A THREE-PART ORAL SENSORY-MOTOR APPROACH TO TREATING APRAXIA OF SPEECH: Using Oral Placement, Feeding, and Speech Tasks.
By: Emilia del Pino, M.S., CCC-SLP
Oral Placement/Feeding Specialist
As speech and language pathologists, we are required to use our clinical judgment in order to
evaluate and diagnose a variety of speech and language disorders. Perhaps one of the most
challenging issues that many of us encounter is the differential diagnosis of motor speech
disorders and subsequent treatment protocol for children with Developmental Apraxia of Speech.
The difficulty begins with the apparent lack of consensus regarding the
terminology used in diagnosing motor speech disorders. Terms such as dyspraxia, apraxia,
developmental verbal apraxia and childhood apraxia of speech are often used to describe the same clinical characteristics commonly associated with a disruption in the ability to voluntarily
program oral, respiratory and laryngeal muscular movements for speech production.
Two additional complicating factors are the absence of definitive diagnostic criteria to aid in diagnosis of apraxia of speech and the fact that not all individuals with this motor speech
disorder display the same characteristics. So where does one begin the process of making sense of the apraxia of speech enigma so appropriate treatment principles and methodology are implemented?
Developing a comprehensive case history form should be the first step. This is essential in order to supplement clinical observation and make appropriate referrals. Several common early case history indicators include limited vocal play and babbling, undifferentiated phonetic patterns from infancy and poor ability to imitate sounds during vocal play. Delays in these early speech milestones however, are not sufficient to diagnose apraxia of speech. Therefore, a thorough case history form should be developed in order to obtain information regarding not only early speech and language development, but the individual’s past and current oral-motor and feeding skills.
In addition to sensory, oral-motor and speech-language components, individuals with apraxia of
speech may require the implementation of a feeding component in their program plan. Often, individuals with apraxia of speech have reported difficulty with feeding skills. This may be manifested in difficulty with breast and/or bottle feeds and food transitions (i.e., from liquids to purees and eventually to semi-solids and solids). In addition, highly restricted food preferences are often noted. This is often due to a child’s difficulty in accurately processing the sensory attributes of a food item with regards to shape, size, smell, texture and consistency.
Obtaining a 5 day diet baseline to include all foods consumed, those avoided and those classified as “challenging” are important factors for baseline data from which treatment will be based. Typically, mixed textures (i.e. Stage 3 foods) are notoriously difficult since a child has to separate a puree from a soft solid which involves chewing small chunks of food that are mixed in to a smooth puree. An analysis of why there is a breakdown is important. The underlying basis will assist the therapist and family in using a task analysis approach in attempts to expand the individual’s diet using food chaining methods. This may involve making minor adjustments in terms of taste, temperature and texture. Modifications must occur slowly, altering one variable at a time, with ongoing data collection.
A second component to treatment of apraxia of speech involves a thorough assessment of a child’s oral-motor skills. Some children with a motor planning disorder may have a coexisting primary or secondary diagnosis of muscle weakness. Deficits may include decreased muscle tone, strength and stability, as well as, decreased precision in articulatory movements. Thus, therapeutic intervention must consider the individual’s current level of performance, any compensatory patterns and specific oral-motor movements that need to be targeted.
In initiating treatment, it is essential that a complete overview of the individual’s communicative, motoric and cognitive skills are considered. The main focus of treatment should be the acquisition of voluntary, accurate and consistent control of speech articulators so phonemes and phoneme sequences are produced precisely and consistently. In order to accomplish this, treatment should involve imitation, auditory-visual stimulation, motor repetition and phonetic placement using oral sensory-motor exercises.
Regardless of the specific exercises implemented, it is important to practice executing the
motor planning processes so that the individual is able to produce successive approximations of
standard speech. Shaping consistent speech patterns can be facilitated using a sensory-motor
approach. This approach includes teaching awareness of the articulators, normalizing tactile
sensitivity and pairing oral-placement exercises with speech production. Due to sensory deficits (i.e., drooling and oral astereognosis) often found in individuals with apraxia of speech, oral-sensory exercises can be implemented to increase the individual’s ability to feel the oral movements.
In using this approach, a therapist might utilize deep pressure to normalize oral-facial sensitivity. Next, to increase oral awareness, the therapist may incorporate therapy tools such as sensory sticks (with flavored powders), ice sticks, vibration and tongue depressors.
The critical element after any oral-motor stimulation, is immediate engagement in functional activities such as feeding and speech production practice. Pairing oral-placement exercises with speech production can be achieved by using therapy tools in conjunction with verbal, visual and tactile cueing, depending on the individual’s speech inventory and motor planning abilities. For example, oral-placement exercises may pair “bite tubes” and “bite blocks” with speech production tasks for vowels. These tools can be used to teach the jaw height required for vowel productions as well as, the difference between tense versus lax vowels.
A tongue depressor can be used not only for phonemic placement, but also to assist an individual in producing the phoneme /m/ plus a vowel (or any other combination based on the word
structure inventory). A therapist using an oral-placement approach to apraxia of speech might also use a Cheerio on the lower lip for production of the labial-dental production of /f/ and request
contraction of the mentalis muscle. Shortly after, the visual cue of the Cheerio may elicit the
motor plan for accurate placement and production while immediately transitioning to a variety of motor sequences to automatize and assist in muscle memory for the motor pattern.
