Coordinated Oral Motor Treatment: From No Speech to Speech
By: Diane Bahr, MS, CCC-SLP, CMT, CIMI
Cole was a 4 ½ when he first visited my office. He used approximately 100 signs and a Dynavox to communicate. His neurologist said it was doubtful Cole would develop speech. However, his parents were not quite ready to accept this.
Cole had been a very low tone baby and had been fed by a G-tube until 4 years of age. By age 5 he was eating and drinking in a functional manner. However, Cole only vocalized laughter and occasional sounds. He had poorly graded movements throughout his body including his respiratory, vocal, and oral mechanisms.
By age 6, Cole was speaking in intelligible phrases and short sentences. What approach/approaches brought this little boy from “no speech to speech” in a year and a half? Cole was treated systematically using the following combination of treatment approaches.
Massage/Facilitation: His family and speech-language pathologists massaged Cole’s mouth using a 1-3 minute awareness massage 3 times daily throughout the treatment process. This was done as part of tooth brushing if it could not be done prior to speech practice. Some of Debra Beckman’s facilitation techniques had also been used early in Cole’s treatment.
Specific Jaw Work: Jaw work was added over time with Cole. He ultimately used a graded munch chew on appropriate Chewy Tubes at least 12-15 times at each back molar area over 3 sets. He completed this activity 3-5 times per week and continued the work throughout the treatment process. Chewing work at the back molar area also encouraged Cole’s tongue retraction. He worked through graded jaw heights using the Bite Block Hierarchy from TalkTools. Sound production work was added to the Bite Block work (i.e., appropriate speech sounds were facilitated via motokinesthetic cueing or PROMPT while the Bite Blocks were in place).
Graded Jaw, Lip, Tongue and Respiratory Work: This was done using the Bubble Blowing, Horn Blowing, and Straw Drinking Hierarchies from TalkTools. These systematic exercise programs assisted Cole in establishing some graded control of his respiratory mechanism (i.e., diaphragm, abdominal muscles, etc.). They also helped him to develop graded jaw, lip, and tongue movement (i.e., just enough movement for the activity). These programs were introduced in such a way that Cole could do them as part of his daily activities 3 to 5 times per week. The manner in which Cole completed the activities was facilitated and monitored by his parents and therapists to be sure that Cole used the tools properly.
Speech: The Kaufman Speech Praxis Treatment Kit for Children was used as a basic curriculum to assist Cole in establishing speech. The Stevenson Language Skills Program, a phonics based reading curriculum, was used to supplement the work with the Kaufman. Both curriculums build speech “from the bottom up.” I used PROMPT, a form of what I call “hand-over-mouth” speech cueing, in conjunction with the Kaufman and Stevenson curriculums. Speech practice was done by the family and therapists a minimum of 5 times per week. I treated Cole privately for one 45-minute session per week. His public school clinician continued to treat him for four 30-minute sessions per week. His family followed-up at home. In conjunction with the techniques previously discussed, the approach from Rosenbek and associates was used. Speech work was begun in unison working toward imitation and ultimately functional daily activities. Many forms of pacing and visual-tactile cues were used. Visual-tactile cues developed by Judy Jelm at the place of articulation were used once “hand-over-mouth” speech work (i.e., Motokinesthetics or PROMPT) was not required. Pacing was done with pacing boards, drums, and movement activities.
Today (5 years later), Cole is speaking in full, understandable sentences. His greatest difficulties continue to be the respiratory support and vocal control needed for speech. He has had pulmonary issues since birth. However, considering his initial prognosis for speech, his progress is truly amazing.
So what made the difference for Cole? At the time he was initially evaluated at age 4 ½, he was already being seen by a speech-language pathologist 4 times per week with good family support and follow-up. This is how he obtained his level of communication using sign language and the Dynavox. However, he had no speech. You might wonder if he was an elective mute, but there were no signs of this. Once he had the awareness in his mouth from consistent use of oral massage and began to develop the appropriate movement patterns needed for speech via systematic oral exercise work along with a systematic speech curriculum, he began speak. The “hand over mouth” speech work showed him how his mouth needed to move for speech. The oral exercise work helped him to learn to retract his tongue as well as begin to grade the movements of his oral and respiratory mechanisms, so that he was not working against me with ungraded movements when I facilitated speech. Dynamic tongue retraction, as well as graded movements of the jaw, lips, tongue, and respiratory mechanism are essential for good coarticulated speech production.
These are the methods that systematically allowed Cole to develop the skills required for the very complex fine motor function we call “speech.” The word systematic is important here. If the work had not been properly and systematically applied, I do not believe that we would have seen these results. It is also important to note the variety of methods used and the intensity of the work. In my opinion, no one approach could have been used to obtain these same results. We are very fortunate, as a field, to have so many wonderful approaches available to us. The therapy we do with our clients is truly our “art.” Thank you all for your dedication to your clients.
Resources:
Clinician’s View; PO Box 458; Fairacres, NM 88033; 505-880-0058;
www.cliniciansview.com (Motokinesthetic Training)
Jelm, J. M. (2000). A Parent Guide to Verbal Dyspraxia. DeKalb, IL: Janelle Publications, Inc.
Kaufman, N. R. (1997). Kaufman Speech Praxis Treatment Kit for Children. Gaylord, MI: Northern Speech Services.
PROMPT Institute, Inc.; 4001 Office Court Dr.; Suite 305; Santa Fe, NM 87507; 505-466-7710;
www.promptinstitute.com
Rosenbek, J. C., & Associates. (1973). A treatment for apraxia of speech in adults. Journal of Speech and Hearing Disorders, 38, 462-472.
Speech Pathology Associates, LLC; PO Box 2289; South Portland, Maine 04116; 1-207-741-2443;
www.chewytubes.com
Stevenson Learning Skills, Inc.; 451 Elm Street; Unit 2; North Attleboro, MA 02760; 1-800-343-1211; www.stevensonsemple.com
TalkTools; 3420 N. Dodge Blvd.; Suite 148 Tucson, AZ 85716; 1-888-529-2879;
www.talktools.net
Diane Bahr is the author of
Oral Motor Assessment and Treatment: Ages and Stages (Allyn & Bacon, 2001). She is currently teaching both nationally and internationally. For more information see
www.oral-motor.com or
www.agesandstages.net. Her e-mail is
dibahr@cox.net, and her phone number is 702-845-0642.
This paper is a draft of an article published in Advance for Speech-Language Pathologists and Audiologists, 9/4/06. Multiple copies may not be reproduced without prior written permission of the author. © Diane Bahr, 2006, All Rights Reserved.