In-Depth with Robyn Merkel-Walsh & Jeff Stepen: On EBP, OMD and OPT

This is a repost from Conversations in Speech Pathology written by Jeff Stepen & Robyn Merkel-Walsh.

The following is an in-depth conversation between Robyn Merkel-Walsh, MA, CCC-SLP and Jeff Stepen, MS, CCC-SLP.

Reposted with permission from the author.

**“It’s chaos, be kind.”**

-Michelle McNamara

Four years ago, I released the first of 2 episodes (here and here) on the topic of nonspeech oral motor exercises (NSOME). The feedback I received from both episodes was telling. In general, listeners either sided with the practice of OPT (oral placement therapy) or with the argument against NSOME (and by extension OPT). Since publishing those episodes, I have thought a lot more about what it all means. Things came to a head for me this past February when I attended my state association’s annual convention. I was listening to a topic more or less tangential to OPT when I came back yet again to a question central to my plea for more information: What do you do when ‘look, listen, and say’ doesn’t work?

Shortly after that convention, I contacted Robyn Merkel-Walsh who agreed to do a round 2 with me. However, this time I wondered if she might be up for an email exchange rather than an audio interview (I thought this would allow us more space to reflect on certain points of discord). Being the gracious and passionate person she is, the answer was “yes”. What follows is an exchange that took place over the course of roughly one month.

My thinking on OPT has evolved somewhat. I don’t consider myself to be in any “camp”, but I certainly desire to go deeper into the world of OPT and all of its related brethren (myofunctional therapy, PROMPT, etc.). I still have my reservations and wonder what it means to have low tone and muscular weakness in the orofacial area. Then there are the issues of task specificity and the uniqueness of speech. But instead of laboring over the talking points of the last 10-15 years, it might be worth asking new questions and questioning old assumptions. For instance, here’s a question: If a 6-year-old client presents with an open mouth posture, a reverse swallow, and interdental /s/ (among other speech sound errors), is it worth our time (in fact necessary) to work on jaw stabilization and tongue retraction before targeting said /s/?

I take Robyn at her word (as well as other practitioners of oral-motor therapy) that she has in fact corrected such maladapted behaviors and postures. And that’s what keeps me up at night. Am I neglecting something big here?

I know a significant number of listeners of this program won’t care for this conversation. There will be pushback. There may be harsh words on social media. So, in anticipation of the flack sure to come our way, let me be frank. Don’t take everything you read here as dogma. Be skeptical. Question sources. But for goodness sake- have an open mind and a tolerance for tension. Because somewhere in that tension might be the answers we’re all looking for.

-Jeff

NSOME=Nonspeech Oral Motor Exercises; OPT=Oral Placement Therapy; OMD=Orofacial Myofunctional Disorders; OPD=Oral Placement Disorder; OME=Oral Motor Exercises; OMI=Oral Motor Institute; RDH=Registered Dental Hygenist

Jeff: Thanks so much for doing this Robyn! I’d like to kick things off by first asking you a two-part question. First, what kind of feedback did you receive regarding our episode? Second, do you feel the conversation on the topic of OPT has moved anywhere since?

Robyn: Hello Jeff. Thanks for the opportunity to converse with you once again. I am happy to share what has been happening since our podcast.

To answer your first question, I received a great deal of positive feedback from our podcast. Of course, the therapists I generally converse with are those who are using oral sensory motor techniques, OPT (oral placement therapy) and Orofacial Myofunctional Therapy. I have not been approached by any therapist opposing these techniques directly to negate the comments made in our discussion, but rather received many comments from SLPs who do practice oral motor therapy/OPT and felt it validated the work they do. I have seen it cited on social media when therapists feel they need more information.

In regards to your second question, there definitely has been ongoing debate more specifically on social media. Unfortunately, debates are not always professional. There has been a trend of “shaming” therapists online as well as banning the topic itself from certain Facebook Groups. When therapists try to post evidence and studies they are quickly removed from the group. Banned topics include OPT, PROMPT, tongue-tie, and myofunctional therapy. I myself have been banned from several of these groups. Words like “pseudoscience” and “controversial therapies” are repetitively used. It is unfortunate that these therapists are not willing to accept other opinions or perhaps take a class and see for themselves.

The fact of the matter is not all therapists and researchers accept all level of evidence-based practices as recommended by the ASHA map. More concerning to me are posts I see speaking in absolute terms such as “there is NO EVIDENCE” to support X-Y and Z (oral motor, PROMPT etc.). If we review our ethical code we shall find:

ASHA Principle of Ethics III: Individuals shall honor their responsibility to the public when advocating for the unmet communication and swallowing needs of the public and shall provide accurate information involving any aspect of the professions.

A. Individuals shall not misrepresent their credentials, competence, education, training, experience, and scholarly contributions;

E. Individuals’ statements to the public shall provide accurate and complete information about the nature and management of communication disorders, about the professions, about professional services, about products for sale, and about research and scholarly activities.

In my opinion, if an SLP is posting a statement about NO EVIDENCE they are misrepresenting the evidence-based map that includes clinical data, patient values, patient feedback, case studies, literature review etc. This is directly in line with the EBP Map that states: the goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve. If one wants to note, “there is a lack of level 1 research”, I am fine with that as this is accurate. If one wants to state that “there needs to be larger double-blind studies”, that is also accurate. The statement “NO EVIDENCE” is completely inaccurate.

In the summer of 2017, Melanie Potock, a well-respected feeding therapist wrote a blog for the ASHA Leader on tongue-tie being associated with picky eating habits. It went viral on social media with phrases like “NOT THIS AGAIN”. ASHA then asked me if I would like to comment on this discussion based on a topic proposal I had already submitted on TOTs (Tethered Oral Tissues). The plan was to do a short piece, and a longer article later on, perhaps at the time my book was released. I published the short blog: Consider Experience as Part of Evidence-Based Practice to Evolve Our Profession in October of 2017 as a reminder of what EBP really means. My article not only discussed the EBP Map but also some of the more recent research on tongue-tie.

Several months later, I inquired when I could do the full feature article on TOT’s previously discussed. It was rejected based on “research demonstrating that a tight frenulum rarely causes speech or swallowing disorders” based on Webb, A.N. Hao, W., & Hong, P. in 2013. ASHA’s clinical team also cited that a later review in 2015 found that data was insufficient for assessing the effects of frentomy on non-breastfeeding outcomes that may be associated with ankyloglossia. (Chinnadurai, O., Francis, D., Epstein, R., Morad, A., Kohanim, S., & McPheeters, M.) Treatment of ankyloglossia for reasons other than breastfeeding: A systematic review. Pediatrics, June 2015, 135 (6,) 1467-1474.). Now here is a perfect example of how anyone can look for studies to prove their case. I provided every piece of EBP I had from my TOTs book, but apparently, these two studies are the only studies that are valid? There was more detail in the conversational exchange with ASHA and I think we left things on a better note………..but my point is that this is a narrow EBP base to not even entertain an article on TOTs. We should be encouraging debates and discussions with all evidence available.

On a more positive note, I have been working with expert clinicians Linda D’Onofrio, Kristie Gatto, Mary Billings, Diane Bahr on a very extensive research list covering the many topics of oral motor. Kristie and Diane put together an extensive list for their ASHA presentation. Linda D’Onofrio developed extensive compendiums (via Dropbox) on her Oromyofunctional Study Group on Facebook. Furthermore, Kristie, Linda, Mary and I worked on research to support an upcoming change to the Scope of Practice portal for OMD on the ASHA website.

Additional projects /news since our last conversation include:

ASHA posters for the convention
Publishing a new course and book with Lori Overland on the Functional Assessment and Remediation of Tethered Oral Tissues.
Writing articles for the ASHA Leader and blog
Updates to the Board of Directors of the Oral Motor Institute
New research coming from the medical community on myofunctional therapy and Sleep Disordered Breathing (SDB)
Assisting on the coding manual with Janet McCarty from ASHA regarding oral motor, feeding and orofacial myofunctional therapy
State advocacy on Scope of Practice for oral motor treatments

Jeff, did you know that lactation consultants (IBCLCs), PTs and OTs are now training for and delivering orofacial myofunctional therapy across the lifespan even though only SLPs, RDHs and DDSs have this written in their scope of practice? IBCLCs are critical for the breastfeeding dyad, OTs have feeding in scope and PTs are excellent in supporting the head and neck for speech, feeding and swallowing; however, historically based on the International Association of Orofacial Myology’s (IAOM) certification process only DDS/RDH/SLP were eligible to become a Certified Orofacial Myologist (COM ™) because of the way each professionals’ scope was written. I am not saying that I am against this newly emerging trend because I see great value in what each of these professions have to offer to the patient; but according to ASHA’s professional portal, OMT is a treatment that occurs for four-year-olds and up. Sandra Holtzman just wrote an article in May 2018 in the Orofacial Myology News about the appropriate age for OMT. Perhaps it is just a matter of using the incorrect terms. Lori Overland always said, “what you see in the body is what you get in the mouth and with TOTs what you see in the mouth is what you will get in the body”. It makes sense that all “bodyworkers” have a role in these disorders. We all have to “stay in their lane” as quoted on Facebook by Michelle Emanuelle, OTR, OMI Board member and method developer of the TummyTime!™. For example, an OT would not be able to address the speech clarity issues in a toddler with TOTs just as I could not address fascial restriction in the body caused from TOTs. It is a team approach. The constant arguing does not help the patients.