Horns are also effective tools in apraxia therapy. Depending on the sound sequences attempted, specific combinations of horns can be introduced. When selecting the horn(s), the therapist must consider the jaw grading, amount of tongue retraction and lip posture required for the phoneme sequences. Rather than using one horn with multiple repetitions, the goal in using horns in apraxia treatment may be to use up to three different horns with a limited number of repetitions, based on the individual’s motor planning skills.
This presentation of horn use is recommended in order to address muscle memory. For example, when targeting bilabials and diphthong combinations, an easy-to-blow horn with a flat mouthpiece will target high jaw posturing with a low level of respiratory demand. This horn can be used along with a “bite tube” to facilitate the jaw height and motor plan needed for the consonant-vowel combination. Likewise, if one wanted to target affricates, a round-mouthed horn might be used. If a fricative and an affricate were targeted on the word level (i.e. fish), the therapist would present the auditory, visual and tactile cues of the Cheerio (for the /f/ production) and a round lip horn (for /sh/). Over time, the amount of support needed would gradually fade.
Regardless of the individual’s feeding skills and speech inventory, the key to progress with children with Develpomental Verbal Apraxia is using a systematic presentation considering sensory motor work targeting oral placement, feeding and speech production exercises.
Red Flags of Children with Sensory-Motor Feeding/Speech Deficits
By: Emilia del Pino, M.S., CCC-SLP
Oral Placement/Feeding Specialist
The purpose of this article is to heighten awareness of sensorimotor speech and feeding delays in the pediatric population. This article will discuss clinical observations on children’s feeding skills that might require an Oral Placement for Feeding and Speech Assessment and possible therapeutic intervention.
The Following Red Flags should warrant concern:
Difficulty latching on to the breast or bottle
Trouble transitioning from breast to bottle and bottle to cup
Difficulty coordinating suck-swallow reflex for either breast or bottle feedings
Overall low tone in the trunk musculature and articulators (abdomen, velum, jaw-lips, tongue, cheeks) Excessive or habitual drooling is not associated with the eruption of teeth
Difficulty dissociating articulators
Hyperactive or hypoactive gag reflex
Difficulty forming a food bolus
Increased number of chews/swallows
Increased duration of mealtimes
Pocketing food in the mouth
History of choking/aspirating
Gastroesophageal reflux issues
Immature feeding skills: The child continues to suckle or use a munch (up and down) pattern versus a more mature rotary chew pattern
Weakness in oral musculature (i.e. as observed by an open mouth posture and forward tongue placement (not secondary to allergies or upper respiratory issues)
Trauma due to intubation and /or Tube feedings
If parents/caretakers are concerned with any of these issues they should speak to their pediatrician and a referral for a comprehensive evaluation may be recommended. A past and present medical history along with documentation from a medical doctor providing medical clearance for oral feedings are essential. In addition, obtaining a log of any dietary restrictions and allergies the child may have is very important. Recording a five-day comprehensive diet baseline is helpful in identifying if there are sensory and/or motor explanations for the foods preferred and those avoided. For example, many children with low tone and hypotensive/hyporeactive oral awareness skills may crave foods that are salty and crunchy which supply increased sensory input. On the other hand, children with low muscle tone and weakness in their jaw musculature may avoid foods that are chewy (i.e. bagels, meats).
If it is determined that a child has feeding issues, it may be due to sensory, motor, or a combination of sensory and motor skill deficits. A comprehensive assessment targeting normalizing sensory skills and achieving adequate (not excessive) strength in one or all of the child’s articulators: the abdomen, velum, jaw, lips, cheeks, and tongue musculature may be recommended. This can be accomplished via the use of Oral Placement Therapy (OPT) techniques that are directly related to oral movements required during the oral preparatory phases of feeding and for standard speech production. Often we see children who have feeding and concomitant speech production and speech intelligibility issues. Thus, implementing a three-part treatment plan consisting of feeding, speech, and OPT techniques is warranted.
Some activities might include normalizing the oral sensory system to allow for a variety of tastes, textures, and temperatures to be consumed. Learning how to drink from a straw or cup can be accomplished early by teaching children a hierarchy of skills. In addition, lateralizing the tongue in order to place the bolus on the back molars is a critical step as it is a prerequisite for lingual elevation (for standard swallows and alveolar and lingual dental sounds). Food placement techniques and nonfood therapeutic tools can also be used to teach tongue-tip lateralization.
Regardless of the goals selected, a speech and language pathologist must work closely with the child’s parents and gain the child’s trust. Feeding is a social experience with lots of dynamics. The therapist, child, parent, and his/her pediatrician along with other professionals must take a team approach and move slowly, ensuring comfort and success along the way.
TalkTools - Speech & feeding therapy tools, techniques & training.
IAOM - International Association of Orofacial Myology
OTA Watertown - The Koomar Center
Oral Motor Institute - Articulation, Motor Speech & Feeding