Understanding and Incorporating Oral Placement Therapy into Everyday Speech Sessions

Understanding and Incorporating Oral Placement Therapy into Everyday Speech SessionsAubrie Hagopian, M.A., CCC-SLPCSHA Hot Topics Dinner SeriesValley Childrens HospitalOctober 13, 2015

Learning Outcomes1. Demonstrate an awareness of the motor foundations for speech production and the importance of dissociated movements for speech clarity2. Demonstrate an understanding of assessing strength and placement of articulators3. Demonstrate an understanding of the rationale for Oral Placement Therapy4. Demonstrate an understanding of the use and implementation of Oral Placement TherapyOral Placement Disorder (OPD)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). (Bahr & Rosenfeld-Johnson, 2010) Oral Placement Therapy (OPT)A non traditional approach to articulation therapyThe goal of OPT is to transition appropriate oral movements into speech during the same therapy session (Bahr & Rosenfeld-Johnson, 2010)A form of oral motor treatment that only targets movements used for speech production (Rosenfeld-Johnson, 2008)Every task is paired with a specific phoneme or function of speech (i.e., stability)General GoalsAwarenessOral tactile sensitivity PrecisionDifferentiationFeeding skillsIntelligibilityWho May Benefit from OPT?Kids (or adults) with:WeaknessLow toneSlidey jawPreviously tongue tied (or currently, but with enough movement)Down syndromeDysarthriaApraxia (in combination with motor speech therapy)Poor imitation and awarenessStructures for Speech ClarityAbdomenJawCheeksLipsTongueVelum

Having the Proper Foundation

Speech clarity collapses when the jaw cannot provide a stable foundation from which to produce soundsDifferentiation of Oral MovementsMorris & Klein, 1987; Bahr, 2001Dissociation- The separation of movement, based on stability and adequate strength, in one or muscle groups (cheeks, velum, lips, tongue, jaw).Grading- The controlled segmentation of movement through space based upon dissociation.Fixing- An abnormal posture used to compensate for reduced stability which inhibits mobility.

DissociationMoving the lips and tongue independently of the jawJaw does all of the work and sounds have a flat qualityToo much extraneous movement takes away from the precision needed for connected speechSome things to watch for:Tongue tip glued to the bottom of the mouthMandible doing a lot of work, constant opening and closingChin jutting forward to round lipsMandible sliding side-to-side, forward, or making circular movements

GradingControlling opening and closing of the jaw, retraction/protrusion of tongue/lipsGrading allows the jaw, lips, and tongue to move in a controlled manner What to look for:Jaw is stuck closed or openJerky movements when opening and closingCannot round or retract lipsCannot retract or point tongueFixingUsing the jaw or head to try to move the tongue, keeping jaw tight with no grading when speaking, talking on inhalation, etc.What to look for:Open mouth postureKeeping teeth clenched togetherSynergyThe interaction or cooperation of two or more organizations, substances, or other agents to produce a combined effect greater than the sum of their separate effects (Oxford University Press, 2015)Origin: from Greek sunergos 'working together', from sun- 'together' + ergon 'work (Oxford University Press, 2015)The jaw, lips, tongue, cheeks, and velum must work synergistically for intelligible connected speechArticulation DevelopmentLips from JawOpen (ah, uh)Closed to open (m, b, p)Open to closedProtrude/retract (oo, oh, w, ee, ih)Lower lip tension (f, v)Lower lip protrusion/tension (sh, ch, j, r, er)Tongue from JawRetraction-Protrusion (balance- equal range of motion)Retraction-Protrusion (imbalance- gradual increase in retraction and decrease in protrusion)Retraction (stability)- lateralization of the tip (midline to both sides, across midline)Retraction Tip Elevation/Depression (t, d, n, l, s, z, sh, ch, j, k, g)Retraction Back of Tongue Side Spread (stability for coarticulation and /er/)SensoryHyposensitive- an under-reaction to input.Hypersensitive- an over-reaction to inputMixed sensitivity- any combination of hyper/hypo or normal sensitivity.Fluctuating sensitivity- responses that change over time.Tactile Defensive- A learned tendency to respond negatively or emotionally to input.