Due to the recent trend in discussing Tethered Oral Tissue(s), there are many newer organizations providing myofunctional training that are not adhering to the IAOM’s or ASHA’s guidelines regarding age and scope. This is resulting in a wider number of therapists from related fields labeling themselves as “Orofacial Myofunctional Therapists”. Some are not even in related fields. I have seen social workers in Facebook groups justifying why “they too” can do this work because they took a “course”. There is no licensure in any state for this title and it is causing confusion, arguments over encroachment and social media wars. Understand that SLPs practicing OMT do not have to be an IAOM member. ASHA states that “Orofacial myofunctional assessments are conducted by appropriately credentialed and trained speech-language pathologists.” Even though the SLP Scope of practice clearly lists orofacial myofunctional disorders including Tethered Oral Tissue, the truth is our own field is ambivalent about our roles as SLPs with these disorders. Why do you think it is that physicians, dentists, RDH’s, oral surgeons, lactation consultants, occupational and physical therapists see the value of this work but our own profession does not? There is no controversy in these fields that “oral motor” is not evidence-based.

Jeff: I’ve spent a lot of time thinking about our talk and the issues of open hostility. I know this is going to upset a lot of readers, but the EBP bandwagon has run a little amok. What I mean by this is that people are using the term to consciously or unconsciously undermine valuable clinical work done by everyday clinicians. Let me be clear that I am just as invested as the next therapist in the scientific method. But as you mention, there are 3 pillars to the EBP decision-making process.

Fundamentally, it seems that some of the attacks against OPT smack of the straw man fallacy. I won’t bemoan this point but suffice it to say, we can all agree that it is not a good idea to have a client simply wag his or her tongue to meet some abstract end of enhancement. But OPT (as I’ve come to understand it) is not about that.

I wonder how many critics of OPT out there truly believe that every part of OPT is nothing more than NSOME. Do you think any progress has been made in terms of this oversimplification?

Robyn: Jeff, I believe some have recognized that NSOME is not the same as OPT. In 2015 Dr. Ryan Kent eluded to this in his article Nonspeech Oral Movements and Oral Motor Disorders: A Narrative Review. One of his quotes was “Among the therapeutic components that a speech-language pathologist might address are efforts to increase awareness of the muscles and postures of the orofacial system and to improve muscle strength and coordination (American Speech-Language-Hearing Association, 2011 in Speech-language pathology medical review guidelines). Presumably, NSOMEs are one means to achieve these objectives.” Kent added that although research on clinical outcomes from orofacial myology is not extensive, promising reports have been published on speech production in cerebral palsy (Ray, 2001) and in adult dysarthria (Ray, 2002). He also commented that “oral motor performance also appears to be a predictor of verbal fluency in individuals with autism.”

To add to that, more studies are popping up about the connection between oral motor, the tongue, and later speech development. For example, take a look at “Sensorimotor Influences on Speech Perception in Infancy” by Bruderer, Danielson, Kandhadai & Werker in 2015. In this study, using ultrasound-imaging technology, it was verified that the teething toys consistently and effectively constrained the movement and positioning of infants’ tongues. With a looking-time procedure, the study found that temporarily restraining infants’ articulators impeded their discrimination of a non-native consonant contrast but only when the relevant articulator was selectively restrained to prevent the movements associated with producing those sounds. The results provide striking evidence that even before infants speak their first words and without specific listening experience, sensorimotor information from the articulators influences speech perception.

Here is how I see it, and this may also upset some…………quite frankly the goal of EBP is not to shame others. Period. I rather spend my time collecting evidence in a way that helps my clients, not in a way to prove another therapist or a group of therapists is “wrong”. It is time for the naysayers to MOVE ON. The goal of our profession is to HELP people who are in need and we need EBP to keep it ethical. There is no ethical violation of using a horn in therapy to achieve phonatory control and lip placement. Why does this annoy others so much? It certainly is not annoying any patient or student I have worked with. Why are researchers who can be helping people, still wasting time doing secondary literature reviews to negate something that therapists all over the world are using daily and seeing results with? OPT does not replace anything. It is designed to assist with the overall outcome. I think part of this problem is perhaps “fear”. Fear that we are replacing something that is already in place. We are not replacing any method. We are simply expanding on Van Riper’s work for a subset of individuals that were not responding to what was in place. We are innovating. We are evolving.

Research “proving” something also has to do with interpretation and what you extract to prove your case. I just wrote a book on Tethered Oral Tissues (TOTs) (with Lori Overland), which is very much related to oral motor therapy. When researching surgical methods, I found a few articles about post-operative complications, but there were very few cases. Another SLP could use this same information to negate having the surgery by stating, “See there are significant risks”. There are two main procedures for TOTs 1) Laser and 2) scissors/scalpel. We had two experts, one for each method, write about the procedure and the pros and cons of each. The two surgeons are quite friendly and see the value in both. Why can’t our field do just the same? The naysayers keep saying NO EVIDENCE even when we provide them with pages upon pages of evidence.

Furthermore, clinicians are performing the therapy and see results. They collect data. Data is evidence. We cannot as clinicians just use one tool or method and make our clients a research project. There is IRB (Institutional Review Board) and controls to consider. Trust me, I have tried case studies and they keep getting rejected due to either conflict of interest, or data collection errors simply because I am not a researcher and quite frankly I do not know the proper design. I also have to use every method possible to help my clients as I am bound by my ethics to do so. When I treat my children, I am not just using TalkTools® methods, but Beckman and Van Riper and Kaufman and Hodson and Pierce etc. I cannot just take a child who is with me for improvement and isolate one exercise to test. Now if you just took a horn, would that all of a sudden (without any other form of speech therapy) change an articulation disorder. NO. What I do is a sequence and series of muscle based and motor-based drills. These naysayers condemn it, but they have never even observed it, nor are they willing to set up the studies to try and prove it does not work. When was the last large case sample, double-blinded articulation study for any method? If they are so certain that what we do is quackery (yes, this word has been used), why aren’t they setting up the controls?

Jeff: I think one major aspect of the problem is that half the time we don’t even know what we’re arguing over due to the many gradations of oral placement therapies. This happens with a number of therapies/products out there that lack a robust evidence base. Too often the academics wind up wanting to throw the baby out with the bathwater without ever asking what components of the program/service/product might be useful for a given population.

I don’t think I brought this point up in the podcast directly enough, but do you think the argument for oral placement therapy would be easier to make if our efforts were directed at a specific population? Without over-generalizing, we know that many if not most of our kids with Down syndrome will experience some type of speech sound disorder (SSD) in the course of their lives. From time to time I’ve done literature searches on SSD’s and DS and typically come up fairly empty. So, when researchers get angry at folks using OPT, they need to understand that at the very least, it’s not as if we have a myriad of alternate approaches to pick from. True, every client is different, and there will be those kids who do fine with phonological-based approaches or perhaps targeting prosodic aspects of speech. But to be blunt, a big void exists in academic speech science right now. That void, of course, is a lack of concrete answer(s) to the question: What do we do when “look-listen-say” doesn’t work?

Robyn: Exactly Jeff. What is the answer? Just keep drilling words because research from 20 plus years ago tells us that is what to do? I read an interesting comment from a colleague on Facebook that fits perfectly with the conversation. She asked a clinician “what do you suggest for thin liquids when someone is aspirating?” The response was “thickener”. (Many professors and feeding specialists would say the same). Guess what? There are no studies on thickener! You know what else there are no studies on? The use of a mirror to improve placement skills in articulation therapy. So, are we just supposed to stop all of these helpful therapeutic methods because we do not have a specific study?

We have been saying since the beginning that OPT helps specific populations included but not limited to: Down syndrome, Autism Spectrum Disorder, Cerebral Palsy, and Moebius syndrome to name a few. These diagnoses come with issues of muscle tone and motor planning and “look-listen-say” does not often work. Since the sensory and motor system cannot be separated, any child or adult that has a deficit in sensory processing or regulation will naturally have issues with motor skills, and any child with muscle or motor dysfunction will have issues with sensory processing. I have seen ongoing debates recently that dysarthria is a “motor output” or “motor execution” disorder based on Caroline Bowen’s diagram on speech articulation disorders:

Since when did we stop describing dysarthria as a muscle-based disorder? Is this a new way to try and discredit oral motor? The ASHA website clearly states that “dysarthria is a speech disorder caused by muscle weakness” that requires “making your mouth muscles stronger”. Are we now going to discredit that individuals can have weak muscles that need help with strength and endurance? I agree that dysarthria impacts motor output but I think we need to be very careful to remember that muscle weakness is involved because it drives the treatment methods we choose.

