOME/NSOMT. Knowledge of motor
learning theories is also crucial for SLPs, because current
OPTs are based on these. The clinical exchange is ultimately needed to develop appropriate treatment studies to
fulfill the requirements of evidence-based practice.
A Call for Research
Of the clinicians listed in Table 1, Hayden (1994, 2006;
Hayden & Square, 1994) and Strand (1995; Strand et al., 2006)
have published information in peer-reviewed journal literature
relative to OPT. Meta-analysis (Robey & Dalebout, 1998) and
randomized controlled trials (e.g., Gillam et al., 2008) comparing the variety of tactile-proprioceptive OPT approaches for
speech are needed. An epidemiological study like the one used
to develop the SDCS (Shriberg, 1994) is recommended to
establish the validity of the proposed subgroups (i.e., children
with speech OPDs vs. those without speech OPDs).
Bahr (2008) also recommended that doctoral-level
researchers and master’s-level clinicians work together on
this process. Doctoral-level researchers with expertise in
oral motor function are needed to develop appropriate studies comparing speech OPT approaches. Master’s-level clinicians who use OPT are needed to collect the data for the
25
5
Table 1. Some Current Oral Placement Therapies
Therapists
Type of Treatment
Description
Diane Bahr (2001, in
press)
Hands-on, tactileproprioceptive and
bottom-up speech
approaches combined
Samuel Fletcher (2008)
Palatometry
David W. Hammer
(personal
communication,
August 19, 2009)
Touch cues
Therapist’s gloved hand/fingers placed near/on lips and/or under tongue base/
mouth floor to facilitate appropriate speech oral movements while presenting
speech production stimuli (e.g., pictures, words, etc.) beginning with vowels
and moving toward increasingly complex speech sound combinations (e.g.,
CV,VC, CVC, etc.). Appropriate props (e.g., bite blocks to attain graded jaw
height) may also be used.
“Computerized visual-auditory feedback tool that provides an online, dynamic
display of the tongue’s contact with the hard palate during speech and
swallowing functions.” (Dorais, 2009, p. 1)
“Combined with sign language (e.g., to prompt the final sound in the signed
word), touch cues are used on the therapist’s structures as a model or on
the child’s structures when needed. Visual prompts are provided to indicate
manner of production and to signal when the vowel or consonant is added
to the sequence (e.g. moving down string for an /s/ and then when hitting a
button at the bottom of the string the èe’ is added for `see’; pushing finger
away from lips while saying àh’ until finger touches other person’s and then
vowel is added like òo’ for `shoe’).”
Deborah Hayden
(2004, 2006)
Prompts for
Restructuring Oral
Muscular Phonetic
Targets (PROMPT)
Visual/tactile cues
Nancy Kaufman (2005)
Pamela Marshalla
(2004);
Pamela Rosenwinkel
(1982)
Merry Meek (1994)
Donna Ridley (2008)
Sara Rosenfeld-Johnson
(1999, 2009)
Barbara Sonies (1998);
Donna Ridley (Ridley,
Sonies, Hamlet, &
Cohen, 1990, 1991)
Edythe Strand (Strand,
Stoeckel, & Baas,
2006)
Uses tactile-kinesthetic input to shape or reshape muscle actions and speech
subsystems to produce speech.
Oral-Motor techniques
in articulation &
phonological therapy
(2004); Tactileproprioceptive
techniques in
articulation therapy
(1982)
Motokinesthetic Approach
[DVDs]
Tactile-kinesthetic
cues, muscular
manipulation,
ultrasound imaging
Oral placement therapy
(OPT)
Ultrasound imaging
Dynamic temporal and
tactile cueing
Uses least invasive tactile-proprioceptive input only when child cannot produce
speech target via visual and auditory cueing. Tactile-proprioceptive cueing
demonstrated on therapist before touching child.
“Hands-on” and “hands-off” tactile-proprioceptive stimulation added to
traditional articulation and phonological therapy for clients who do not
progress with visual and auditory stimuli.
Meek demonstrates hands-on, tactile-proprioceptive manipulation of the oral
structures to assist the child in producing specific speech sounds/sound
combinations (originally developed by Young & Hawk, 1955).
Hands-on manipulation of child’s oral structure to directly facilitate speech
sound production. See description of ultrasound imaging below.
Therapist task analyzes dissociation, grading, and direction of oral and
respiratory movements needed for targeted speech sound production
and applies appropriate tool(s) with required number of repetitions to
teach motor plans similar to standard speech production. Movements and
placements are transferred directly into speech production as soon as
possible.
Provides auditory and visual feedback regarding tongue shape, movement, and
placement during speech production.
When child cannot produce speech target via typical auditory-visual imitation,
various levels of cueing systematically added (e.g., unison, oral movement
without voice, rate variation, and tactile/gestural cues as appropriate). Based
on the work of Rosenbek, Lemme, Ahern, Harris, and Wertz (1973).
26
6
studies. This could be completed with relative ease as there
seem to be a significant number of clinicians using these
techniques. This type of collegial effort could facilitate
more cohesion in the field between doctoral level researchers and master level clinicians.
Here are some important questions to ask with such
research:
v Which tactile-proprioceptive OPT techniques (for
speech) are most effective?
v Which combination of treatment approaches work
best with OPT?
v For whom is OPT most effective?
Acknowledgments
Feedback obtained and incorporated from colleagues: Heather
Clark, PhD, Raymond D. Kent, PhD, Edwin Maas, PhD, and
Donna Ridley, MEd.
Declaration of Conflicting Interests
The authors declared a potential conflict of interest (e.g. a financial relationship with the commercial organizations or products
discussed in this article) as follows: Diane Bahr, is the co-owner
of Ages and Stages, LLC (providing workshops for professionals)
and Sara Rosenfeld-Johnson is the owner of TalkTools Therapies
(providing materials and workshops for professionals).
Funding
The authors received no financial support for the research and/or
authorship of this article.
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About the Authors
Diane Bahr, MS, CCC-SLP, NCTMB, CIMI, is a certified
speech-language pathologist in private practice. She teaches
nationally and internationally on the topics of feeding, motor
speech, and other aspects of mouth function.
Sara Rosenfeld-Johnson, MS, CCC-SLP, is a certified speechlanguage pathologist who 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 (OPT).
29
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       
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         
       
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     
         
       
       
     
      
       
      

     

  
     
      


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
        
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
    
       


       
       
        
      
     
        
    
      
     

       
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     
     
      
       

      
        
     


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
       

       
         
          
        


       

      

       
      
      



        
      
       
        
       
        

         



30

        
      


        
   
     

      
      
       
       
     

      
      

        
       

      
      




     
      
       
    
     
      
     
     
       


        
      
        
        
        

      
       
        

      
        
     
        


        


        




        
        
        
       
          

     



         

        
        
      



      
      
     

    
       

        
      


      
      

     
       



31
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* Contains a comprehensive reference list for “oral-motor” articles.
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Oral Placement Therapy - Down Syndrome Information Alliance

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