DefinitionsDysarthria: muscle weakness characterized by reduced mobility, coordination, and precision of the oral musculature resulting in poor speech intelligibility and oral movement patternsApraxia: inability to motor plan volitional movements for speech production in the absence of muscle weaknessMotor Planning Disorder: difficulty formulating the motor plan for volitional movements for speech production with or without muscle weaknessApraxia and Dysarthria can co-occur in children with Down syndromeHypotoniaHypotonia is a decrease in muscle tension at rest.Our tone is something we are born with, we cannot change itLack graded control (precision in carrying out a movement)

Some CharacteristicsOpen mouth postureForward tongue carriageLarge rounded tongueHigh and narrow palateSqueezable cheeksDroolingMouth breathingTherapeutic FeedingWhat you see in the body is what you get in the mouth - Lori Overland, M.S., CCC-SLPA sensory-motor approach to addressing feeding difficultiesTeaches proper feeding/eating techniques as a foundation for speechIncludes breast/bottle feeding, spoon and fork feeding, chewing and bolus control, straw and open cup drinking, etc.

Bite TubesCreate adequate strength for up/down chew pattern, and initial movement for beginning speech soundsUsed to increase jaw gradingCan also be used to teach proper chewing for safer feeding

Bite BlocksFor children over 3 years oldIncrease jaw strength and stabilityTeach proper jaw height for phoneme production

Straw Hierarchy

Lip rounding and tongue retractionMore tongue retraction and effort is required as the straws get harderCan help with tongue carriage at rest

Horn Hierarchy

Lip rounding, tongue retraction, breath controlMore breath control is required as horn difficulty increases

Bubble Blowing Hierarchy

Start as low as lip awareness for kids with open mouth postureTeach lip rounding and breath controlAdditional ToolsApraxia ShapesVisual and Tactile promptsLip rounding tubesGrading of lip rounding

www.talktools.com

ExercisesSara Rosenfeld-Johnson wrote a book filled with all the different exercises she has developed and used for Oral Placement TherapyOral Placement Therapy for Speech Clarity and Feeding

Moving to SpeechFocus on jaw height (high, medium, low) and transitionsEasy words have no place shift, one jaw height- all high jaw, medium jaw, or low jaw sounds (i.e., beam)Moderate words have one place shift, two jaw heights- high to medium, medium to high, low to high, etc. (i.e., bum, bye)Difficult words have two jaw place shifts, three jaw heights (i.e., mug)Picking WordsComplexity (easy words with sounds established in isolation and work up to difficult words)Oral Placement Skills (grading, lip rounding, lip closure, tongue tip elevation, etc.)Traditional Articulation/Phonology Therapy (select words with specific phonemes)A Typical Session5 minutes of Therapeutic Feeding (if necessary)and OPT drill (bite blocks, straw drinking, horn blowing) paired with specific sound practiceThen dive into traditional therapy session with intermittent OPT workBite blocks, horns, and straws may be used as a promptOPT drills may be done immediately before sound trials, especially if proper placement has been lost

Example GoalsJohnny will produce alveolar sounds with dissociated tongue tip elevation in all positions of single words with 80% accuracy.Johnny will approximate his lips for production of bilabial sounds /m, b, p/: a) with a tool, b) with a tactile cue, c) with a model, d) spontaneously with 80% accuracy.Johnny will use correct placement and manner of production of /m, b, p, t, d, and n/ with /oo, ah, ee, oh, aa/ in CV1CV2 syllable shapes (mommy, daddy, baby, puppy, etc.) when presented with a picture or object with 80% accuracy.

Myths about Down SyndromeChildren with DSs speech clarity plateaus at second gradeChildren with DS have a larger tongueChildren with DS can achieve speech clarity with tongue protrusionChildren with DS are born with high palatal archesApraxia and/or dysarthria are not challenges for children with DS30Questions??

ReferencesBahr, D.C. (2001). Oral Motor Assessment and Treatment: Ages and Stages. Boston: Allyn and Bacon.Bahr & Rosenfeld-Johnson. (2010). Treatment of children with speech oral placement disorders (OPDs): A paradigm emerges. Communication Disorders Quarterly, 31, 3, 131-138.Marshalla, P. (2012). Horns, whistles, bite blocks, and straws: A review of tools/objects used in articulation therapy by Van Riper and other traditional therapists. Oral Motor Institute, 4, 2. Morris, S.E., & Klein, M.D. (1987). Pre-feeding skills: A comprehensive resource for feeding and development (2nd ed.). San Antonio, TX: Therapy Skill Builders.Oxford University Press, 2015. www.oxforddictionaries.com/us/definition/american_english/synergyRosenfeld-Johnson, S. (2008, November). Effects of oral-motor therapy for tongue thrust and speech production. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Chicago, IL. TalkTools. (2014). A three-part treatment plan for oral placement therapy. www.talktools.com.TalkTools. (2015). Oral placement to speech- Transitioning muscle memory into speech sound production. www.talktools.com.