Let’s take the example you brought up, Down syndrome. I have worked with this diagnosis my whole career, but it became more personal when my best friend’s daughter was diagnosed in utero. She was born with a global hypotonia, a weak suck and needed immediate attention for pre-feeding skills, in order to support safe and effective bottle feeding. Her issues continued via pureed foods and solids, cup, and straw. I worked with the family to provide techniques such as Lori Overland’s myofascial release technique, tap and tone, upper lip roll and also did Beckman Stretches with her. Speech was delayed. Early Intervention was not able to use traditional models for articulation because her mouth was often open, with parted lips and excessive drooling. I, of course, started her on OPT and she started speaking within a few months of treatment. The combined efforts of floor time for language and OPT for improving jaw-lip-tongue dissociation gave her the pre-requisite skills she needed. As she grew we needed to combine many OT/ST/PT techniques that involved tactile cues and strength and dissociation tasks. Her joints including the jaw were hypermobile and orofacial myofunctional disorder proved challenging for both speech and swallowing. I incorporated verbal imitation tasks but they were: 1) following OPT exercises 2) words specifically chosen from Kaufman Praxis or OPT-S cards and 3) always accompanied by PROMPT facial cues. Now that she is older and more verbal (see pics at end of post) she can engage in more traditional tasks but still needs to work on orofacial myofunctional and feeding therapy especially as the orthodontist has placed in devices to expand her palate. It is an ongoing journey. I never suggest OPT as a replacement for all therapies, but rather as a supplement to my tool-kit for these complex populations.

Jeff: I’d like to talk more about the issues of strength and tone again, but first I need to get this next question off my chest. You mentioned when talking about your friend’s daughter that you would do OPT exercises prior to going into speech production practice. This continues to be at the crux of my ongoing confusion regarding OPT. I wholeheartedly believe that PROMPT and other placement tools which work directly on speech have a place in our toolkit, but I still haven’t seen for myself how working on the jaw independent of speech is going to guarantee success. There was a chunk of our podcast talk that never made it into the final cut (because of technical difficulties). In that section, I had talked about a client with whom I had used the bite block hierarchy. She progressed with all of the exercises, but I never saw a demonstrable outcome in speech. In fact, despite the modest gains she had made since, I would wager that if I re-introduced the bite block hierarchy to her now, we would be starting back at square one. (I’m not necessarily saying the blocks failed me. I fully accept the possibility that I was missing a piece of the puzzle in my treatment from the perspective of an OPT practitioner). This brings up an associated question I’ve had kicking around. Suppose you worked with a client and only addressed oral motor issues by directly working on feeding and exercises completely independent of speech (such as jaw grading). Would you hypothesize that there’d be some improvements in speech clarity (assuming the child was verbal to begin with)?

Robyn: Jeff this takes a book to explain or a two-day class but I will do my best to condense the information to help you understand…….

Let’s start by thinking about physical therapy. I myself attend PT several times a week for lower back issues. In the acute phase, the PT spent a great deal of time on stabilization (brace) and massage therapy. As I improved, he task-analyzed movements for me for the activities of daily living such as: putting on my shoes and getting out of bed. He broke down the steps of the motor plan and then we practiced sequencing them so I could perform these tasks in a better way (without injury). PTs and OTs task analyze movements all the time, and they understand the properties of tone and the impact on motor skills, as well as the fact that stability is needed to gain mobility. For example, if your core is weak, your back will have stress. If your neck is injured head stability will be impaired and so forth. In our world, if the jaw is weak, the lips and tongue cannot function properly. This concept is based on the work of Moore and Ruark.

OPT follows the same philosophy. So, let’s say a child is nonverbal, this is the acute stage. I would be working on sensory-motor input at the pre-feeding, OPT, and feeding levels because there is no speech to work with yet. I would, of course, give opportunities for communication, such as a PECS book, ASL and/or use PROMPT to help facilitate language and verbal approximations. An example of an acute phase for me would be a toddler with a primary dx of Down syndrome and a secondary dx of low tone and feeding issues. I know the nay-sayers always point out we only need adequate tone for speech, but guess what? These kids do not have “adequate tone”; therefore, I would be zeroing in on improving muscle strength and endurance and facilitating age appropriate oral motor skills for feeding. If those important skills are not intact, I am going to have a very hard time using traditional methods or even PROMPT. I also know the nay-sayers say “to improve speech you need to work on speech”, but how do you drill sounds and words with non-verbal children? This answers your question about “not working on speech”.

Now on to your next question in regard to working on OPT in absence of speech and if it will help improve clarity……this is a tricky question because I view OPT therapy as “speech directed” at all times. I am never working on “non-speech movements”. I was taught the model to work my sessions including four parts: 1) pre-feeding 2) feeding 3) OPT and 4) speech. This is the TalkTools® philosophy founded by Sara Rosenfeld-Johnson. All four parts work together so yes, I feel the individual aspects of the therapy session all have a part in facilitating speech clarity, but the tasks are very specific. Pre-feeding for feeding and OPT for speech.

When a child is non-verbal or in the acute phase, essentially I am working mostly with pre-feeding tasks, the actual “tools” and facial cueing to facilitate neuromuscular education/habilitation to support oral placements for speech. I do see a difference in clinical outcomes since I started doing therapy this way. The greatest evidence I can find is within the 3-8-year-old population that never spoke with prior therapy but start speaking within months of initiating this model of treatment. I have children in my caseload that were told by prior clinicians that they would “probably never speak” that are now saying “I need the bathroom!” Understand that as the child progresses verbally and sounds are being made, my program is going to shift and change to allow for more verbal work to be done. Just like the PT does less massage and more movement, I start to do the same in my sessions and work on verbal drills and language-based articulation activities. My school office and private office are filled with articulation cards, board games and toys just like I am sure yours is!

On to Bite Blocks………..Bite Blocks are one tool, one part of the program. Sara Rosenfeld-Johnson always said, “it is not the horn it is the hierarchy.” Same is true with the Bite Blocks. I am sorry you did not have a positive experience with this tool but there may be several factors contributing to this.

When we learned about phonetic placements in school no one taught us what the jaw is doing. They taught us that the tongue elevates for /l/, but they did not say “and with a medium jaw height”. When you look at Sara’s OPT book and Muscle Based Articulation Test, she describes what height the jaw is in for each phoneme, along with labial and lingual placements. That is what the Bite Blocks are in alignment with. So a level 2 Bite Block aligns with /m/,/b/,/p/,/s/,/z/, f/, /v/,/∫/,/t∫/,/dз/. There must be a solid understanding of jaw height and which sounds are associated with each level. So, for example, if you are on Bite Block #2, do not expect improvement yet on grading from high to low postures or vice versa in words because you have not completed the whole hierarchy. You may see however some improvement on jaw positioning for a specific sound in that specific jaw height. Remember, you have only worked on strength and stability on one plane of movement so in terms of carryover to speech other steps have to occur. As Van Riper taught us, use the tool in isolation to shape the phonetic placement, then fade it and then practice the sound without the tool. In addition, muscle tone is static we cannot change it. So, let’s say your client has orofacial hypotonia. Just because they master a level of Bite Blocks does not mean they never have to do them again. Strength and endurance in muscle-based disorders often require maintenance, just like if I do not do my stretching for my back, I am going to stiffen up and probably pull a muscle again (this just happened last week).
Bite Blocks are ONE part of an OPT or jaw program. I am rarely JUST doing Bite Blocks and then speech. OPT training is so critical for understanding this. Sure, you can read the directions or even watch a YouTube video online to ensure you are actually using the tool correctly, but have you worked with an OPT mentor or observed a whole treatment session with someone very experienced with these tools? For example, if I was working with a child who was fixing their jaw in a high position because of poor jaw–tongue dissociation secondary to a tongue-tie, I am doing a series of jaw exercises, most likely including the Bite Blocks, Bite Tube program, the Chewing Hierarchy and pairing it with speech words that work on jaw grading. I would not expect the Bite Block alone to change the jaw grading. I also know that the program as a whole is a process and can take time. Muscle weakness and motor execution issues can cause compensations that are ingrained and do not change quickly. I need to monitor progress each session, assign homework and add/remove exercises based on the progress of the programs AND the speech clarity. This, of course, is also influenced by the primary diagnosis and how often the child practices.
I do not know this child so I immediately have a ton of questions. Was your student/client practicing the tool each day? Did they thoroughly master each level and maintain the skill? Was dissociation of the jaw-lips-tongue present? Was the dentition in alignment or was there a malocclusion? So many variables to consider.

I often hear therapists make the same “complaint” you have and when I talk to them about individual cases and how they were executing the tool in relation to speech, there is a fundamental element missing in their understanding of the tool or implementation of the program. Not to say this is what happened to you, but I find those who have failed success with OPT sort of “dabbled” in it without implementing the whole program ensuring that jaw, lips, and tongue were targeted in relation to what was actually the problem with the client. This really is an area that requires post-graduate training and one class is not enough. Understand I have been training in this area for 23 years, and I am still training with other SLPs and OTs who teach these skill sets. There is still so much to learn and whenever I think I am a “master” another therapist opens my eyes to something new all over again.

Jeff: I had a vague notion as to what I was walking into with that question, but thank you for that response 🙂

As I just alluded to in my previous question, one of my major questions has to do with task specificity & the uniqueness of speech: the fact that the same structures which are used in both speech and non-speech tasks operate under very different parameters.

I can already hear the critics tearing apart the physical therapy analogy you provided. They would argue that large muscles of the back, for example, only aid in movement and stability of the torso (extension, abduction, etc.). Speech is a completely different ballgame. I’m sure they would also argue that at best, an exercise that works on the jaw couldn’t possibly impact the jaw duringspeech. This one’s going to baffle me for some time I’m sure…

Robyn: Yes Jeff, there are definite arguments on this, but why do you think more and more OT’s are doing the oral motor piece for feeding? As I mentioned before, even PTs are now involved in post-frenectomy care and they use CranioSacral Therapy inside of the mouth. When we look back in our own field there has never been a debate on oral motor for low tone or feeding. Pre-feeding exercises have always been accepted and implemented based on the belief that working on the motor skills for feeding is needed for safely introducing a bolus/liquid. This is true for the newborn with on an NG Tube and the elderly patient with post CVA dysphagia. Funny that “oral motor” is also used for dysarthria and dyspraxia in rehabilitative therapy without debate. So, one can argue, but it is somewhat common sense that if a motor plan or motor execution is disrupted (whether it is a feeding sequence or a speech sequence), we have to task analyze what is needed to help the client.

Jeff: Back to my previous response…I suppose it would help the reader if I backed up and explained where I am with respect to my understanding (or lack of) regarding OPT at this point in my career. Back around 2001, I purchased Sara Rosenfeld Johnson’s book Oral Motor Exercises for Speech Clarity (Now called Oral Placement for Speech Clarity & Feeding). I probably purchased the whistle and bite block sets around the same time. I read the book as well as instructions for both hierarchies and really used them only occasionally. I hadn’t taken any courses in OPT (but had taken at least one in feeding). I would later go on to complete level 1 PROMPT training in 2009. So, all in all, I guess you could call me a dabbler (though I certainly tried my best given the knowledge I had. I read the book/instructions with care).

If not for all of the cautionary papers surrounding NSOME’s during the 2000’s, I could have seen myself actually taking the courses, but my clinician mind was always stuck in the netherworld- not fully accepting OPT was a real thing and needing something more than “look-listen-say”. I think PROMPT served as a bridge towards a further realization that there had to be more.

Ultimately it took me doing 2 podcast episodes on “oral motor” for a further evolution in my thinking to begin.

So, here’s where I am today: I do want to see more evidence (single subjects, longitudinal studies, etc.). My skeptic hat is still on. But, I don’t want to wait any longer to start actually studying this area with more focus.

Speaking of training then, I take it that most speech pathologists that take courses through Talk Tools start with the Three-Part Treatment Plan for Oral Placement Therapy. Do you recommend that therapists also get trained in myofunctional therapy? If so, would that come before, during, or after taking a course on OPT? Or let’s put this a different way. What progression of courses (from Talk Tools or other sources) would you recommend a new graduate interested in this area embark on?

Robyn: I have done feeding/OPT/PROMPT and Orofacial Myofunctional training and there is great overlap. I suggest you take it all! Why do I know what I know? I have taken every course out there when it comes my way. I have an advantage being in the NYC metropolitan area, but in my “single” years I followed Sara Rosenfeld Johnson to Tucson, upstate NY and Rhode Island for training. Take all that you can afford and all that interests you from a variety of presenters.

The overlap of these approaches was the basis of my position paper I created with a group of SLPs for AAPSPA found here. Basically, there are some aspects of what we teach in OPT that is similar to orofacial myofunctional therapy. My tongue thrust and lisps course is pretty much all about orofacial myofunctional therapy with an OPT “twist” in relation to the speech component. It ensures that SLPs are phonetic placement minded when approaching the remediation of the speech sounds that an orofacial myofunctional disorder impacts. Example: the /s/ and /z/ are often impacted by a tongue thrust, and a tongue thrust is just a symptom of a problem such as tongue tie or enlarged adenoids. So, the lisp can actually be a sign of a much bigger issue than just a developmental speech sound disorder, but you can’t see what you don’t know, and most SLPs are trained to look at θ/s as “developmental”. This is what this type of training gives you, a new perspective on diagnosis. You are not going to correct a lisp if there is an underlying physical etiology such as adenoidal hypertrophy. Unfortunately, without training an SLP will be less likely to differentiate myofunctional from phonological and some therapists even teach compensatory placements for lisps or lingual sounds. For example, teaching interdental placement for /l/ if the child cannot elevate the tongue tip. This leads to jaw tension, fixing, and often causes further distortion of the sound.

I am a strong advocate for the fact that to understand abnormal you must first understand normal. They do not spend a heck of a lot of time teaching us about 0-3 oral motor development in school from a motor perspective. The focus is mostly language. I have supervised many graduate students over the past 15 years, and time and again my students tell me they are not learning about early oral motor skills. For example, when is a baby ready for a spoon, what are the pre-requisites? How are young clinicians supposed to know about infant feeding if they are not taught?

When you learn normal development from a master feeding clinician like Lori Overland or Diane Bahr, you have a greater understanding of 1) the pre-requisite skills for feeding and 2) based on oral motor developmental norms how feeding and speech overlap. So many pieces were missing from the puzzle until I was trained in normal development. For example, did you know that around 4-6 months the gag reflex starts moving back to the posterior third of the tongue around the very same time a spoon can be introduced? Paired with that is the emergence of bilabial babbling. So when you see a 5-year old that is gagging on pureed foods, does not effectively use the lips for spoon feeding and is nonverbal, you have to say “wow this child does not even have the skills achieved in infancy!” I would strongly suggest Lori’s feeding class in addition to Level 1 OPT course because the two together gives you a great baseline of knowledge.

The same is true for orofacial myofunctional therapy. The development of the mouth and orofacial structure and the relationship to function is such a valuable tool. OMT looks at developmental of the craniofacial structure from in utero across the lifespan.

Kristie Gatto, president of the IAOM has an amazing book on structure.

Char Boshart, who was one of my initial training instructors, does a great job as well.

Oral resting posture, airway, sleep, dental structure, swallowing, oral habits, frena, the shape of the palate, the appearance of the face are related to the interaction of structure and function. For example, if you know how to analyze dental malocclusions, you can determine what is congenital and what is functional. If you have a strong knowledge of structural and functional assessment of the frena, you can determine whether or not a speech or feeding issue is secondary. Without this knowledge, I do not know how any SLP truly can assess articulation challenges. There are many children being diagnosed with phonological issues that clearly have an orofacial myofunctional disorder (OMD). The signs are so obvious to me when these children come for evaluations. I can just look at their facial features and see the signs, yet they’ve been receiving traditional articulation therapy for years with minimal gains. At the very least, SLPs need to know when to refer out to an SLP who is also a Certified Orofacial Myologist (COM™) and/or oral motor/feeding specialist. Not all SLPs have to perform the therapy but we need to know enough to refer out when it is needed.

The future of our profession is slipping from us because this work needs to be done, and our field is “lumping” all aspects of oral motor into “NSOME”. ENTs know this work is needed. Oral surgeons/DDS/RDH know this work is needed. PT and OT know this work is needed. IBCLCs know this work is needed. If we are not going to do it, they will! Hopefully, because this is becoming more prominent on an international level, more SLPs will advocate for appropriate training. Just look at all that was discussed on this topic at ASHA 2017:

Topic Area: Swallowing and Swallowing Disorders
Session Number: 1759
Title: Mouth & Airway Development, Disorders, Assessment & Treatment: Birth to Age 7
Session Format: Seminar 1-hour
Day: Saturday, November 11, 2017
Time: 2:30 PM – 3:30 PM
Author(s): Diane Bahr (Author who will be presenting at the session), Kristie Gatto (Author who will be presenting at the session)

Topic Area: Interprofessional Education and Practice
Session Number: 1018
Title: An Interdisciplinary Approach to Pediatric Sleep-Disordered Breathing: SLP, ENT & Dental Professional “Airway” Team
Session Format: Seminar 2-hours
Day: Thursday, November 9, 2017
Time: 10:30 AM – 12:30 PM
Author(s): Nicole Archambault Besson (Author who will be presenting at the session), Soroush Zaghi (Author who will be presenting at the session), Hila Robbins (Author who will be presenting at the session)

Topic Area: Academic and Clinical Education
Session Number: 7301 Poster Board 137
Title: A Big Picture Focus: The Basis for Future SLPs to Screen for Airway Function Disorders
Session Format: Poster
Day: Friday, November 10, 2017
Time: 9:00 AM – 10:30 AM
Author: Nicole Archambault Besson (Author who will be presenting at the session)

Topic Area: Literacy Assessment and Intervention
Session Number: 8777 Poster Board 588
Title: Emotions & Executive Functions: Integrating the Limbic System & the Prefrontal Cortex in Myofunctional Therapy
Session Format: Poster
Day: Friday, November 10, 2017
Time: 2:00 PM – 3:30 PM
Author: Nicole Archambault Besson (Author who will be presenting at the session)

Topic Area: Swallowing and Swallowing Disorders
Session Number: 8281 Poster Board 596
Title: Treating Oromyofunctional Disorders: A Survey of the Field for SLPs
Session Format: Poster
Day: Thursday, November 9, 2017
Time: 3:00 PM – 4:30 PM
Author: Linda D’Onofrio

Topic Area: Swallowing and Swallowing Disorders
Session Number: 1381
Title: Differential Diagnosis of Orofacial Myofunctional Disorder from Oral Stage Dysphagia
Session Format: Seminar 1-hour
Day: Friday, November 10, 2017
Time: 10:30 AM – 11:30 AM
Author: Linda D’Onofrio

Topic Area: Academic and Clinical Education
Session Number: 7609 Poster Board 135
Title: Oromyofunctional Disorders & Therapy as a Basic Part of Speech Pathology Graduate Programs
Session Format: Poster
Day: Saturday, November 11, 2017
Time: 8:00 AM – 9:30 AM
Author: Linda D’Onofrio

Topic Area: Swallowing and Swallowing Disorders
Session Number: 9292 Poster Board 584
Title: Functional Assessment of Feeding Challenges in Children with Ankyloglossia
Session Format: Poster
Day: Saturday, November 11, 2017
Time: 11:00 AM – 12:30 PM
Authors: Robyn Merkel-Walsh (Author, but will NOT be presenting at the session), Lori Overland (Author who will be presenting at the session)

Jeff: If you could design a graduate program from scratch, how would OPT be incorporated? Courses, clinical hours??

Robyn: Linda D’Onofrio discussed this at ASHA sessions 7609! Let me list my dream:

There would be a class on normal mouth development for feeding and speech 0-3 years, (just like Diane Bahr is out there teaching).

There would be a course on muscle and motor-based speech disorders, not just “articulation and phonology”.
There would be a course on OMD/OPD specifically, not just cleft palate or a concentrated area. This would teach how to assess an OMD and understand how to treat it.
There would be courses/segments required that bring in “master clinicians” to teach on therapy methods for complex populations just as TOTs, Kaufman, OMD, PROMPT, OPT etc.
Clinical hours would include the diagnosis and treatment of OMD (which would then be inclusive of feeding, oral rest, OPT etc.).

Students need to STOP being told all NSOME are bad and that there is NO EVIDENCE. They are coming out of school without the proper tools to treat complex populations and this is all over social media. Large “evidence-based” groups are deterring new therapists and students from learning on their own. I met an SLP from a very prestigious University who took my TOTs class. She is an adjunct teaching articulation and the syllabus she was given included teaching the students “why NSOME is not EBP” and was instructed to tell the students “not ever go on the TalkTools® site”. That is clearly unethical. She was brave enough to go to the supervisor and advocate for modifying the way in which this was being presented to the students. It is a start. I also note that Malloy College in Long Island is fantastic about teaching their students about feeding and oral motor development. So times are changing…….but not fast enough for me!

Jeff: I’m interested to know what your services look like in the school setting. You’ve been in the schools for more than 20 years now. What did your service delivery look like in the early days vs. today (assuming your caseload did not significantly shift either in number or quality)? Did you ever find yourself having to advocate for feeding therapy as impacting the larger piece of communication? What does scheduling look like? How do you train teachers/paras/parents?

Jeff, I am going to start this with the most important FACTS. IDEA supports a free and appropriate education (FAPE). In 2004 health care services were added to FAPE. These services include swallowing and feeding services. The problem, however, is that many school systems do not have feeding protocols in place so the therapists are afraid to address it. If it impacts education SLPs must advocate for services. SLPs may be asked to assess and provide speech-language services for students with dysphagia. As noted in the Discussion Section of IDEA 2004 Part B final regulations, students may be eligible for dysphagia services under the disability category of “Other Health Impaired (OHI).” Recent ASHA surveys indicate that 10% of school-based SLPs now provide services to children with dysphagia. School districts are forming dysphagia management teams that include school nurses, SLPs, occupational therapists, physical therapists, and other school personnel. Some of the activities in which teams engage include interpreting medical records, organizing continuing education, developing educational materials, and writing feeding treatment plans. Two ethical considerations are relevant to this area of practice:

Principle 1B: Individuals shall use every resource, including referral and/or interprofessional collaboration, when appropriate, to ensure that quality service is provided.

Principle 2A: Individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience.

*ASHA Reference:

With that being cited, this should also apply to Orofacial Myofunctional and oral motor disorders such as dysarthria. SLPs are often misinformed that they “can’t” touch kids in a school setting or the “can’t” do oral motor as if it against the law. This could not be further from the truth. If a child has speech clarity issues and the root of the disorder is tone, motor planning or tongue thrust, why would the therapist NOT treat the underlying condition? Not to mention, with the Medicaid initiative in the schools for reimbursement of speech services, the forms INCLUDE oral motor and feeding as covered services so why would SLPs think that they cannot administer them? Educational programs teach toileting and dressing as ADLs, so why would they not teach feeding as an ADL?

The key words are EDUCATIONAL IMPACT. If a feeding disorder or orofacial myofunctional disorder does not impact education then that would not be educationally appropriate, but what if it does? There are many ways that these disorders impact education including: hydration, satiation, safety, nutrition for brain development and socialization. A child in preschool should not be spoon fed purees, nor should a second grader be at lunch with open mouth chewing and difficulty with bolus management to the point where his peers are teasing him. These aspects of feeding disorders are often ignored but should not be.

My job in the Ridgefield school has really been something to be proud of. Luckily over the years, my administrators have supported by advocacy for feeding oral motor and OPT including ongoing training that is required to maintain my TalkTools® certification status. To answer your question about the “evolution” of my career in the schools, I will share with you what I often say in my lectures:

EARLY DAYS: I started at Slocum Skewes School (grades 1-6 and self- contained classes) in 1995 as a maternity replacement. This was my CFY year, immediately after completion of my school-based clinical practicum in a multiply disabled program. I had been seeing many kids with Down syndrome/low tone at that time, and was moving into uncharted waters of “neurotypical/regular ed” students presenting with “articulation disorders.” Understand I already had some ITI (the former name of TalkTools®) under my belt because my aunt, an SLP, took me with her to the state conference. I had about 60 children on my caseload out of the gate, mainly groups.

Right away I noted that some, or should I say many of these children were not responding to what I learned in graduate school. I implemented the traditional model. Listen for the sound? They could do that. Discriminate between the target and error sound? Well, that went pretty well too. When I started teaching the placement cues for the sounds, well they just could not get it. I failed and I really did not have a backup plan other than what Sara Rosenfeld Johnson taught me at the state convention.

I started looking at their mouths, watching them eat, noting their oral resting postures. I ordered Roberta Pierce’s Swallow Right program and a bunch of articulation materials from Speech Dynamics and ITI (TalkTools®). I realized that many of these children had the same problems that my low tone kids had in my previous setting. They presented with poor diadochokinesis, poor motor control, open mouth posture, oral habits (thumb sucking, nail biting), mouth breathing, dental anomalies and so on. This provoked me to go for more training such as: Pam Marshalla, Char Boshart, Lori Overland and the IAOM convention. I started converting groups to one on one sessions. I requested more tactile supplies. The tools I used back then were mostly disposable such as: tongue depressors, feathers, string pipes, generic straws, and myobands.

I noted the methods I implemented were working. Kids were making gains. Kids were being discharged. I took data and wrote a state grant for the purchase of therapeutic tools and won the award. I ordered 3,000 dollars’ worth of horns, straws, Bite Blocks, bubbles etc. that I learned from Sara Rosenfeld-Johnson and Char Boshart. Simultaneously, I started writing my own program which later became known as Systematic Intervention for Lingual Elevation (SMILE). I also started adjuncting at two colleges, opened my private practice and quickly became known as a therapist who was a local “oral motor expert”. I was only three years into the field when I started working with Sara. Do not get me wrong…I used traditional methods when they worked (cycles, minimal pairs etc.) but when they did not, I had an arsenal of “tools” I could turn to, including PROMPT. I had a successful decade at Slocum Skewes School with a very supportive principal to make this all happen.

Ten years into my tenure, my administration decided that because 1) I had a unique specialization and 2) my private work was well known in the autism community, it was time to move me into our ABA-based ASD preschool program at Shaler Academy. The concept was to have me pioneer programs for feeding disorders and Childhood Apraxia of Speech (CAS) that other districts were not offering. By this point, Ridgefield was housing over 200 students from other districts as a magnet school program. They wanted new ways to help the program grow and felt I could help assist with this.

My time at Shaler was the most intense period of my career for many reasons. Firstly, while my caseload dropped to about 18-25 children, the intensity of services changed to 3-4 x a week individually. All of my children had significant oral sensory-motor challenges that required intensive work and parent training. I went for a great deal of ABA and Verbal Behavior training in this period due to the severity of challenging behaviors and aggression in my caseload. Secondly, it was the period of the NSOME controversy and from 2007-2010 the Lof articles and presentations were prominent. This made pioneering a new protocol very challenging. All of a sudden, my work went from helping children to defending everything I did in session. I had over a decade of evidence at this point and knew what I needed to do to advocate, but I admit at times it was really stressful and draining.

Over the years at Shaler, I came up with many systems and protocols for conducting oral motor, OPT and feeding in the schools including:

Clinical data sheets for assessments and therapy that marked baselines and progress in an ABA format. (Example, OPT Goals for IEPs and Insurance Reimbursement, a TalkTools® product).
Utilization of the Rethink First ABA data analysis system to track student progress. (Award granted, Rethink “teacher” of the month).
Yearly budgeting for therapy tools and a rotation system which allowed for students to borrow the tools from inventory and return them upon completion for the next student. Tool contracts were formulated to ensure the parents took proper care of the tools and understood replacement was needed for lost and damaged tools.
Co-treatment with OT for feeding therapy. We actually had an OT/ST clinic so that we could share students at the same time. This facilitated maximum progress and landed the school a NJSHA “Program of the Year “ award.
Integrated lunchtime feeding rotation to observe and assist students at mealtimes.
Staff and parent training and workshops in the district, and SLP/OT training at the county and state levels.
Mentoring and externship programs for local colleges.
Parent observation and training opportunities both in school and in the evening.
Disinfection protocols including the concept of the “clean” and “dirty” tool bags for safe transport of therapeutic materials. The children brought in Ziplocs at the start of the year. Each session they bring their disinfected tools in a “clean” bag and as they are used they are placed in the “dirty” bag to be sent home and disinfected.
Advocacy for SLPs in other districts to understand how to implement feeding and OPT programs into their caseloads via TalkTools® lectures and ASHA posters/presentations.

PRESENTLY, I have been transferred to a more eclectic setting at Bergen Boulevard School and am back in regular education, with a small subset of children in our ASD program. Now returning to my roots, it was very easy to determine which children have phonological/developmental issues and which needed a more tactile approach. I did not have so much to figure out as I did in 1995. Thus far I have been able to discharge several children with the addition of OPT within six months, referred out two children for frenectomy and reorganized group vs. individual sessions based on the underlying etiology of the articulation disorder. I am enjoying the combination of traditional vs. tactile methods with my students.

I am basically following the same protocols I developed at Shaler in terms of tool use, data, computer tracking and service delivery. I do find there are fewer parent observations with the regular education population. There is a big difference in severity between working with nonverbal children with significant feeding issues and children who have a lisp. In the grand scheme of things it is certainly not as much of an impact on the overall quality of life, but I do see the impact on education varying from ADLs to literacy. OPT for provoking postures to help the emergence of language in a nonverbal child is critical while OPT for assisting with the placement of sounds in a neurotypical child is supplemental (in most scenarios). I am not called into classrooms as often that a child may not be safe during a meal, and I have less medical interactions than I did at Shaler (ENTs, GI specialists etc.) Never the less, I feel each case is equally as important and feel that each case should be treated with the highest standard of care.

Jeff: Just to clarify that point about eligibility and IDEA…you mentioned that swallowing could be treated for kids who qualify under “OHI”- but it would be perfectly ethical and within our scope to also treat feeding/swallowing when the primary eligibility is “Autism” or even just “developmental delay”, correct?

Robyn: Of course. The examples given were direct from the federal government and ASHA to show that even “just” a feeding diagnosis could impact education but certainly when a feeding disorder is comorbid with ASD, or any other developmental diagnosis, the same principles apply.

Jeff: You talked about how your caseload shifted to 18-25 kids when you worked at Shaler and saw kids there 3-4X per week. It seems that if one wanted to implement a feeding/OPT program in a low-incidence program (or in any other program for that matter), it would, in fact, require one to one therapy and be next to impossible in a group setting. What advice would you give to therapists working with a similar population, but with a caseload approaching 60 students? Can we reliably train paras/teachers/others to help fill in the gap?

Robyn: I mentioned that it was challenging at first with all the groups. I do not deny tactile therapies are not ideal in the group setting but also not impossible. I have changed gloves 3x in a session when that is what I am faced with. The first step to reducing the groups/group size was separating the traditional vs. tactile needs. When that happened, I increased the size of the traditional groups (up to 5 in NJ) and gave the kids who needed 1:1 that service. I also paired one child that needed OPT in a group of 2 others who did not. This way I could quickly implement OPT programs at the start of sessions and then have all the children drill words. This was more effective than changing gloves 3x. There are also many models such as the 15-minute artic program or the #3-2-1 service model that can assist with complex scheduling needs.

Certainly, high caseloads and the push for groups in public education is a problem, but therapists have the law on their side. IDEA and state regulations protect the students, and therapists must advocate for the students. I do believe we can utilize paras/teachers and parents to assist with treatment protocols. For example, anyone can take the Beckman training, but only a licensed SLP or OT can assess, design the plan and is responsible for that plan; however, a nurse, caregiver, parent or 1:1 aide can assist with carryover. As I mentioned, a huge part of my role as a feeding therapist in the school is training and push in. This is also true of children who need OPT. Here is an example of roles and responsibilities within the schools:

PT: Posture and alignment/ seating

OT: utensils/sensory support/ self-regulation

ST: position/supports/size and shape of bolus/design therapy plan

Nurse: respiration and saturation/medication/checking the airway after meals

Teacher: monitoring of skills/data collection

Assistants: specific carryover plans (Ex. Use of straw #1 at lunch)

EX: The speech therapist shall provide suggestions on the size and shape of the bolus for classroom safety, along with therapeutic supports such as where the food is placed in the mouth to maximize the oral motor skills necessary for feeding safety. The classroom staff sees that the protocol is followed at snack and lunch.

Jeff: The other question I’m sure many will have reading this is: what did your language intervention look like at Shaler? Was there additional time to push-in or otherwise help support communication/literacy in the classroom?

Robyn: I will respond with the same response I give all the time: I am a speech and LANGUAGE pathologist. Communication is my end game. For any child I have in my caseload with language needs I am responsible for those goals as well. At Shaler (and here at Bergen in the ASD program) students also have receptive, pragmatic and expressive goals and objectives. In the past, we used Eden and ABBLS to assess students in addition to standardized speech and language tests like the CELF or the TOLD. We now use the Rethink First program to assess our students and develop goals. When the program first came to our district, I used it to create a district-wide screening tool for all students receiving speech and language as a related service. This screening tool included: receptive and expressive actions, curriculum-based vocabulary, object ID, labeling common objects, categories, oral motor imitation, articulation, object functions, same and different and object associations. This screening measure established a baseline tool to create not only speech and language programs but assisted the classroom teachers on creating objectives, selecting programs and vocabulary targets. Based on the success of my Primary Screening, the speech team created a Secondary Screening for those students who have mastered programs at the primary level.

A typical speech session for me has four parts: 1) Pre-feeding and Oral Sensory Motor 2) Feeding (when applicable) 3) Oral Placement Therapy (modern extension of Van Riper) and 4) speech and language tasks. In part 4, this could mean verbal imitation drills, receptive ID of objects, play-based therapy, articulation games, Kaufman Praxis drills, PROMPT intervention, ABA trials and so forth. I am not doing the tactile therapies without the cognitive or verbal therapies. That would be NSOME and that would NOT make sense. I teach a full day course on how to set up these clinical parameters based on my experiences in both the schools and private practice. I do integrated services, collaborative services, push in, inclusion and pull out throughout the day.

Jeff: My last question has to do with our kids on the spectrum. I vaguely remember you talking about the importance of working on speech for kids who are “nonverbal” (I’m fairly sure it was in the DVD course on OPT and autism, but I could be wrong). I thought about this recently after attending a local presentation. The speaker gave a little soapbox talk about how we (SLP’s) are taking the “easy” way out by introducing PECS or other forms of AAC too quickly and giving up on speech entirely. In fact, that presenter’s long-term goal is to develop verbal abilities for every client.

My assumption from our discussion so far is that you would agree with at least half of that argument (the part that says we’re not working on speech enough). But putting aside the issue of time/effort allotted for speech vs. language…is that expectation of a fully verbal client realistic? Don’t outcomes vary with every population? I’d hate to be the SLP who worked only on speech for 10 years and wound up with a client who only had a handful of semi-intelligible words to show for it. (Or am I just that misinformed on the possibilities on OPT, PROMPT, and myofunctional therapy?)

Robyn: The million-dollar question. I do not believe that PECS takes away from verbal behavior. In fact, it enhances it and Pyramid Consulting Group certainly have evidence to support that. However, I do not believe in working on “only language” when a child clearly has motor or muscle-based deficits. I see so many SLPs dismiss articulation and tone and praxis issues in kids on the spectrum because they prioritize language as being “more important”. I also see ABA trials and language programs that only work on receptive skills as a pre-requisite before any expressive programs are attempted. Receptive, expressive and articulation skills develop simultaneously. I work on them simultaneously. Ironically, I get the most referrals from ABA specialists who suspect oral motor/praxis issues.

I do not assume that kids on the spectrum have low cognition or do not want to speak. In fact, I am always looking for oral motor, praxis and feeding issues in children on the spectrum being research have shown that up to 65% of children with ASD also present with apraxia and there is a higher prevalence of motor deficits including low tone in this population. In addition, studies show that up to seventy percent of children with ASD are selective eaters and up to ninety percent have feeding problems. In my opinion, every child on the spectrum (especially the nonverbal children) needs a thorough structural and functional assessment of oral motor skills including feeding. Just because a child has a diagnosis of ASD does not mean that there is not another reason for low language output.

You mentioned my autism course. In this class, I discuss clinical parameters of dealing with challenging behaviors to be able to implement oral sensory motor programs with this population. If I have heard “well I cannot get in the child’s mouth” one time I have heard it one thousand times. Therapists need help in setting up clinical parameters to even start a proper structural assessment.

I do believe in using an ABA model to deliver OPT/feeding/OMT services with careful consideration of a reinforcement system and consideration of general sensory processing issues. We cannot predict how verbal a child may or may not become, but I do not believe in the notion that children who are not speaking at 7 will not speak. I have seen children with ASD at 7-9 years old who was completely nonverbal (but perhaps used AAC) develop word approximations with OPT intervention. I show a case study of this in my class. I am shocked when therapists or physicians tell parents their child “will never speak” when they have not yet tried all interventions possible. You mentioned you do not want to have a child who only has a few approximations, but that is better than having zero approximations. Parents want to hear their child’s voice no matter how minimal.

You mention several types of tactile therapies, OPT, (orofacial) myofunctional therapy and PROMPT. These are all tools. The trouble starts when social media posts shame these therapies and claim they “do not work” even though the people posting these were never trained in, or have not used the methods. That results in clinicians like you being misinformed. There is also a false notion (and it is claimed by some instructors) that certain methods are enough and should not be used with other tactile methods. I do not believe in absolutes. I do Beckman, TalkTools®, PROMPT and Kaufman (and more) all in the same session. It depends on what the student/client needs. Many of these kids are not “just” low tone or “just” apraxic, they have multiple issues that require multiple techniques. This loops us back to our initial discussion on clinical studies. How do you find the perfect subjects that only have ONE problem and then try to prove you only need this ONE method to assist with progress? Therapy does not occur in a bubble and that is why clinical evidence is so critical in driving treatment.

Laci and Mom

Laci

REFERENCES

Collected by:

Diane Bahr, Mary Billings, Linda D’Onofrio, Kristie Gatto

and Robyn Merkel-Walsh

Incidence, Prevalence

Abreu, R.R., Rocha, R.L., Lamounier, J.A., & Guerra, Â.F.M. (2008a). Prevalence of mouth breathing among children. Jornal de pediatria, 84(5), 467-470.

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Signs and Symptoms

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Causes

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Roles and Responsibilities

Assessment

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Massignan, C., Cardoso, M., Porporatti, A.L., Aydinoz, S., Canto, G.D.L., Mezzomo, L.A.M., & Bolan, M. (2016). Signs and symptoms of primary tooth eruption: a meta-analysis. Pediatrics, peds-2015.

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Valera, F.C., Trawitzki, L.V., Anselmo-Lima, W.T.(2006) Myofunctional evaluation after surgery for tonsils hypertrophy and its correlation to breathing pattern: a 2-year follow up. International Journal of Pediatric Otorhinolaryngology, Feb; 70 (2): 221-5.

Viviers, M., Kritzinger, A., Vinck, B., Graham, M. (2017) Preliminary psychometric performance of the Neonatal Feeding Assessment Scale. South African Journal of Communication Disorders, Jan 30, 64(1), ee1-e8.

Walsh, J., Links, A., Boss, E., Tunkel, D. (2017) Ankyloglossia and Lingual Frenotomy: National Trends in Inpatient Diagnosis and Management in the United States, 1997-2012. Otolaryngology Head Neck Surgery, Apr, 156(4), 735-740.

Treatment

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Bahr, D., & Banford, R. J. (2012). The oral motor debate part III: Exploring research and training needs/ideas. Oral Motor Institute, 4(1). Available from www.oralmotorinstitute.org.

Bahr, D. (2011a). The Oral Motor Debate Part I: Understanding the Problem. Oral Motor Institute, 3(1). Available from www.oralmotorinstitute.org.

Bahr, D. (2011b). The Oral Motor Debate Part II: Exploring Terminology and Practice Patterns. Oral Motor Institute, 3(2). Available from www.oralmotorinstitute.org.

Bahr, D. (2010). Nobody ever told me (or my mother) that! Everything from bottles and breathing to healthy speech development! Arlington, TX: Sensory World.

Bahr, D., Rosenfeld-Johnson, S. (2010). Treatment of children with speech oral placement disorders (OPDs): a paradigm emerges. Communication Disorders Quarterly, XX(X), 108.

Bahr, D. (2001). Oral motor assessment and treatment: Ages and stages. Boson, MA: Allyn& Bacon.

Bahr, D., & Johanson, N., (2013). A family-centered approach to feeding disorders in children (birth to 5- years). ASHA SIG 13: Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 22, 161-171

Bhattacharjee, R., Kheirandish-Gozal, L., Spruyt, K., Mitchell, R.B., Promchiarak, J., Simakajornboon, N., … & Marcus, C. L. (2010). Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med, 182(5), 676-683.

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Chuang, L.C., Lian, Y.C., Hervy-Auboiron, M., Guilleminault, C., & Huang, Y.S. (2017). Passive myofunctional therapy applied on children with obstructive sleep apnea: A 6-month follow-up. J Formos Med Assoc, 116(7), 536-541.

Colson, S.D., Meek, J.H., & Hawdon, J.M. Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Hum Dev, 84(7):441-449.

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Da Costa, S.P., Remijn, L., Weenen, H., Vereijken, C., van der Schans, C. (2017) Exposure to texture of foods for 8-month-old infants: Does the size of the pieces matter? Journal of Texture Stud, April 27.

Diaferia, G., Santos-Silva, R., Truksinas, E., Haddad, F.L.M., Santos, R., Bommarito, S., Gregorio, L.C., Tufik, S., Bittencourt, L. (2017) Myofunctional therapy improves adherence to continuous positive airway pressure treatment. Sleep Breath, May, 21(2), 387-395.

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Ferret-Amat, E., Pastor-Vera, T., Ferres-Amat, E., Mareque-Bueno, J., Prats-Armengol. J. & Ferres-Padro, E. (2016). Multidisciplinary management of ankyloglossia in childhood. Treatment of 101 cases. A protocol. Journal of Oral Medicine and Pathology, 1:21 (1):39-47.

Francis, D.O., Chinnadurai, S., Morad, A., Epstein, R.A., Kohanim, S., Krishnaswami, S., Sathe, N. & McPhetters, M. (2015). Treatments for ankyloglossia and ankyloglossia with concomitant lip tie. Effective Healthcare Program: Comparative Effectiveness Review, US Department of Health and Human Services, NO.149 AHRQ Publication No. 15-EHC011.-EF.

Ferrante An, & Ferrante A. (2015). Finger or thumb sucking. New interpretations and therapeutic implications. Minerva Pediatrica, 67(4), 285-297.

Ferrés-Amat, E., Pastor-Vera, T., Ferrés-Amat, E., Mareque-Bueno, J., Prats-Armengol, J., & Ferrés-Padró, E. (2016). Multidisciplinary management of ankyloglossia in childhood. Treatment of 101 cases. A protocol. Med Oral Patol Oral Cir Bucal, 21(1), e39-47.

Genna, C.W., & Barak, D. (2010). Facilitating autonomous infant hand use during breastfeeding. Clinical Lactation, 1(1), 15-20.

Ghahaeri, B.A., Cole, M., Fausel, S.C., Choup, M., Mace, J.C. (2017) Breastfeeding improvement following tongue-tip and lip-tie release: A prospective cohort study. Laryngoscope, May, 127(5), 1217-1223.

Ghaheri, B, (2015). The importance of active wound management following frenectomy. Retrieved From: http://www.drghaheri.com/blog/2015/6/21/the-importance-of-active-wound-management-following-frenotomy

Gosa, M.M., Carden, H.T., Jacks, C.C., Threadgill, A.Y., Sidlovsky, T.C. (2017) Evidence to support treatment options for children with swallowing and feeding disorders: A systematic review. Journal of Pediatric Rehabilitative Medicine, May 19, 10(2), 107-136.

Green. R., Moore, C. A., Reilly, K.J. (2000). The sequential development of jaw and lip control for speech. Journal of Speech, Language and Hearing Research, 45, 66-79.

Guilleminault, C., Huang, Y.S., Monteyrol, P.J., Sato, R., Quo, S., & Lin, C.H. (2013). Critical role of myofascial reeducation in pediatric sleep-disordered breathing. Sleep Med, 14(6), 518-525.

Guilleminault, C., & Sullivan, S.S. (2014). Towards restoration of continuous nasal breathing as the ultimate treatment goal in pediatric obstructive sleep apnea. Enliven, 1(1), 1-5.

Hari Iyer, V. & Sudarson, S. (2015). A comprehensive treatment protocol for lingual frenectomy with combination of laser and speech therapy. International Journal of Laser Dentistry, 5(1): 12-21.

He, T., Stavropoulos, D., Hagberg, C., Hakeberg, M., & Mohlin, B. (2013). Effects of masticatory muscle training on maximum bite force and muscular endurance. Acta Odontol Scand, 71(3-4), 863–869.

Hill, A.S. (2005). The effects of nonnutritive sucking and oral support on the feeding efficiency of preterm infants. Newborn Infant Nurs Rev, 5(3), 133-141.

Hodge, M. M. (2002). Non-speech oral motor treatment approaches for dysarthria: Perspectives on a controversial clinical practices. Perspectives in Neurophysiology and Neurogenic Speech Disorders, 12 (4), 22-28.

Hoefer, C., & Hardy, M.C. (1929). Later development of breast fed and artificially fed infants, JAMA, 96, 615-619.

Huang, Y.S., Guilleminault, C., Lee, L.A., Lin, C.H., & Hwang, F.M. (2014). Treatment outcomes of adenotonsillectomy for children with obstructive sleep apnea: a prospective longitudinal study. Sleep, 37(1), 71-76.

Inoue, N., Sakashita, R., & Kamegai, T. (1995). Reduction of masseter muscle activity in bottle-fed babies. Early Hum Dev, 42(3), 185-193.

Khaimar, M., Pawar, B. & Khaimar, D. (2014). A novel pre-surgical technique for the management of ankyloglossia. Journal of Surgical Technique Case Reports, 6(2): 49-54.

Klockars, T., & Pitkäranta, A. (2009a). Pediatric tongue-tie division: Indications, techniques and patient satisfaction. Int J Pediatr Otorhinolaryngol, 73(10), 1399-1401.

Kummer, A. (2016). To clip or not to clip? That’s the question. Presented at the annual convention of The American Speech and Hearing Association, Philadelphia, PA.

Kummer, A. (2005). To clip or not to clip? That’s the question. The ASHA Leader, 10:6-30.

Larjava, H. (2012) Oral wound healing: cell biology and clinical management. Wiley-Blackwell: Vancouver BC, Canada.

Laughlin, J., Luerssen, T.G., Dias, M.S., & Committee on Practice and Ambulatory Medicine. (2011). Prevention and management of positional skull deformities in infants. Pediatrics, 128(6), 1236-1241.

Lima, L.C.D.O., Baraúna, M.A., Sologurem, M.J.J., Canto, R.S.D.T., & Gastaldi, A.C. (2004). Postural alterations in children with mouth breathing assessed by computerized biophotogrammetry. J Appl Oral Sci, 12(3), 232-237.

Lundberg, A.J., & Stone, M. (1999). Three-dimensional tongue surface reconstruction: Practical considerations for ultrasound data. J Acoust Soc Am, 106(5), 2858-2867.

Manno, C.J., Fox, C., Eicher, P.S., & Kerwin, M.E., (2005). Early oral-motor interventions for pediatric feeding problems: What, when and how. J Early Intensive Behav Interv, 2(3), 145-159

Marcus, C.L., Katz, E.S., Lutz, J., Black, C.A., Galster, P., & Carson, K.A. (2005). Upper airway dynamic responses in children with the obstructive sleep apnea syndrome. Pediatr Res, 57(1), 99-107.

Marshalla, P. (2008). Oral Motor Treatment vs. Non-speech Oral Motor Exercises. Oral Motor Institute, 2(2). Available from www.oralmotorinstitute.org.

Marshalla, P. (2007). Oral Motor Techniques Are Not New. Oral Motor Institute, 1(1). Available from www.oralmotorinstitute.org.

Meaux, A., Savage, M., & Gonsoulin, C. (2016). Tongue ties and speech sound disorders: what are we overlooking? Presented poster at the Annual ASHA Convention, Philadelphia, PA.

Mennella, J.A., Reiter, A.R., & Daniels, L.M. (2016). Vegetable and fruit acceptance during infancy: Impact on ontogeny, genetics, and early experiences. Adv Nutr, 7 (Suppl), 2115-, 2195.

Merkel-Walsh, R. (2016). A modern look at Van Riper’s phonetic placement approach. . Poster session. ASHA Connect Convention. Minneapolis, MN.

Merkel-Walsh & Overland, L.L. (2017). TOTs: the functional impact on feeding and speech (joint lecture).Presented at: Connecting the Dots in TOTs. New York, N.Y.

Merkel-Walsh, R. (2016). A modern look at Van Riper’s phonetic placement approach. Poster session. ASHA Connect Convention. Minneapolis, MN.

Merkel-Walsh, R. & Jahn, A. (2014). Teaming up to correct tongue-tie. The ASHA Leader, 19. Retrieved from: http://leader.pubs.asha.org/article.aspx?articleid=181487.

Merkel-Walsh, R. (2011) Systematic Intervention for Lingual Elevation (SMILE). Charleston, SC: TalkTools®.

Messner, A.H. & Lalakea, M.L. (2000). Ankyloglossia: controversies in management. International Journal of Pediatric Otorhinolayryngology, 54(2):123-31.

Miranda, P.P., Cardoso, C.L., Gomes, E. (2016) Intervention in the alteration on lingual frenum: systematic review. International Archives of Otorhinolaryngology, 20(03), 275-280.

Moeller, J., (2017). Orofacial myofunctional therapy: a creative way to make a difference in patient’s lives. RDH. Retrieved from: http://www.rdhmag.com/articles/print/volume-29/issue-11/feature/orofacial-myofunctional-therapy.html

Moeller, J.L., Paskay, L.C., & Gelb, M. L. (2014). Myofunctional therapy. Sleep Med Clin, 9(2), 235-243.

Moore, C.A., Smith, A., & Ringel, R.L. (1988). Task-specific organization of activity in human jaw muscles. JSHR, 31(4), 670-680.

Morris, S.E. (1987). Therapy for the child with cerebral palsy: interacting frameworks. Semin Speech Lang, 8(1), 71-86

Morris, S. & Klein, M. (2000). Pre-feeding skills (2^nd ed). San Antonio TX: Therapy Skill Builders.

Mysak, E. (1971). Speech pathology and feedback therapy. Charles C. Thompson Publisher.

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

Ramsay, D.T., & Hartmann, P.E. (2005). Milk removal from the breast. Breastfeed Rev, 13(1), 5.

Ruark, J.L., & Moore, C A. (1997). Coordination of lip muscle activity by 2-year-old children during speech and nonspeech tasks. JSLHR, 40(6), 1373-1385.

Steeve, RW., Moore, C.A., Green, J.R., Reilly, K J., & McMurtrey, J.R. (2008). Babbling, chewing, and sucking: Oromandibular coordination at 9 months. JSLHR, 51(6), 1390-1404.

Villa, M.P., Brasili, L., Ferretti, A., Vitelli, O., Rabasco, J., Mazzotta, A. R., … & Martella, S. (2015). Oropharyngeal exercises to reduce symptoms of OSA after AT. Sleep Breath, 19(1), 281-289.

Vlahandonis, A., Walter, L.M., & Horne, R.S. (2013). Does treatment of SDB in children improve cardiovascular outcome?. Sleep Med Rev, 17(1), 75-85.

Volkert, V.M., Peterson, K.M., Zeleny, J.R., Piazza, C.C. (2014) A Clinical Protocol to Increase Chewing and Assess Mastication in Children with Feeding Disorders. Behavior Modification, June 5, 38(5), 705-29.

Wada, S., Tohara, H., Iida, T., Sato, M., Ueda, K. (2012) Jaw-opening exercise for insufficient opening of upper esophageal sphincter. Archives of Physical Medicine Rehabilitation, Nov, 93(11), 1995-99.

Wilson, E.M., Green, J.R., Yunusova, Y., & Moore, C A. (2008). Task specificity in early oral motor development. Semin Speech Lang, 29(4), 257-266.

Wohlert, A.B., & Smith, A. (2002). Developmental change in variability of lip muscle activity during speech. JSLHR, 45(6), 1077-1087.

Service Delivery

Bahr, D., & Banford, R. J. (2012). The oral motor debate part III: Exploring research and training needs/ideas. Oral Motor Institute, 4(1). Available from www.oralmotorinstitute.org.

Bahr, D. (2011a). The Oral Motor Debate Part I: Understanding the Problem. Oral Motor Institute, 3(1). Available from www.oralmotorinstitute.org.

Bahr, D. (2011b). The Oral Motor Debate Part II: Exploring Terminology and Practice Patterns. Oral Motor Institute, 3(2). Available from www.oralmotorinstitute.org.

Bahr, D. (2010). Nobody ever told me (or my mother) that! Everything from bottles and breathing to healthy speech development! Arlington, TX: Sensory World.

Bahr, D., Rosenfeld-Johnson, S. (2010). Treatment of children with speech oral placement disorders (OPDs): a paradigm emerges. Communication Disorders Quarterly, XX(X), 108.

Bahr, D. (2001). Oral motor assessment and treatment: Ages and stages. Boson, MA: Allyn& Bacon.

Talktool admin 21 Jun 18

In-Depth with Robyn Merkel-Walsh & Jeff Stepen: On EBP, OMD and OPT

“It’s chaos, be kind.”

-Michelle McNamara

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**“It’s chaos, be kind.”**